Interstitial Cystitis, feat. Dr. Edward Kim
/Here’s the RoshReview Question of the Week!
A 41-year-old woman presents to your office for dysuria. She states that she has been having persistent urinary urgency and frequency for the past six months. She reports discomfort with bladder filling, pain with urination, and relief after voiding. A review of her history reveals normal fluid intake. A workup for pelvic pain performed by her primary care provider and gastroenterologist was negative. On physical exam, you note suprapubic tenderness. Her urinalysis and culture are negative. Which of the following is the best therapeutic option?
Check out if you answered correctly at the links above!
Today we welcome Dr. Edward Kim to the podcast. He is a urogynecology fellow at the University of Pennsylvania, performing research on a challenging topic: interstitial cystitis. Dr. Kim is looking to recruit more patients into a study on quality of life and patient education in IC — if you have questions or someone to refer, let us know by emailing us or contacting us with the form on the website!
Overview
IC: kind of a misnomer!
There is no conclusive evidence that there is an inflammation nor distinct pathology in the bladder interstitium.
Contemporary thinking: chronic pain condition related to or perceived to be originating from the bladder.
Newer terminology has been proposed: bladder pain syndrome.
In clinical practice, some patients seem to prefer ‘interstitial cystitis’ because to them is sounds more like a more medical diagnosis and they don’t want to be labeled as having a pain syndrome. So IC/BPS are used interchangeably.
Epidemiology
Can affect men and women but more common in women.
High prevalence in age 40s.
Don’t know the precise prevalence given complexity of syndrome.
Estimate that is often quoted is 3 to 8 million women in the U.S
Clinical Presentation
Variable
Persistent urinary urgency, urinary frequency, and pain or discomfort related to voiding.
Note that we say pain or discomfort. Some patients describe what they’re feeling as discomfort and not pain.
Classic: patient with these symptoms who had been treated multiple times for urinary tract infections despite having negative urine cultures. They also may report going to the bathroom frequently or spending a lot of their day on the toilet to relieve their urgency and discomfort or pain.
Many of these patients may also have associated conditions like irritable bowel syndrome, fibromyalgia, and pelvic floor muscle dysfunction.
They also may have concurrent psychiatric comorbidities such as depression or anxiety.
Diagnosis
American Urological Association: “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.”
In other words, IC is a clinical diagnosis and diagnosis of exclusion.
Differential diagnosis should include:
Infection
Overactive bladder
Bladder or urethral cancer, gynecologic cancer
Uterine fibroids with compression effect on the bladder
Bladder stone
Bladder diverticulum
Foreign material such as synthetic mesh or suture
Neurologic conditions that may cause urinary retention in particular
Other chronic pelvic pain conditions such as endometriosis.
This is why it’s important to perform a thorough history and physical and obtain a post void residual and urine tests as an initial evaluation to rule out these other etiologies.
Hunner lesions can be seen on cystoscopy.
They are specific for IC, but they only are seen in about 10% of patients with IC.
Potassium sensitivity test KCl is instilled into the bladder.
This is not performed anymore due to its low sensitivity and specificity and also it’s very painful!
Urodynamics is not typically used to diagnose IC but it can be done to rule out other etiologies.
Treatment
Management strategy is multi-faceted.
American Urological Association’s website has a great treatment algorithm for IC.
First-line treatments are patient education, behavior and diet modification, and general stress management.
There is good evidence behind teaching patients bladder retraining where they learn to increase the interval between each voids.
Avoidance of things like artificial sweetener, caffeine, alcohol, spicy food, citrusy or acidic foods can help with symptoms.
Doesn’t require elimination, but helps to make informed decisions about diet.
Applying heat or ice packs to the suprapubic or perineal regions can also be helpful.
Pelvic floor muscle tenderness or dysfunction on exam —> consider pelvic floor PT.
Second-line treatments include oral medications and bladder instillation.
PRN medication is usually pyridium or over the counter AZO.
Warn patients that their urine will turn orange and may stain clothing.
Daily medications, the most commonly used ones are: amitriptyline, hydroxyzine and pentosan polysulfate sodium (Elmiron).
Note that Elmiron is the only FDA approved medication for IC. However, use of Elmiron has been associated with macular eye disease. Thus, in 2020, the FDA inserted a warning label to reflect this and use of Elmiron has been declining.
Between amitriptyline and hydroxyzine, currently there is more data on amitriptyline. Some patients find amitriptyline helpful in controlling their symptoms but some cannot tolerate its sedative and anticholinergic side effects.
If there is inadequate response to medications, then bladder instillation can be considered. This involves instilling a mixture of local anesthetic, heparin, DMSO, etc. via a catheter. Usually this involves repeated treatments.
Third-line treatment is hydrodistention.
Hyper-distention of the bladder under anesthesia for about 10 minutes and emptying the bladder.
The thought is that sensory nerves in the bladder are disrupted due to the hyper distention.
For patients who see prolonged and significant benefit, repeat treatments are considered.
If on cystoscopy Hunner lesions are found, they can be addressed with cautery, resection or injection with steroids.
Fourth-line treatments include neuromodulation using Botulinum toxin A injection into the bladder and sacral neuromodulation.
These techniques have been used for overactive bladder and neurogenic bladder but recent clinical trials have reported efficacy for interstitial cystits.
Fifth-line treatment is cyclosporine A. Use is limited due to its side effects and paucity of convincing data.
Sixth-line and last resort is surgical diversion of the bladder with or without cystectomy.
Fortunately, patients seldom have to go past fourth-line treatments. As with any chronic pain condition, it is a difficult journey for many of them and it is critical for providers to listen and empathize with them.