Interstitial Cystitis

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Definition/Description

Interstitial cystitis (IC) aka. Painful Bladder Syndrome (PBS) is a disorder affecting the bladder characterized by uroepithelial inflammation and/or hypersenstivity of the afferent nerves of the bladder.(Oyama, IA) The difference between cystitis and interstitial cystitis is the presecence of infection in the bladder. Cystitis presents with an infection while interstitial cysitis does not. (Goodman) The International Continence Society definition is "the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night time frequency, in the absence of proven urinary infection or other obvious pathology." (Bharucha & Trabuco)

Prevalence

IC affects more than 700,00 individuals each year in the United States. Women make up 90% of those affected by this disorder. (Goodman/Synder)

Characteristics/Clinical Presentation

• Urinary frequency
• Urinary urgency
• Low back pain
• Pelvic/lower abdominal pain
• Dysuria (discomfort with urination)
• Hematuria
• Pyuria
• Bacteria
• Dyspareunia (pain with intercorse)
• Pelvic floor dysfunction
  
• Genital Pain (men)
• Perineal Pain
  
• Worsen at menstral cycle

Associated Co-morbidities(Irion, JM)

• Vulvodynia
• Irritable Bowel Syndrome (IBS)
• Urethral Burning
• Genital pain (tip of penis & testicles in males)

Medications (Nickel, JC)

Oral therapy

• Antispasmodics
• Pentosan polysulfate sodium (PPS)
• Hydroxyzine
  
• Tricyclic antidepressants

Intravesical therapy administered by urologist

• Dimethylsulfoxide (DMSO)
  
• Heparin
• Hyaluronic acid Bacillus Calmette-Guérin (BCG)

Diagnostic Tests/Lab Tests/Lab Values

Diagnostic approaches for IC vary widely and there is not a general agreement on a diagnostic algorithm. Currently, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Criteria is used.

NIDDK Diagonostic Critera for Interstitial Cystitis (MacDiarmid SA)

Automatic Inclusion:

• Hunner's ulcer

Positive factors (2 must be present for inclusion):

• Pain on bladder filling relieved by emptying
• Pain (suprapublic, pelvic, urethral, vaginal, or perineal)
• Glomerulations on cystoscopy
• Decreased compliance on cystometrogram

Exclsuions:

• Nocturia < 2 times per night
• Symptoms duration < 12 months
• Bladder Capacity > 400 mL
• Involuntary bladder contractions
• Other causes of sxs:

Bladder Cancer, Cystitis (radiation, tuberculous, bacterial, vaginitis, active herpes, bladder or lower calculi, involuntary bladder contractions.

Medical tests that help identify other conditions often include:

• Urinalysis and urine culture - will help rule out if their is a bacterial infection and UTI
  
• Cystoscopy - test to detect inflammation in the bladder and urethra; Once the bladder is stretched, findings such as a thick, stiff bladder wall; Hunner's ulcers; and glomerulations (pinpoint bleeding) that may be seen.
  
• Biopsy of the bladder wall - for a microscopic examination of tissue to rule out bladder cancer and confirm bladder wall inflammation.
• Intravesical Potassium Sensitivity test (Parson's Test)- a solution of KCl is left in the bladder for 5 minutes. Provocationa of urgency and frequency is rated on a 0-5 scale. A positive test is a MDC of 2. (Parsons CL)

Three consensus panels concluded that the diagnosis is suspected on the basis of history, physical examination, and laboratory tests, including negative urinalysis, negative urine culture, negative cytology, and possibly cystoscopy findings. (Nickel JC)

Causes

The etiology and pathogenesis are still not fully understood. Several theories for IC include epithelial dysfunction from a defect in the glycosaminoglycan (GAG) component of the mucin layer, mast cell abnormalities in the bladder wall, subclinical infection, neurogenic inflammation, vascular abnormalities, and autoimmune phenomena. (Evans,R) Due to the amount of possible influential factors it is probable that the etiology is more multifactoral rather than a singular cause. 

Systemic Involvement

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Medical Management (current best evidence)

• Dietary Modification
• Bladder Training & Voiding Diary

Physical Therapy Management (current best evidence)

In IC patients result in a high tone pelvic floor muscle dysfunction.(Whitmore KE)

• Physical Therapy of external pelvis (manual therapy)
• Physical therapy of internal pelvis (Thiele massage)
• Biofeedback/Electrical Stimulation

Alternative/Holistic Management (current best evidence)(Whitmore, KE)

• Nutraceuticals
• Acupuncture
• Stress Reduction
• Sex Therapy

Differential Diagnosis

Since there is not a definitive test to identify IC, ruling out other conditions becomes necessary before a diagnosis can be made.

Among these disorders are:

• Bladder cancer
  
• Bladder inflammation or infection caused by radiation to the abdomen
  
• Chronic bacterial or non-bacterial prostatitis (in men)
  
• Endometriosis
• Eosinophilic and tuberculous cystitis
  
• Kidney stones
  
• Low-count bacteriuria
  
• Neurological disorders
  
• Sexually transmitted diseases (STDs)
  
• Urinary tract infections (UTI)
  
• Vaginal infections
  
  

Case Reports

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Resources

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Recent Related Research (from Pubmed)

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References

1. Dell JR. Interstitial Cystitis/Painful Bladder Syndrome: Appropriate Diagnosis and Management. Journal of Women's Health. 2007; 16 (8):1181-1187.
2. Evans RJ. Treatment Approaches for Interstitial Cystitis: Mulitmodality Therapy. Rev Urol. 2002; 4(suppl 1): S16-S20.
3. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, MO: Saunders Elsevier; 2007.
4. Irion JM, Irion GL. Women's Health in Physical Therapy. Baltimore, MD: Lippincott Williams & Wilkins; 2010.
5. MacDiarmid SA, Sand PK. Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome in Patients with Overactive Bladder Symptoms. Rev. Urol7; 9(1): 9-16.
   
6. Nickel JC. Interstitial Cystitis: The Paradigm shifts: International Consultations on Interstitial Cystitis. Rev. Urol.
   2004; 6: 200-202.
   
7. Nickel JC. Interstitial Cystitis: Etiology, Diagnosis, & Treatment. Canadian Family Physician. 2000; 46:2430-2440.
8. Oyama IA, Reijba A, Lukban JC, Fletcher E, et al. Modified Thiele Massage as Therapeutic Intervention for Female Patients with Interstitial Cystitis and High-Tone Pelvic Floor Dysfunction. Urology; 64 (5): 862-865.
9. Parsons CL, Zupkas P, Parsons JK. Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome. Urology; 2001; 57: 482-32.
10. Peters KM, Carrico DJ, Kalinowski SE, Ibrahim IA, Diokno AC. Prevalence of Pelvic Floor Dysfunction in Patients with Interstitial Cystitis. Urology; 2207; 70: 16-18.
    
11. Whitmore KE. Complementary & Alternative Therapies as Treatment Approaches for Interstitial Cystitis. Rev Urol. 2002; 4 (suppl 1) S:28-S35.