Interstitial Cystitis

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Original Editors - Sam Gerding from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Interstitial cystitis (IC) is a defined by its characteristics due to lack of a standardized diagnostic criteria globally. Both the definition and the diagnosis name have evolved with time.

In 1887, A.J.C. Skene first coined the term IC as meaning "inflammation of the bladder wall". In 1969, Hanash & Pool, described IC as a condition characterized by urinary symptoms of severely reduced bladder capacity and cystoscopic findings of Hunner’s ulcers. This is also referred to as the "classic IC" due to a finding in 1978 by Messing & Stanley of a "non-ulcer IC". We have since discovered that the Hunner ulcer is only in 10-50% of IC cases. In 1987, the National Instititute of Diabetes and Digestive and Kidney Diseases (NIDDK) introduced a research definition of IC. This definition used inclusion and exclusion factors in describing the syndrome. Many professionals accepted the NIDDK definition as the clinical care definition although the primary purpose was to formulate a basis for research purposes rather than use by clinicians. 

In 2002, the International Continence Society has proposed a new definition to clarify. While the term interstitial cystitis is reserved for diagnosing patients with characteristic cystoscopic and histologic features of the condition based off the NIDDK criteria another term was developed due to the lack of cytoscopic findings. A new term, Painful Bladder Syndrome (PBS), was accepted to account for the patients with "typical IC symptoms" but without the cystoscopic finding. PBS was defined as "suprapubic pain with bladder filling associated with increased daytime and nighttime frequency in the absence of proven urinary infection or other obvious pathology"". The new term is preferred by some clinicians because it defines IC as a syndrome of chronic pain, pressure, or discomfort associated with the bladder, usually accompanied by urinary frequency in the absence of any identifiable cause. The use of IC/PBS is commonly seen in the United States.

In 2008, the European Society for the Study of Interstitial Cystitis (ESSIC) proposed a new nomenclature and classification system. The propsed name change was to Bladder Pain Syndrome (BPS) since pain was the fundamental feture of the condition. The definition proposed is "diagnosed on the basis of chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptoms like persistent urge to void or urniary frequency".

Finally, an international consensus panel from Europe, Asia, and the United States were sponsored by the Society for Urodynamics and Female Urology to form an international consensus on IC/BPS/PBS to avoid all the confusion.The agreed definition of BPS/IC: an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks’ duration, in the absence of infection or other identifiable causes.

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)

Self Administered Symptom Scores for IC/PBS:(Carr LK)

• Interstitial Cystitis Symptom Index (ICSI)
• Interstitial Cysitis Problem Index (ICPI)
• Wisconsin Interstitial Cystitis Scale (UW-IC Scale)
• Pelvic Pain, Urgency, & Frequency (PUF) score

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
• Surgery

Physical Therapy Management (current best evidence)

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

Manual Physical Therapy of External Pelvis (6-12 weeks)

• Direct myofascial release
• Joint mobilization
• Muscle energy
• Strengthening & Stretching
• Neuromuscular Re-Education

Physical therapy of Internal Pelvis (Intravaginal Thiele massage- 6 weeks)

• Intravaginal Myofascial Release

Biofeedback/Electrical Stimulation (6-12 weeks)

• Neuromuscular re-education
• Electrical Stimulation 25-50 Hz

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

add appropriate resources here

Recent Related Research (from Pubmed)

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References

1. Carr LK, Corcos J, Nickel JC, Teichman J. Diagnosis of Interstitial Cystitis June 2007. Can Urol Assoc J; 2009; 3 (1): 81-86.
2. Dell JR. Interstitial Cystitis/Painful Bladder Syndrome: Appropriate Diagnosis and Management. Journal of Women's Health. 2007; 16 (8):1181-1187.
3. Evans RJ. Treatment Approaches for Interstitial Cystitis: Mulitmodality Therapy. Rev Urol. 2002; 4(suppl 1): S16-S20.
4. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, MO: Saunders Elsevier; 2007.
5. Irion JM, Irion GL. Women's Health in Physical Therapy. Baltimore, MD: Lippincott Williams & Wilkins; 2010.
6. MacDiarmid SA, Sand PK. Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome in Patients with Overactive Bladder Symptoms. Rev. Urol7; 9(1): 9-16.
   
7. Nickel JC. Interstitial Cystitis: The Paradigm shifts: International Consultations on Interstitial Cystitis. Rev. Urol.
   2004; 6: 200-202.
   
8. Nickel JC. Interstitial Cystitis: Etiology, Diagnosis, & Treatment. Canadian Family Physician. 2000; 46:2430-2440.
9. 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.
10. Parsons CL, Zupkas P, Parsons JK. Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome. Urology; 2001; 57: 482-32.
11. 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.
    
12. Whitmore KE. Complementary & Alternative Therapies as Treatment Approaches for Interstitial Cystitis. Rev Urol. 2002; 4 (suppl 1) S:28-S35.