Interstitial Cystitis – Diagnosis, Symptoms, and Treatment

What is Interstitial Cystitis?

Interstitial cystitis is caused by inflammation in the bladder that leads to chronic pain and discomfort. It usually presents with symptoms similar to urinary tract infections such as urinary frequency (polyuria), burning on urination (dysuria), and urgency.  The diagnostic criteria require that symptoms be present for more than six weeks with no other potential cause of the patient’s symptoms.  Interstitial cystitis is typically diagnosed around age 40 or later and is more common in women compared to men. Patients with the disease tend to have coexisting pain syndromes such as fibromyalgia and irritable bowel syndrome. 

What Causes Interstitial Cystitis?

The cause of interstitial cystitis is unknown.  Studies show that certain foods and beverages (eg, caffeine, alcohol, citrus) can worsen symptoms, but these findings are inconsistent. 

Bladder biopsies in patients with interstitial cystitis often show abnormalities in the cells that line the bladder but it is not clear whether these findings are related to interstitial cystitis or another disorder.  Female gender is the only consistently identified risk factor for the condition.  There may also be a genetic susceptibility to developing the disease as cases are more common in those who have a relative with the disease.

How Common is Interstitial Cystitis?

Interstitial cystitis is relatively uncommon, with an estimated 1 to 5 out of 100,000 individuals in the United States being diagnosed with the condition. Several research studies have shown that up to 12% of individuals have one or more symptoms of the disease without ever having a formal diagnosis. Interstitial cystitis is 5 times more common in women than men and more common in middle-aged to elderly individuals. 

Signs and Symptoms

The symptoms of interstitial cystitis generally change in severity and quality over time. Often these symptoms are present in times of stress or after consuming certain foods. The most common symptoms that are seen in patients with interstitial cystitis are:

• Frequency (polyuria)
• Burning on urination (dysuria)
• Urgency
• Urinating frequently at night (nocturia)

Individuals often experience an increase in discomfort with bladder filling and an improvement with urinating.  Patients also typically have pelvic tenderness on physical examination, although this finding is not present in all patients.

Diagnosis

The diagnosis of interstitial cystitis is a diagnosis of exclusion. In order to be diagnosed with the condition, numerous other disorders must be ruled out. By definition bladder discomfort or pain that is not explained by another condition must be present for at least 6 months. 

Laboratory studies, imaging studies, and diagnostic procedures will be performed to rule out other conditions that present with similar symptoms.  Your doctor will order a urinalysis with microscopy to evaluate for signs of infection such as white cells, red cells, high protein, positive nitrites, and leukocyte esterase.  They will also obtain a urine culture to evaluate for bacterial growth if your urinalysis is consistent with infection.

Your doctor may also request a postvoid residual volume  – during this test, a radiology technician will typically measure the volume of urine in your bladder with ultrasound before and after urinating.  Cystoscopy is not necessary but may help support the diagnosis and exclude other disorders.  During this procedure, a urologist will visualize the bladder by inserting a scope through the urethra.

Interstitial Cystitis Medication and Treatment

The goals of therapy for interstitial cystitis are to improve symptoms and quality of life as there is no cure for the condition.  During the initial evaluation, patients are normally educated about the condition, coexisting conditions are evaluated and treated, and psychosocial support is provided.

Physical therapy is often beneficial for individuals with interstitial cystitis, it can reduce tenderness and discomfort from the pelvic floor muscles. Pelvic floor exercises such as Kegels have also shown benefit in patients with interstitial cystitis. 

Opiate pain medications (analgesics) may be used for short-term relief of disease flares to reduce pain and maximize function.  These medications may include codeine, Vicodin (hydromorphone-acetaminophen), or Percocet (hydrocodone-acetaminophen).  They should be used cautiously in patients with a history of substance-dependence and at the lowest dose possible for the shortest duration of time.

Urinary analgesics may also be helpful and include Pyridium (phenazopyridine) and antibacterial agent Hiprex (methenamine).  These agents are taken orally but coat the urinary tract with a numbing medication.  Intravesical lidocaine may be used for refractory pain episodes.  This therapy involves the injection of lidocaine with heparin into the bladder through the urethra and is often performed in the clinic.

Elavil (amitriptyline) is a tricyclic antidepressant that may be effective, particularly in patients with coexisting depression.  Treatment with Elmiron (pentosan polysulfate sodium) is an alternative to amitriptyline.  Patients with interstitial cystitis and coexisting allergies may notice improvement with use of oral antihistamines such as Benadryl (diphenhydramine).

Patients with refractory symptoms that have not responded to the aforementioned measures often require cystoscopy, distention of the bladder with water, and treatment of any visualized bladder lesions.  Botox (botulinum toxin) injections are often considered in those that fail to respond to cystoscopy.

References:

1. Rovner E, Propert KJ, Brensinger C, et al. Treatments used in women with interstitial cystitis: the interstitial cystitis data base (ICDB) study experience. The Interstitial Cystitis Data Base Study Group. Urology 2000; 56:940. - https://www.ncbi.nlm.nih.gov/pubmed/11113737
2. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2011; 185:2162. - https://www.ncbi.nlm.nih.gov/pubmed/21497847
3. Pazin C, de Souza Mitidieri AM, Silva AP, et al. Treatment of bladder pain syndrome and interstitial cystitis: a systematic review. Int Urogynecol J 2016; 27:697. - https://www.ncbi.nlm.nih.gov/pubmed/26272202