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interstitial cystitis

Severe, chronic bladder disorder. Etiology: 1) infection a) fastidious bacteria b) latent viruses 2) dysfunctional bladder epithelium a) defective glycosaminoglycan layer b) abnormal intercellular junctions 3) toxic substances in urine 4) allergic/immune/autoimmune 5) neurogenic disorders 6) bladder mastocytosis 7) psychogenic 8) food intolerance 9) endocrine disorders 10) idiopathic Epidemiology: 1) generally affects women 2) rare in blacks Pathology: -> irritants in the urine penetrate the mucous layer of the bladder epithelium & activate nerves & muscles in the bladder wall [4] Clinical manifestations: 1) urinary frequency (not always present) [4] 2) urinary urgency 3) nocturia 4) suprapubic pain, lower abdominal pain [7] (not always present) [4] 5) dyspareunia (75%) 6) symptoms may be worsened by certain foods -> citrus fruits, foods high in K+, caffeinated beverages, alcoholic beverages 7) symptoms may be provoked by physical or emotional stress, seasonal allergies Laboratory: 1) urinalysis & urine culture are negative 2) hematuria is NOT a sign of interstitial cystitis Special laboratory: 1) cystoscopy: a) glomerulations (submucosal vascular anomalies) after hydrodistension b) biopsy 2) potassium stimulation test Diagnostic criteria: 1) Exclusion criteria - < 18 years of age - benign or malignant bladder tumors - radiation cysititis - bacterial cystitis - vaginitis - cyclophosphamide cystitis - symptomatic urethral diverticulum - uterine, cervical, vaginal or urethral cancers - active Herpes - bladder or lower urethral calculi - waking frequency < 5 times in 12 hours - nocturia < twice nightly - symptoms relieved by antibiotics, urinary antiseptics or urinary analgesics (phenazopyridine {Pyridium}) - duration < 12 months - involuntary bladder contractions (urodynamics) - absence of sensory urgency with bladder capacity > 400 mL 2) Inclusion criteria - Hunner's ulcer Differential diagnosis: - pelvic inflammatory disease - fever, no urinary frequency [7] Management: 1) symptoms do NOT respond to antibiotic therapy 2) pharmaceutical agents a) amitriptyline or imipramine, start 25 mg PO QHS b) hydroxyzine c) oxybutynin 20 mg PO QD d) phenazopyridine 200 mg PO TID after meals e) pentosan polysulfate of no benefit [6] 3) intravesicular agents a) dimethylsulfoxide b) chlorpactin c) heparin 4) surgery rarely indicated

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Hunner's ulcer

General

cystitis

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 264
  2. Journal Watch 23(21):167, 2003 Sant GR et al, J Urol 170:810, 2003 PMID: 12913705 Nickerl JC, J Urol 170:816, 2003
  3. Lukban JC et al, Urol Clin North Am 29(3):649, 2003 (review) PMID: 12476528
  4. Rosenberg MT, Moldwin RM, Stanfod EJ, Early diagnosis and mangaement of interstitial cystitis, Women's Health in Primary Care 7:456, 2004
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, American College of Physicians, Philadelphia 2012 - Vercellini P, Somigliana E, Vigano P et al Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach. Gynecol Endocrinol. 2009 Mar;25(3):149-58. PMID: 19347704
  6. Nickel JC et al. Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder pain syndrome: Insights from a randomized, double-blind, placebo controlled study. J Urol 2015 Mar; 193:857 PMID: 25245489 http://www.jurology.com/article/S0022-5347%2814%2904431-0/abstract
  7. NEJM Knowledge+ Nephrology/Urology
  8. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Interstitial Cystitis (Painful Bladder Syndrome) https://www.niddk.nih.gov/health-information/urologic-diseases/interstitial-cystitis-painful-bladder-syndrome