1. Interstitial Cystitis
Nora Brody, Will Huebner, Krysten Malcolm, Seema Marshall,
Anita Vadaken

2. What is IC?
 Clinical syndrome
 AKA painful bladder
syndrome
“Unpleasant sensation
perceived to be related
to the urinary bladder
and associated with
lower urinary tract
symptoms of 6+ weeks
duration, in the
absence of infection or
other identifiable
causes.”
(http://www.mayoclinic.com/images/image_popup/r7_interstitialcystitis.jp
g)
(Rovner & Kim)

3. Epidemiology
 500,000 – 1,000,000 cases estimated in U.S.
 ICSI from 1990 to 2002: 1.2 to 450 per 100,000
 Proposed pain and urgency/frequency symptom scale
(PUF) has been used to identify patients with IC
 Prevalence may be as high as 1 in 45 women
 http://www.lasvegasurogynecology.com/PUF.pdf
 Almost exclusively in women
 40% report symptoms worsen pre-menstrually,
specifically around time of ovulation
(Marshall, 2003; Parsons et al., 2002)

4. Interstitial Cystitis Symptoms
Index (ICSI)
 During the past month:
 How often have you felt the strong need to urinate with
little or no warning?
 Have you had to urinate less than 2 hours after you
finished urinating?
 How often did you most typically get up at night to
urinate?
 Have you experienced pain or burning in your bladder?
(Sirian et al., 2005)

5. Etiology
 Unknown, multifactorial
 Deficiency in the
glycosaminoglycan (GAG)
layer
 Toxic substances
 Autoimmune disorder
 Infection

History of UTIs
 Toxic substance in urine
 Neurogenic hypersensitivity
or inflammation
 Pelvic floor muscle
dysfunction/dysfunctional
voiding
(Nickel, 2000; Rovner & Kim)
(http://jama.jamanetwork.com/data/journals/jama/23565/
m_jpg120007fa.png)

6. Patient History
 Questionnaires
 Risk factors: consumption of caffeinated and alcoholic
drinks, anorectal disease, IBS
 Associated conditions: depression, sexual
dysfunction/abuse, emotional/physical abuse or
neglect, constipation, chronic pain or inflammatory
conditions
(Offiah et al., 2013; Quillin & Erickson, 2012)

7. Signs & Symptoms
 PAIN: suprapubic or pelvic
 Bladder pain that worsens with





bladder filling and is alleviated
with voiding
Dysuria
Urinary frequency & urgency
Nocturia: mild to severe (1 to
>12 times per night)
Spasm of the rectum and levator
ani muscles
Anterior vaginal wall, suprapubic
region, and pelvic floor muscle
tenderness on pelvic
examination
 Women
 Dyspareunia
 Female sexual dysfunction
 Men
 Pain at the tip of the penis,
the groin, or the testes
 Ejaculation often produces
pain owing to severe spasm
of the pelvic floor
 Prostate, bladder, testes,
and epididymis tenderness
(Ching, 2013)

8. Other Examination
Techniques
 Perform pelvic examination
to help exclude gynecologic
disease
 Measure the patient's
temperature
 Fever suggests infection
rather than IC
 Examine the abdomen for
masses, hernias, and other
abnormalities suggesting
alternate diagnoses
(http://www.soothetube.com/tag/doctor/)
(Ching, 2013)

9. Diagnosis
 Cystoscopy
 Findings: glomerulations,
mucosal ulcers (Hunner’s
lesions), petechial hemorrhage
 Urodynamics
 Poorly compliant bladder
 Urinary biomarkers
 Nitric oxide
 Bladder biopsy
 Controversial
(http://2.bp.blogspot.com/cfuq6XwwRiE/ThRoNDIPU4I/AAAAAAAAAys/A2l6
NTX6SEc/s1600/pathology.jpg)
(Offiah et al., 2013; Quillin & Erickson, 2012)

10. Clinical Guidelines
(American Urological Association, 2011)

11. Clinical Guidelines
 AUA created flowchart of suggested order of treatment
 Progress 1st line through 6th line as needed
 JUA created clinical practice guidelines




Level A evidence: highly recommended
Level B evidence: recommended
Level C evidence: no clear recommendation possible
Level D evidence not recommended
 Conservative treatments first
 Avoid surgery if possible
 Exception is fulguration of Hunner’s lesions, must be done first
 Multiple simultaneous treatments often best
 Pain management should be priority
(American Urological Association, 2011; The Japanese Urological Association, 2009)

12. Clinical Guidelines
 1st line treatments: conservative
 Patient education about IC and treatment options
 Behavioral modifications (B)





Timed voiding
Controlled fluid intake
Stress reduction
Avoidance of triggers
Dietary changes: avoid acidic foods, coffee, tea, soda, spicy
foods, artificial sweetener, and alcohol
 4 C’s: carbonated, caffeine, citrus, high concentration of vitamin C
(American Urological Association, 2011; The Japanese Urological Association, 2009;
http://www.mayoclinic.com/health/interstitial-cystitis/DS00497)

13. Clinical Guidelines
 2nd line treatments
 Physical Therapy (C)




Biofeedback
Soft tissue mobilization
Stretching
Pelvic floor muscle training?
 AUA says avoid
 JUA says nothing
 Research mixed
(American Urological Association, 2011; The Japanese Urological Association, 2009; Weiss, 2001)

14. Physical Therapy
FitzGerald et al., 2009;
FitzGerald et al., 2012
Weiss JM, 2001
 Manual release of myofascial

Soft tissue mobilization of all trigger
points found in pelvic floor, anteriorly
from knees to costal cartilages, and
posteriorly from T10 to popliteal
crease

Manual stretching, scar mobilization,
and myofascial release

Individualized HEP of stretching and
exercises
 Explicitly told participants to
avoid Kegels until trigger points
resolved

59% reported moderate or marked
symptom improvement
trigger points via internal
palpation, compression, and
lateral stretching
 HEP: biofeedback, Kegel
exercises, external pelvic muscle
stretches and strengthening, and
stress reduction
 70% had moderate to marked
improvement

15. Clinical Guidelines
 2nd line treatments
 Pharmacology for pain management
 Amitriptyline (B), Cimetidine (C), Hydroxyzine (C) : inhibit
histamine receptors to decrease pain signal transmission
 Pentosan polysulfate (B): repairs damaged GAG layer of
bladder mucosa
 Takes 3-6 months to see effects and only effective in
approximately 25% of patients
 Intravesical treatments
 Dimethyl sulfoxide (B): anti-inflammatory, analgesic, and
muscle relaxant
 Heparin (C): functions as GAG layer for bladder
 Lidocaine (C): analgesic
(American Urological Association, 2011; The Japanese Urological Association, 2009)

16. Clinical Guidelines
 3rd line treatment:
cystoscopy with short
duration, low pressure
hydrodistension (B)
 Most common
treatment, 50% efficacy,
effects last about 6
months
 Inflate bladder with
saline to 80cmH2O or
800-1000mL, maintain
pressure for a few
minutes then drain
bladder
(http://www.umm.edu/graphics/images/en/1089.jpg)
(American Urological Association, 2011; The Japanese Urological Association, 2009)

17. Clinical Guidelines
 4th line treatment:
neurostimulation (C)
 Bilateral S3 nerve stimulators
 Significant decrease in

frequency and nocturia
 Significant improvement in
Urinary Distress Inventory
short form scores, showing
patient satisfaction
 Decrease in episodes of fecal
incontinence
TENS for pain relief
 External low back or suprapubic placement
 Internal placement of device
in vagina
(http://www.kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis_ez/images/nerve_
stimulation.jpg)
(American Urological Association, 2011; The Japanese Urological Association, 2009; Steinberg et al., 2007,
http://www.mayoclinic.com/health/interstitial-cystitis/DS00497 )

18. Clinical Guidelines
 5th line treatments
 Cyclosporine A (C)
 Anti-inflammatory and immunosuppressive
 More effective for patients with Hunner’s lesions
 85% vs. 30% effective
 Intradetrusor botox injection (C)
 Risk of requiring intermittent catheterization after treatment
 Up to 4 injections, separated by 6 months effective for
symptom and pain relief as well as increasing bladder
capacity
 Not as effective for patients with Hunner’s lesions
(American Urological Association, 2011; The Japanese Urological Association, 2009; Forrest et al.,
2012; Kuo HC, 2013)

19. Clinical Guidelines
 6th line treatment: surgery (C)
 Cystoplasty
 Part/all of bladder removed and replaced by section of bowel to
function as new bladder
 Uncommon
 Urinary diversion with/without cystectomy
 Section of bowel becomes conduit for ureters, stoma created in
abdomen, allows urine to drain continually into external
collection bag
 Section of bowel becomes conduit for ureters, drains into
another section of bowel that has become internal pouch that
must be emptied through intermittent self-catheterization
 Rarely performed because many patients will still experience
some symptoms, mainly pain, after surgery
(http://www.ichelp.org/page.aspx?pid=384 Revised June 03, 2011)

20. Questions?
(http://i.qkme.me/35n0m0.j
pg)

21. Resources









Ching,
C.
Interstitial
Cystitis.
MDConsult.
2013.
Available
at:
http://www.mdconsult.com/das/pdxmd/body/4123693384/1445372623?type=med&eid=9-u1.0-_1_mt_1010371#1144427. Accessed May 29,
2013.
Hanno PM, Burks DA, Clemens JQ, et al. AUA guidelines for the diagnosis and
treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170.
Homma Y, Ueda T, Tomoe H, et al. Clinical guidelines for interstitial cystitis and
hypersensitive bladder syndrome. Int J Urol. 2009;16:597-615.
FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of
myofascial physical therapy for the treatment of urological chronic pelvic pain
syndromes. J Urol. 2009;182:580-580.
FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter feasibility trial of
myofascial physical therapy for the treatment of urological chronic pelvic pain
syndromes. J Urol. 2012;187:2113-2118.
Forrest JB, Payne CK, Erickson DR. Cyclosporine A for refractory interstitial
cystitis/bladder pain syndrome: experience of 3 tertiary centers. J Urol.
2012;188(4):1186-1191.
Hanley RS, Stoffel JT, Zagha RM, Mourtzinos A, Bresette JF. Multimodal therapy for
painful bladder syndrome/interstitial cystitis: pilot study combining behavioral,
pharmacologic, and endoscopic therapies. Int Braz J Urol. 2009;35:467-474.
Kuo HC. Repeated intravesical onabotulinumtoxinA injections are effective in
treatment of refractory interstitial cystitis/bladder pain syndrome. Int J Clin Pract.
2013:67(5):427-434.
Marshall, K. Interstitial Cystitis: understanding the syndrome. 2003. Alternative
Medicine Review, 8 (4).

22. Resources











Nickel JC. Interstitial cystitis. Canadian Family Physician. 2000;46:2530-2440.
Offiah I, McMahon SB and O’Reilly BA. Interstitial cystitis/bladder pain syndrome:
diagnosis and management. Int Urogynecol J. 2013 Feb 22. Epub ahead of print.
Parsons C, Dell J, Stanford E et al. Increased prevalence of interstitial cystitis:
previously unrecognized urologic and gynecologic cases identified using a new
symptom questionnaire and intravesical potassium sensitivity. 2002. Adult Urology,
4295(02).
Quillin, Renee B and Erickson, Deborah R. Practical use of the new American
Urological Association Interstitial Cystitis guidelines. Curr Urol Rep. 2012; 13:394401.
Rovner ES and Kim ED. Interstitial Cystitis. Medscape Reference: Drugs, Diseases
and
Procedures.
http://emedicine.medscape.com/article/2055505overview#aw2aab6b2b3. Accessed May 27, 2013.
Sirinian E, Azevedo K, Payne CK. Correlation between 2 interstitial cystitis symptom
instruments. J Urol. 2005;173:835-840.
Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with
interstitial cystitis. Urology. 2007;69(3):441-443.
Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis
and the urgency-frequency syndrome. J Urol. 2001;166:2226-2231.
http://www.mayoclinic.com/health/interstitial-cystitis/DS00497
http://www.ichelp.org/page.aspx?pid=384
http://www.lasvegasurogynecology.com/PUF.pdf

23. Example of Treatment Protocol
 Dietary restrictions
 Fluid restriction to 64 oz per day, 16 oz per meal and 8 oz between
each meal
 Timed voiding every 2-3 hours
 Kegels: 15 contractions 2x per day
 Pharmacology: macrodantin (anti-inflammatory), hydroxyzine (antiinflammatory), Urised (anti-spasmodic)
 Continued pentosan polysulfate if patient had been on it at least 6
months prior
 Hydrodistension
 3x in one session, 2 weeks after treatment initiated
 All participants did not have Hunner’s lesions
 Saw statistically signficant improvement in quality of life measured
on O’Leary-Sant IC Symptom Index
(Hanley et al., 2009)