Interstitial Cystitis

Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called bladder pain syndrome and hypersensitive bladder syndrome. 

There is no simple explanation for the symptoms, and the pathophysiology is likely a complex combination of various factors, including dysfunction of the blood vessels, nerves, immune system and epithelium.

It is much more common in women than men. It can have a significant impact on quality of life and mental health.

 

Presentation

The symptoms are similar to a lower urinary tract infection, but are more persistent. 

The typical presentation is more than 6 weeks of:

  • Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
  • Frequency of urination
  • Urgency of urination
  • Symptoms may be worse during menstruation

 

Investigations

Other causes of symptoms need to be excluded, with:

  • Urinalysis for urinary tract infections
  • Swabs for sexually transmitted infections
  • Cystoscopy for bladder cancer
  • Prostate examination for prostatitis, hypertrophy or cancer

 

Hunner lesions, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

Granulations are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall. 

 

Management

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life. 

 

Supportive management is used initially:

  • Diet changes such as avoiding alcohol, caffeine and tomatoes
  • Stopping smoking
  • Pelvic floor exercises
  • Bladder retraining
  • Cognitive behavioural therapy
  • Transcutaneous electrical nerve stimulation (TENS)

 

Oral medications may be helpful, including;

  • Analgesia
  • Antihistamines
  • Anticholinergic medications (e.g., solifenacin or oxybutynin)
  • Mirebegron (beta-3-adrenergic-receptor agonist)
  • Cimetidine (histamine-2-receptor antagonist)
  • Pentosan polysulfate sodium
  • Ciclosporin (an immunosuppressant)

 

Intravesical medication may be helpful, given directly into the bladder:

  • Lidocaine
  • Pentosan polysulfate sodium
  • Hyaluronic acid
  • Chondroitin sulphate

 

Hydrodistention involves filling the bladder with water, to high pressure, during a cystoscopy. It requires a general anaesthetic. This can give a temporary (3-6 month) improvement in symptoms.

 

Surgical procedures may be used, including:

  • Cauterisation of Hunner lesions during cystoscopy
  • Butulinum toxin injections during cystoscopy
  • Neuromodulation with an implanted electrical nerve stimulator
  • Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
  • Cystectomy (removal of the bladder)

 

TOM TIP: Interstitial cystitis is a complex condition with complex treatments. You certainly don’t need to remember all the treatments, and they are unlikely to be tested in medical school exams. Just keep it in mind as a differential diagnosis and be generally aware of the investigations (including cystoscopy) and treatment options.

 

Last updated May 2021
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