About interstitial cystitis (ic)/painful bladder syndrome (pbs)

What is interstitial cystitis (ic)/painful bladder syndrome (pbs)?

Interstitial cystitis facts

  • PBS/IC is an inflammatory disease of the bladder that can cause ulceration and bleeding of the bladder's lining and can lead to scarring and stiffening of the bladder.
  • The symptoms of PBS/IC are
    • pelvic pain,
    • frequent urination,
    • urinary urgency.
  • PBS/IC has a variable clinical course, meaning that symptoms can appear and disappear over time. Moreover, the intensity of symptoms varies among individuals and even within the same individual over time.
  • The cause of PBS/IC is unknown, but abnormalities in the leakiness or structure of the lining of the bladder are believed to play a role in the development of PBS/IC.
  • The diagnosis of PBS/IC is based on the symptoms, an abnormal potassium sensitivity test (PST), and elimination of other conditions that may be responsible for the symptoms.
  • Treatment for PBS/IC most commonly utilizes heparinoid drugs to help restore integrity of the bladder lining along with other oral medications. Bladder distension and intravesical drug therapy are other treatments that may provide relief in PBS/IC.

Overview of urinary function

The urinary system consists of the kidneys, ureters, bladder, and urethra. The kidneys, a pair of purplish-brown organs, are located below the ribs toward the middle of the back. The kidneys remove water and waste from the blood in the form of urine, keeping a stable balance of salts and other substances in the blood. The kidneys also produce erythropoietin, a hormone that stimulates the formation of red blood cells. Narrow tubes called ureters carry urine from the kidneys to the bladder, a triangle-shaped, muscular chamber in the lower abdomen. Like a balloon, the bladder's muscular, elastic walls relax and expand to store urine and contract and flatten when urine is emptied through the urethra. The typical adult bladder can store about 1 ½ cups of urine.

Adults urinate about 1 ½ quarts of urine each day. The amount of urine varies depending on the fluids and foods a person consumes. The volume formed at night is about half that formed during the day.

Normal urine contains fluids, salts and waste products, but it is free of bacteria, viruses, and fungi. The tissues of the bladder are isolated from urine and toxic substances by a coating on the inside of the bladder that discourages bacteria from attaching and growing on the bladder wall.

What is interstitial cystitis (IC)?

Interstitial cystitis (IC) is a term that has been used to refer to a clinical syndrome characterized by chronic urinary urgency (feeling the need to urinate immediately) and frequency (frequent urination), usually with suprapubic discomfort or pressure and usually relieved by urinating. The symptoms of this condition vary among individuals and may even vary with time in the same individual. The term cystitis refers to any inflammation of the bladder. In contrast to bacterial cystitis that results from an infection in the bladder, a type of urinary tract infection (UTI), no infectious organism has been identified in people with interstitial cystitis.

There has been controversy in the medical literature regarding the definition of interstitial cystitis and use of the term. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the U.S. National Institutes of Health (NIH) established a set of diagnostic criteria for inclusion in research studies relating to interstitial cystitis and its causes that were used for research purposes until 2002. However, the NIDDK criteria were felt to be overly restrictive for diagnostic use, and in 2002, new criteria were proposed for the diagnosis of painful bladder disorders, including the condition referred to as painful bladder syndrome (PBS) by the International Continence Society (ICS). These criteria felt that the term PBS was preferable and that the term IC should be restricted to use in those patients having typical findings observed upon cystoscopy and biopsy of the bladder tissues.

The ICS criteria state the following:

  • Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology...The ICS believes this to be a preferable term to "interstitial cystitis." Interstitial cystitis is a specific diagnosis and requires confirmation by typical clinical cystoscopic and possibly histological features.

What are the symptoms for interstitial cystitis (ic)/painful bladder syndrome (pbs)?

Interstitial cystitis signs and symptoms include:

  • Pain in your pelvis or between the vagina and anus in women
  • Pain between the scrotum and anus (perineum) in men
  • Chronic Pelvic pain
  • A persistent, urgent need to urinate
  • Frequent urination, often of small amounts, throughout the day and night (up to 60 times a day)
  • Pain or discomfort while the bladder fills and relief after urinating
  • Pain during sex

Symptoms severity is different for everyone, and some people may experience symptom-free periods.

Although signs and symptoms of interstitial cystitis may resemble those of a chronic urinary tract infection, there's usually no infection. However, symptoms may worsen if a person with interstitial cystitis gets a urinary tract infection.

What are the causes for interstitial cystitis (ic)/painful bladder syndrome (pbs)?

The exact cause of interstitial cystitis isn't known, but it's likely that many factors contribute. For instance, people with interstitial cystitis may also have a defect in the protective lining (epithelium) of the bladder. A leak in the epithelium may allow toxic substances in urine to irritate your bladder wall.

Other possible but unproven contributing factors include an autoimmune reaction, heredity, infection or allergy.

What are the treatments for interstitial cystitis (ic)/painful bladder syndrome (pbs)?

Diet

(Please see the later discussion of diet, "Are lifestyle modifications of value in managing interstitial cystitis?")

Oral medications

Oral medications that may be used to treat PBS/IC include antidepressants of the tricyclic group such as amitryptiline (Elavil). This is not due to a belief that PBS/IC is a psychological condition; rather, tricyclic antidepressants can help reduce the hyperactivation of nerves within the bladder wall. The antiseizure medication gabapentin (Neurontin, Gabarone) also has been used to treat nerve-related pain and has sometimes been used to treat the pain of IC/PBS. Oral antihistamines also may be prescribed to help reduce allergyic symptoms that may be worsening the patient's PBS/IC.

For patients who may not respond well to amitryptiline, another type of oral medication that can be used is the heparinoid (heparin-like) drug pentosan polysulfate sodium (PPS; brand name Elmiron). PPS is chemically similar to the substance that lines the bladder, and it is believed that PPS assists in the repair or restoration of the lining tissues in the bladder. Even after therapy with PPS has begun, patients may still experience symptoms for some time because the sensory nerves in the bladder have been hyperactive, and it takes time for the nerves to return to their normal state of activation. Therefore, doctors recommend giving up to one year of PPS treatment in mild PBS/IC (and two years in severe PBS/IC) before deciding if the drug is effective or not. Between one-third and two-thirds of patients will improve after three months of treatment.

For those individuals who are unable to sleep well because of the discomfort of PBS/IC, antihistamines such as hydroxyzine can be given to facilitate sleep.

Aspirin (Bayer) and ibuprofen (Advil) are sometimes used as a first line of defense against mild discomfort. However, they may make symptoms worse in some patients. Over-the-counter forms of phenazopyridine hydrochloride (Azo-Standard, Prodium, and Uristat) may provide some relief from urinary pain, urgency, frequency, and burning. Higher doses of the drug are available by prescription as Prodium and phenazopyridine (Pyridium).

Bladder distension

As mentioned previously, because some patients have noted an improvement in symptoms after bladder distension done to diagnose PBS/IC, bladder distension (termed hydrodistension) sometimes is used for therapy of PBS/IC. Bladder distension helps reduce symptoms in many patients with interstitial cystitis. (Studies have shown an improvement in 40-80% of patients.) When it is effective, the relief of symptoms persists for several weeks to months after the procedure. It is usually performed under anesthesia or heavy sedation, and some patients have a temporary worsening of symptoms following the procedure.

Bladder instillation (intravesical therapy)

This procedure may also be called a bladder wash or bath. During a bladder instillation, the bladder is filled with a solution that is held for varying periods of time, from a few seconds to 15 minutes, before being drained through a narrow tube called a catheter.

In severe cases of PBS/IC, intravesical solutions may be administered along with oral PPS to provide relief until the oral medication has had time to take effect.

Drugs that have been used for bladder instillations include dimethyl sulfoxide (DMSO, RIMSO-50), heparin, sodium bicarbonate, PPS, and hydrocortisone (a steroid).

Other surgical therapies for interstitial cystitis

In severe cases of PBS/IC that do not respond well to oral medications or to bladder distension or instillation, more invasive surgical procedures may be attempted. A procedure known as sacral neuromodulation has been shown to be effective in controlling symptoms in some people with PBS/IC. The term "neuromodulation" refers to an alteration of the nervous system. In sacral neuromodulation, a device is implanted that allows for electrical impulses to stimulate the nerves in the sacral (lower back) area. Sacral neuromodulation is believed to work by inhibiting the hyperactive signals from the sensory nerves within the bladder wall. For sacral neuromodulation, a wire from an electrical impulse generator is implanted in the sacral region of the spinal column. If there is relief of symptoms, the impulse generator can be implanted beneath the skin in the region of the buttocks. A remote control programmer allows the patient to adjust the impulse frequency and power to provide optimal relief of symptoms.

Therapies that also have been used include transcutaneous electrical nerve stimulation (TENS), a form of neuromodulation that does not involve surgical placement of wires or an impulse generator. With TENS, mild electric pulses enter the body for minutes to hours two or more times a day either through wires placed on the surface of the lower back or the suprapubic region, between the navel and the pubic hair, or through special devices inserted into the vagina in women or into the rectum in men. It is believed that the electric pulses may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of hormones that block pain. TENS is generally more effective in reducing pain than in reducing urinary frequency.

Other surgical procedures that may rarely be performed to treat severe PBS/IC include peripheral denervation (disrupting the nerves to the bladder wall), bladder augmentation to increase bladder capacity, and cystectomy (bladder removal) with diversion, or re-routing, of urine flow.

Are lifestyle modifications of value in the management of interstitial cystitis?

Diet

There is no scientific evidence linking diet to PBS/IC, but doctors and patients believe that certain foods, including alcohol, spices, chocolate, and caffeinated and citrus beverages, may contribute to bladder irritation and inflammation. Foods containing acid, for example, carbonated beverages, tomatoes, vitamin C, citrus fruits and beverages, vinegar, cranberries, strawberries, grapes, guava, mango, and pineapple also are believed to aggravate PBS/IC. Other foods that may increase symptoms because they contain the natural chemical tyramine include wine, beer, cheese, nuts, yogurt, bananas, soy sauce, chicken livers, raisins, sour cream, avocados, canned figs, corned beef, fava beans, brewers' yeast, and chocolate.

Some patients with PBS/IC also have noticed a worsening of symptoms after eating or drinking products containing artificial sweeteners. Patients may try eliminating such products from their diet and, if there is a reduction of symptoms, they can reintroduce them one at a time to determine which product seems to be aggravating their symptoms.

Smoking

Many PBS/IC patients feel that smoking worsens their symptoms. (Because smoking is the major known cause of bladder cancer, one of the best things a smoker can do for the bladder is to quit smoking.)

Exercise

Many PBS/IC patients feel that regular exercise helps relieve symptoms and, in some cases, hastens remission.

Bladder training

People who have found some relief from pain may then be able to reduce frequency using bladder training techniques. Methods vary but basically the patient decides to urinate at designated times and uses relaxation techniques and distractions to help keep to the schedule. Gradually, the patient lengthens the time between urinations. A diary usually is helpful in keeping track of progress.

What are the risk factors for interstitial cystitis (ic)/painful bladder syndrome (pbs)?

These factors are associated with a higher risk of interstitial cystitis:

  • Your sex. Women are diagnosed with interstitial cystitis more often than men. Symptoms in men may mimic interstitial cystitis, but they're more often associated with an inflammation of the prostate gland (prostatitis).
  • Your age. Most people with interstitial cystitis are diagnosed during their 30s or older.
  • Having a chronic pain disorder. Interstitial cystitis may be associated with other chronic pain disorder, such as irritable bowel syndrome or fibromyalgia.

Is there a cure/medications for interstitial cystitis (ic)/painful bladder syndrome (pbs)?

Interstitial cystitis, also known as painful bladder syndrome is a chronic condition that causes bladder pain, bladder pressure, and pelvic pain. The condition mostly affects women, creating a long-lasting impact on the quality of their life. Even though there is no cure, certain medications and other therapies may relieve the pain and symptoms.

Some appropriate treatments include,

  • Diet changes – Certain foods or drinks make the symptoms of Interstitial cystitis get worse. Hence, it is important to plan a diet, without the acidic foods that might irritate the bladder. Ensure to avoid alcohol, caffeine, carbonated beverages, chocolate, tomatoes and artificial sweeteners.
  • Physical therapy – Following physical therapy will train the pelvic muscles to hold the bladder in place and control urination.
  • Oral medications – Pentosan polysulfate sodium is an ideal drug to treat the pain caused by the condition. Moreover, muscle relaxants and drugs that treat heartburn can help in reducing symptoms. Amitriptyline is also prescribed to reduce pain and frequent urination in patients.
  • Surgery – Surgery is only recommended when the patient shows no improvement to other treatments and when the pain is unbearable. It will remove the parts of the bladder or even the entire bladder, depending on the severity of the condition.


Conditions
Reduced bladder capacity,Decreased quality of life,Problems in emotional well-being
Drugs
Amitriptyline,Pentosan (Elmiron),Hydroxyzine,Dimethyl sulfoxide (DMSO),Cyclosporine
Symptoms
Bladder pressure and pain while the bladder is filling,Pain in lower back, pelvis, urethra and abdomen,Frequent need for urination,Urinating in small amounts

Video related to interstitial cystitis (ic)/painful bladder syndrome (pbs)