Interstitial cystitis

Background

• Chronic bladder disorder
• About 3-6% prevalence in adult women

Clinical Manifestations

• Pelvic pain with urinary symptoms, such as urinary frequency (the most common presenting complaint), urgency, or nocturia
  • The pain is often described as discomfort, pressure, burning, sharp
  • The pain is typically suprapubic but may be referred to other parts of the pelvis, including the urethra, vagina, labia, inguinal area, perineum, or lower abdomen or back
• Sterile pyuria
• Often worse a few days before onset of menses
• Occurs episodically, with flares triggered by stress, intercourse, menses, or diet
  • Dietary triggers include coffee, alcohol, citrus fruits, tomatoes, carbonated beverages, and spicy foods
• May have a classic Hunner's ulcer or lesion seen on cystoscopy
  • Have more severe symptoms

Differential Diagnosis

Disease	Distinguishing Features
Endometriosis	pain worse during menses (rather than a few days prior)
Non-infectious cystitis	history of radiation, NSAID unse, cyclophosphamide, or ketamine use
Vulvar disorders	pain only during voiding (when urine contacts vulva) and/or pain with sex
Overactive bladder syndrome	responds to antimuscarinics; patients void to avoid incontinence (rather than to relieve pain)
Pudendal nerve entrapment	positional; worse with sitting
Prostate disorders	pain during or after ejaculation, pain on prostate examination
Pelvic floor disorders	trigger point, fascial, or muscle pain and tenderness; spasms on palpation

Diagnostic Criteria

• An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable causes1

Management

• Non-pharmacologic management, including education, dietary modification, and sexual counselling
• Management based on specific phenotype
  • Urinary: bladder training, anticholinergics, intravesical agents (heparin, DMSO, hyaluronic acid, chondroitin sulfate, PPS, oxybutynin), hydrodistension, botulinum toxin A, sacral neuromodulation, radical surgery
  • Psychosocial: stress management and psychological support
  • Organ-specific
    • Non-Hunner's: amitriptyline, cimetidine, hydroxyzine, PPS, quercetin, intravesical agents (DMSO, heparin, hyaluronic acid, chondroitin sulfate, alkalinized lidocaine, PPS), hydrodistension, botulinum toxin A, radical surgery
    • Hunner's: cyclosporine A, endoscopic treatment (fulguration, laser, resection, steroid injection), hyperbaric oxygen, radical surgery
  • Infectious: antimicrobials
  • Neurologic: gabapentinoids, hydroxyzine, cimetidine, sacral neuromodulation
  • Tenderness: pelvic floor physiotherapy, massage, acupuncture, trigger point injections

Medication	Dose	Notes
Alkalanized lidocaine	intravesicular
Amitriptyline	25 to 75 mg p.o. qhs
Chondroitin sulfate (CS)	intravesicular
Cimetidine	400 mg p.o. bid
Cyclosporine A	2 to 3 mg/kg divided bid
Dimethylsulfoxide (DMSO)	intravesicular
Gabapentin	300 to 2100 mg p.o. divided tid
Heparin	intravesicular
Hyaluronic acid (HA)	intravesicular
Hydroxyzine	10 to 50 mg p.o. qhs
Oxybutynin	intravesicular
Pentosan polysulfate (PPS)	100 mg p.o. tid; or intravesicular	monitor for maculopathy
Quercetin	500 mg p.o. bid

Further Reading

• CUA guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Can Urol Assoc J. 2016;10(5-6):E136-E155. doi: 10.5489/cuaj.3786