Urology Book

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Interstitial Cystitis

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  1. Epidemiology
    1. U.S. Prevelance: 450,000 to 700,000 (52-67 per 100,000)
    2. Women account for 90% of patients
    3. Jewish persons account for 15% of patients
    4. Age Distribution
      1. Less commonly occurs in children
      2. Onset between ages 30 to 70 years old
      3. Patients under age 30 account for 25% of cases
      4. Median age: 40 to 43 years old
  2. Cause
    1. Unknown
  3. Pathophysiology
    1. Glycosaminoglycan deficiency in bladder mucin layer
      1. Hydrophilic layer is water barrier for urothelium
      2. Glycosaminoglycan deficiency disrupts protection
      3. Response to prior bacterial Urinary Tract Infection
    2. Allows urinary solutes to provoke inflammation
      1. Tissue irritation and injury
      2. Sensory nerve depolarization
      3. Mast cell degranulation
        1. Mast cells may also be abnormal
  4. Types
    1. Non-ulcer type of Interstitial Cystitis (90%)
    2. Severe Interstitial Cystitis with Hunner's Ulcers (10%)
  5. Symptoms
    1. Suprapubic Pain or Pelvic Pain
      1. Relieved with small volume voids
      2. Pain recurs with bladder filling
    2. Nocturia
    3. Excessive urinary urgency
      1. Uncomfortable constant urge to void
      2. Not relieved with voiding
    4. Urinary Frequency
      1. More than 8 voids per day
      2. Average: 16 voids per day
      3. Reported as high as 40 voids per day
    5. Symptoms persist over 9 months
      1. Symptoms not due to recent Urinary Tract Infection
      2. Symptoms worse during week before Menses
    6. Dyspareunia
    7. Gross Hematuria (20%)
    8. Incontinence suggests other diagnosis
  6. Signs
    1. Bladder capacity under 350 ml
    2. Urge to void occurs if bladder distended >150 ml
  7. Differential Diagnosis
    1. Tuberculous cystitis
    2. Radiation cystitis
    3. Genitourinary tumor
    4. Chemical cystitis
    5. Active Genital Herpes
    6. Chlamydia trachomatis infection
    7. Vaginitis
    8. Vulvar Vestibulitis
    9. Urethral diverticulum
    10. Neuropathic bladder dysfunction
    11. Endometriosis
      1. Contrast: Symptoms worse during menstruation
    12. Prostatitis
  8. Associated Conditions
    1. Major Depression (50%)
    2. Suicidal Ideation (relative risk: 3-4)
    3. Allergic disease
    4. Irritable Bowel Syndrome
    5. Vulvodynia
    6. Fibromyalgia
    7. Migraine Headache
    8. Endometriosis
    9. Chronic Fatigue Syndrome
    10. Chronic Pelvic Pain
      1. May be responsible for 33% of Chronic Pelvic Pain
      2. Clemons (2002) Obstet Gynecol 100:337
  9. Labs
    1. Urinalysis
      1. Microscopic Hematuria may be present
      2. Pyuria may be present
    2. Urine Culture sterile
    3. Urine Cytology
  10. Evaluation
    1. Careful examination including pelvic exam
    2. Patient keeps 24 hour log of voiding
    3. Urodynamic Studies
      1. Shows decreased bladder capacity
      2. Not specific for interstitial cystitis
    4. Cystoscopy
      1. Hydrodistention may relieve symptoms for months
      2. Hunner's Ulcers
        1. Mucosal Ulcers on bladder wall with granulation
        2. Brownish red ulcers involve all bladder wall layers
      3. Glomerulations on hydrodistention with saline
        1. Multiple petechial-like hemorrhages in mucosa
        2. May be seen in asymptomatic patients
        3. Blood tinged fluid occurs in 90% of patients
      4. Biopsy
        1. Evaluate for neoplasia, dysplasia or Tuberculosis
        2. Confirms bladder wall inflammation
        3. Identify subgroups (e.g. Eosinophil excess)
  11. Management: General
    1. Reassurance
      1. Not cancer
      2. Not indicator for more severe systemic disease
      3. Therapy is symptomatic not curative
    2. Avoid exacerbating foods
      1. Coffee
      2. Alcohol
      3. Carbonated beverages
      4. Citrus fruits or beverages
      5. Artificial Sweeteners
      6. Tomatoes
      7. Chocolate
    3. Chronic Pain Management adjuncts
      1. Support groups (See resources below)
      2. Transcutaneous electrical nerve stimulation (TENS)
      3. Physical Therapy with biofeedback
        1. Pelvic floor relaxation Exercises
  12. Management: First Line Medications
    1. Pentosan polysulfate (Elmiron) 100 mg PO tid
    2. Tricyclic Antidepressants
      1. Doxepin (Sinequan)
      2. Imipramine (Tofranil)
      3. Amitriptyline (Elavil)
        1. Start Elavil 25 mg qhs
        2. Increase every 2 to 4 weeks up to 150 mg maximum
    3. Hydroxazine (Atarax) 25-75 mg PO qhs
      1. May reduce mast cell degranulation symptoms
  13. Management: Other Medications
    1. Nifedipine XL (Procardia XL)
      1. Start: 30 mg PO qd
      2. Increase to 60 mg qd
    2. Cimetidine (Tagamet) 300 mg PO bid
    3. Aspirin
    4. Oxybutynin chloride (Ditropan)
    5. Phenazopyridine (Pyridium)
    6. Gabapentin (Neurontin)
  14. Management: Intravesicular Instillation
    1. Instillation Agents
      1. Dimethyl sulfoxide (Rimso-50) q1-2 weeks x4-8 times
      2. Heparin 10,000 Unit 3x/week (may potentiate Rimso-50)
      3. Hyaluronic acid 40 mg qWeek
      4. Bacillus Calmette-Guerin (BCG) qWeek x6 times
    2. Administration
      1. Initially performed in clinic via Urinary Catheter
      2. Patient may learn to self-catheterize for home
    3. Efficacy
      1. Long-term remission seen in >50% of patients
  15. Prognosis
    1. May be severely debilitating
    2. Waxing and waning course
  16. Resources
    1. Interstitial Cystitis Association
      1. http://www.ichelp.org
  17. References
    1. Jensen (1989) Urol Int 44:189
    2. Metts (2001) Am Fam Physician 64(7):1199
    3. Mobley (1996) Postgrad Med 99:201

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