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Synonyms: interstitial cystitis/painful bladder syndrome, painful bladder syndrome, bladder pain syndrome, hypersensitive bladder syndrome
Interstitial cystitis is a chronic bladder condition of unknown cause characterised by pelvic pain, dysuria, urinary frequency, urgency of micturition, and pressure in the bladder and pelvis. Some believe the condition to be an autoimmune reaction. Interstitial cystitis has been defined as a disease of the urinary bladder diagnosed by:
- Lower urinary tract symptoms
- Bladder pathology, eg Hunner's ulcer on the bladder wall, and mucosal bleeding after overdistension
- Exclusion of other possible causes for the presenting symptoms, eg infection, malignancy and calculi of the urinary tract
- The exact prevalence is unknown because of misdiagnosis. Although once thought to be rare, interstitial cystitis is now believed to have a much higher prevalence.
- Females to males ratio is reported as about 9:1. However, it is claimed that many more men have interstitial cystitis than is appreciated and are often misdiagnosed as having other conditions such as prostatitis. It has also been reported that interstitial cystitis can occur in children.
- Approximately one third of women with chronic pelvic pain and referred for laparoscopy have interstitial cystitis.
Symptoms vary widely in severity and nature but the onset of symptoms is often acute and may be sudden.
- Recurrent symptoms similar to urinary tract infections (urgency, frequency, dysuria), lower abdominal pain, pressure in the bladder and/or pelvis, and dyspareunia.
- In women the symptoms are often worse during menstruation.
- There is wide variation in symptoms between individuals and in any one individual over time.
- It may be recurrent and persistent in some, resulting in the bladder becoming scarred and small.
- Examination may be normal apart from suprapubic tenderness.
- The severity of the symptoms bears little correlation with the clinical findings.
- Trials of antibiotic treatment do not cure the condition.
- Associated chronic illnesses include endometriosis, inflammatory bowel disease, systemic lupus erythematosus, irritable bowel syndrome, fibromyalgia and allergy disorders.
- Associated psychiatric conditions include anxiety disorder, depression and adjustment reactions.
Other causes of urinary frequency, urgency of micturition and pelvic pain, including:
- Infection or other inflammatory conditions, eg recurrent urinary tract infection, urethral diverticulum, infected Bartholin's gland, tuberculous, bacterial or viral vaginitis, schistosomiasis
- Gynaecological, eg pelvic malignancy, uterine fibroid, endometriosis, mittelschmerz (ovulation pain), pelvic inflammatory disease, genital atrophy
- Urological, eg bladder cancer, radiation cystitis, overflow incontinence, chronic pelvic pain syndrome, bladder outlet obstruction, urolithiasis, urethritis, chronic prostatitis, prostate cancer
- Neurological, eg detrusor overactivity, Parkinson's disease, lumbosacral disc disease, spinal stenosis, spinal tumour, multiple sclerosis, cerebrovascular disease
- Others include inflammatory bowel disease, gastrointestinal neoplasm, diverticulitis,and adhesions from previous surgery
The diagnosis of interstitial cystitis is usually based on typical symptoms and exclusion of other causes.
- Urinalysis and midstream urine for urine cultures: rule out urinary tract infection, including tuberculosis.
- Cervical swabs for herpes and chlamydia.
- Urodynamic studies: there are no specific findings but pain with bladder filling that reproduces the symptoms is very supportive of a diagnosis of interstitial cystitis.
- Most cases need cystoscopy to exclude bladder cancer. Hunner's ulcers (large areas of mucosal inflammation and damage) may be seen but are uncommon.
- Biopsies of the bladder wall do not show signs of infection.
- Men should have urethral swabs and prostatic secretion cultures (for chronic prostatitis).
- Management is often difficult and only partially effective. Early diagnosis and management is important.
- The cause of the condition is unknown and there is no one treatment that helps everybody.
- Treatment is mainly symptomatic and supportive.
- Management consists of finding the best combination to suit the patient.
- Behavioural therapy: biofeedback, pelvic floor exercises and bladder training programmes may be effective.
- Diet: there is no evidence for specific dietary measures but alcohol, tomatoes, spices, chocolate, caffeinated and citrus drinks and acidic foods may contribute to bladder irritation and inflammation.
- Some people report a reduction in symptoms following distension of the bladder during diagnostic cystoscopy. There is belief that distending the bladder causes the nerve cells to be stretched and thus less sensitive for a time.
- Transcutaneous electrical nerve stimulation (TENS) helps in conjunction with other therapies.
- Ibuprofen and tricyclic antidepressants may be beneficial for pain relief.
- In highly motivated chronic sufferers, self-catheterisation and therapeutic dimethyl sulfoxide (DMSO) is instilled into the bladder, retained for fifteen minutes and then voided. Treatments are repeated every two weeks for 8-week cycles and may help to reduce frequency and urgency. Most people find improvement after 3-4 weeks of finishing treatment.
- H2-receptor antagonists such as cimetidine have been found to help in some 60-70% of cases but the mechanism of action remains uncertain.
- In the severest of cases, strong opiates are needed for pain relief. Again, because of the chronic nature of the problem, the lowest dose possible in conjunction with other therapies is advisable.
- Anticholinergic agents (eg oxybutynin, tolterodine) reduce urinary frequency but can impair bladder emptying and so exacerbate pelvic pain. They should therefore be used with caution in patients with interstitial cystitis.
- Some women improve on the oral contraceptive pill.
- Sacral nerve stimulation (neuromodulation) has been shown to be effective in patients with refractory interstitial cystitis.
- Urinary diversion may be resorted to in refractory cases but results are poor.
- The prognosis is very variable from complete resolution of symptoms within months, a waxing and waning course, completely asymptomatic with intermittent flares, or a chronically progressive course of increasing symptoms over several years.
- Some people do recover spontaneously, but individuals may have the condition for many years and there may be spontaneous resolution only to return days or months later.
- Interstitial cystitis can have a significant and even profound effect on quality of life.
Further reading & references
- Rovner E, Propert KJ, Brensinger C, et al; Treatments used in women with interstitial cystitis: the interstitial cystitis data base (ICDB) study experience. The Interstitial Cystitis Data Base Study Group. Urology. 2000 Dec 20;56(6):940-5.
- Cystitis and Overactive Bladder Foundation
- Interstitial Cystitis Association
- Oravisto KJ, Alfthan OS; Treatment of interstitial cystitis with immunosuppression and chloroquine derivatives. Eur Urol. 1976;2(2):82-4.
- International Painful Bladder Foundation (IPBF)
- Rosenberg MT, Newman DK, Page SA; Interstitial cystitis/painful bladder syndrome: symptom recognition is key to Cleve Clin J Med. 2007 May;74 Suppl 3:S54-62.
- Rovner ES; Interstitial Cystitis; eMedicine, November 2009.
- Clemons JL, Arya LA, Myers DL; Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol. 2002 Aug;100(2):337-41.
- Gousse AE, Tiguert R, Madjar S; Current investigations and treatment of interstitial cystitis. Curr Urol Rep. 2000 Oct;1(3):190-8.
- Moldwin RM; Similarities between interstitial cystitis and male chronic pelvic pain syndrome. Curr Urol Rep. 2002 Aug;3(4):313-8.
- National Kidney and Urologic Diseases (US); Interstitial Cystitis/Painful Bladder Syndrome
- MaLossi J, Chai TC; Interstitial cystitis: diagnosis and treatment options. Curr Womens Health Rep. 2002 Aug;2(4):298-304.
- Sun Y, Chai TC; Effects of dimethyl sulphoxide and heparin on stretch-activated ATP release by bladder urothelial cells from patients with interstitial cystitis. BJU Int. 2002 Sep;90(4):381-5.
- Dasgupta P, Sharma SD, Womack C, et al; Cimetidine in painful bladder syndrome: a histopathological study. BJU Int. 2001 Aug;88(3):183-6.
- Morales A, Emerson L, Nickel JC; Treatment of refractory interstitial cystitis. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7(4):215-20.
- Peters KM, Konstandt D; Sacral neuromodulation decreases narcotic requirements in refractory interstitial BJU Int. 2004 Apr;93(6):777-9.
- Lentz GM, Bavendam T, Stenchever MA, et al; Hormonal manipulation in women with chronic, cyclic irritable bladder symptoms and pelvic pain. Am J Obstet Gynecol. 2002 Jun;186(6):1268-71; discussion 1271-3.
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Dr Colin Tidy
Dr Colin Tidy