Interstitial Cystitis

Interstitial cystitis is a chronic condition, which presents with pelvic pain, dysuria, frequency, dyspareunia and irritation symptoms similar to chronic urinary tract infections. On examination of the urine by microscopy and culture there is no bacteria. Some believe the condition to be an autoimmune reaction.¹

• Females to males ratio is about 9:1.
• Approximately one third of women with chronic pelvic pain syndrome referred for laparoscopy have interstitial cystitis.^2,3
• The condition is worse during menstruation.
• Individuals can have the condition for many years and there may be spontaneous resolution only to return days or months later.
• Many have endometriosis as well as interstitial cystitis.
• Increased risk includes sexual activity and perimenopause.

• Recurrent UTI type symptoms: lower abdominal pain, urgency, frequency, dysuria and dyspareunia.
• There is wide variation in symptoms between individuals and in any one individual over time.
• 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 bear little correlation with the clinical findings.
• Trials of antibiotic treatment do not cure the condition.

• Vaginal infection
• Non-specific urethritis
• Tuberculosis, chlamydia, genital herpes
• Endometriosis
• Bladder, pelvic cancer
• Pelvic irradiation
• Neurological disorders, e.g. multiple sclerosis
• Chronic prostatitis and prostate cancer⁴
• Crohn's disease and diverticulitis may cause similar symptoms

• MSU, urine cultures for tuberculosis.
• Cervical swabs for herpes and chlamydia.
• Most cases need cystoscopy to exclude bladder cancer. Hunner's ulcers (large areas of mucosal inflammation and damage) and submucosal haemorrhages in the trigone are present in about 90% of people with interstitial cystitis.
• Biopsies of the bladder wall do not show signs of infection.
• Men should have urethral swabs and prostatic secretion cultures (for chronic prostatitis).

• 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.

Non-Drug

• Precautions to reduce development of recurrent urinary tract infections may help to reduce some symptoms.
• Education about perineal cleaning, avoiding harsh soaps and antiseptics in the vulval area may help.
• Douches should be avoided as they tend to upset the protection offered by the normal vaginal flora.
• Use of simple (KY jelly) or hormonal (dienoestrol cream) lubricants if sexually active helps maintain the vaginal lining thus reducing some urethral irritation. Simple precautions like emptying the bladder after intercourse reduce the risk of introduction of bacteria per urethra.
• In chronic symptomatic cases aggravated by intercourse, advice about changing positions may need to be advised to help reduce symptoms.
• As some people report a reduction in symptoms following the distension of the bladder during diagnostic cystoscopy this can be the first therapeutic as well as a diagnostic step. There is belief that distending the bladder causes the nerve cells to be stretched and thus rendered inactive for a time.
• TENS (transcutaneous electrical nerve stimulation) helps in conjunction with other therapies. It has been of the most help in cases with Hunner's ulcers. The stimulators need to be placed on the lower back or the suprapubic area below the navel. Smokers do not respond as well to treatment as non-smokers.

Drugs

• Simple analgesic and anti-inflammatory action of ibuprofen helps in mild cases.
• Tricyclic antidepressants may be beneficial for pain relief.
• In highly motivated chronic sufferers, self-catheterisation and therapeutic DMSO (dimethyl sulfoxide) 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.⁵ Most people find improvement after 3-4 weeks of finishing treatment.
• H₂ antagonists such as Cimetidine have been found to help in some 60-70% of cases but the mechanism of action remains uncertain.^6,7
• In the severest of case 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.
• Some women improve on the oral contraceptive pill.⁸

Surgical

Urinary diversion may be resorted to in refractory cases but results are poor.⁹

• Prognosis and progress is uncertain due to the lack of knowledge of the mechanism of the illness.
• Some people do recover spontaneously, but in most cases symptoms of this remitting and relapsing condition can be kept under control.

• Some people do find some help from dietary avoidance of caffeine, citrus fruits and spicy food.
• Cranberry juice may be worth trying.