INTERSTITIAL CYSTITIS (IC) OR PAINFUL BLADDER SYNDROME

This is a poorly understood condition, which millions of people suffer from around the world. Two thirds of these are women.  Here we will focus mainly on women. They suffer from pain in the bladder area (that is why it is also called bladder pain syndrome or BPS). There is pain in the inner thighs, back ache, chronic pelvic pain, pain on passing urine, need to pass urine frequently without much urine in the bladder. There is no bladder infection. The problem must be going on from 6 weeks to 6 months. The Bladder is the bag where the urine collects from the kidneys, when it is full the brain sends a message to pass urine. Normally it is not painful; except when there is a bladder infection. However IC or BPS the frequency of going to the toilet 50 – 60 times during a 24hr period, middle of meetings or odd times makes sex life distorted, due to exaggeration of symptoms for several days following sex.  Even more pain during menstruation and any kind of stress, acidic type of food, strawberries, lemons, oranges, coffee, and chocolate.  It is commonly believed that cranberry juice helps urinary symptoms but in fact it makes IC worse all this makes life very difficult for women. There are many conditions, which cause symptoms similar to IC that women suffer with and some of these are Irritable bowel syndrome, Endometriosis, Sexually transmitted infections, kidney disease, bladder cancer or stone, chronic fatigue, fibromyalgia, multiple sclerosis, emotional behavioural and sexual dysfunction consequences.  Many of these are quite serious. What causes IC is not understood. There is some genetic predisposition, female sex, fair skin, red hair, chronic pain disorders, some kind of autoimmune problem (that is when the body attacks itself). Can it be Hormonal, as it is more common in females?  Is this a viral or unknown infection?  There are defects  seen in the bladder mucosa, it is not  clear, if it is the cause or the result of the disease, a leak  from these  areas  irritates the bladder by the substances in the urine.

Many researchers believe that a substance called, antiproliferative factor (Substance that can interfere with healing, APF) found in the urine of people, with IC hinders the healing of the damaged mucosa of the bladder. In fact these researchers are seeking to use APF as a biomarker for IC. Many other conditions need to be excluded before we start thinking of IC. Some of these are, as already mentioned others can be radiation treatment, drugs that may have caused allergy to the bladder, pelvic floor disorders, damage or entrapment of pelvic nerves, vulvodynia, (pain in the vulval area without any obvious infection or skin disease) prolapse of pelvic organs, vulval or vaginal or cervical pathology, pelvic masses such as ovarian disease, and trigger points causing pain tenderness and muscle spasm.  

For making a diagnosis history is very important. It must be going on for 6 weeks to 6 months, take a family history, any radiation any drugs or any other problems. It is most important to exclude any bladder infection at present and during this time. Do a urine culture and urine cytology, this will exclude any infection or cancer cells. A clinical pelvic examination can exclude any prolapse, vaginal, vulval, uterine and often ovarian pathology.  In IC the bladder base is tender on an internal examination. Another test that is that can be performed is called Urodynamics. This can measure the bladder pressure and its capacity, women with IC start feeling the pain very soon after it starts to fill and get a desire to pass urine. The other test that is done by a few   doctors but not recommended by everyone is a Potassium solution test. In this test, water is used to fill the bladder followed by a potassium solution and in women with IC; filling with potassium solution is very painful. The other test called a Cystoscopy needs to be done by a specialist gynaecologist, urologist or urogynaecologist. In this test the bladder is instilled with fluid and then examined by a Fibroptic light with a Telescope. 

This shows petechial haemorrhages in the bladder wall (small pinpoint bleeding, also called Glomerulations) in different quadrants of the bladder, reddened mucosa, submucosal bleeding, and mucosal disruption, oedema with or without bleeding. This is diagnostic of some forms of IC. Depending on these finding IC is classified into four grades. Then, there are striking reddened patches on the bladder wall called Hunners ulcers. 

This finding also suggests another type of IC. Hunners areas, decreases the bladder capacity due to fibrosis and is more distressing than the one with minute haemorrhages.  A bladder biopsy is taken from these ulcers; this shows inflammation, mast cells that can cause severe allergic reaction, fibrosis and granulation. There is a questionnaire about pelvic pain frequency (PPF) and urgency of micturition which is filled by the client and if the score is 10 or more it is in favour of IC. It has been shown that the Clinicians under diagnose IC by a large percentage because they do not always think of IC in women suffering from chronic pelvic pain.
This  is  difficult  to  understand  what  causes  all  these  problems? The main question is; what is the solution? This depends on the age, severity, and how much stress is it causing and interfering with the quality of life.  

For a start, self help is required, stop the trigger factors, stress, foods that upset IC, smoking, meditation, yoga, planned breaks for toilet, gentle stretching exercises and restrict drinks before bed time. Physiotherapy for pelvic floor muscles, psychotherapy, proper bladder retraining.  Some drugs such as simple paracetamol, non steroidal anti inflammatory drugs (NSAIDS), antihistamines (anti allergy drugs) and antidepressants have all   been tried. Some tablets that help to relax the bladder are tried in more serious cases

There is one special tablet called, Pentosan Polysulphate Sodium which is an oral medication which is tried in many clinics. It takes 2-6 months to help.  Pain relief takes the longest time .First it is tried for 3 months and then for further 3 months. Its side effects are minimal nausea, headaches, dyspepsia and liver dysfunction, these are all reversible. They probably act by mast cell deregulation, immunological and neurological effects. These down regulate the activity of the sensory fibres that take the pain sensation to the brain. There are also drugs that are instilled into the bladder weekly for 6-8 weeks and then 2-5 weeks to relieve the pain and relax the bladder for three months. These are called Dimetylsulfoxide (DMSO). Some clinicians mix Heparin and Lidocaine( a local anaesthetic) for better relief of symptoms. Nerve stimulation technique is also tried by a Tens Machine, or Sacral Nerve Stimulation by a device similar to a Pacemaker called InterStim.

In some cases surgery is tried by electro  cautery or laser for  the bladder ulcers, resection of  the  abnormal area, Sub mucosal   injection. In rare situations enlarging the bladder size by using the gut is performed, but this does not help with pain. Extremely rare situations bladder is replaced by a bowel loop. There are many such techniques; this requires very special surgeons and special care of the urinary diverted loops or opening stoma. On a simpler front acupuncture and herbal remedies are tried.

Interstitial cystitis is a very stressful condition which mainly affects women causing pain, urgency and frequency of micturition in absence of any infection of the blabber or any other discernible pathology. There is no definitive treatment for IC. It cannot be cured. A combination of treatments goes a long way to relieve symptoms. Treatment is generally started in simple ways.  Progressively more and more complicated procedures are performed to help a very distressed woman.