Interstitial Cystitis
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)
Painful Bladder Syndrome
Disease Description
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by pain during or immediately after urination, or pelvic discomfort related to the bladder, accompanied by frequency, urgency, and nocturia. The disease affects mainly women, with an incidence of 5.2-50/10,000 in women compared to 0.8-4.1/10,000 in men. The pathophysiology involves a combination of factors: urothelial dysfunction, chronic inflammation, neuronal hyperactivity, mast cell activation, and a deficiency in the glycosaminoglycan (GAG) layer in the bladder mucosa.
There are two main subtypes: IC/BPS with Hunner lesions (Hunner type), an inflammatory condition with pancystitis and epithelial changes, and IC/BPS without Hunner lesions (non-Hunner type), with minimal if any histological changes.
Risk factors
Studies indicate several significant risk factors:
- Gastrointestinal factors: irritable bowel syndrome (IBS) - odds ratio (OR) of 2.9
- Urological factors: recurrent urinary tract infections - OR of 3.2
- Autoimmune diseases and psychiatric conditions
- Genetic background: 0.35 correlation in IC/BPS scores in identical twins
- Other factors that have been associated with this disease include: advanced age, fibromyalgia, frequent headaches, drug allergies, and history of physical abuse
Diagnosis
The clinical diagnosis is based on history, physical examination, and urinalysis
Clinical criteria: unpleasant sensation (pain, discomfort, pressure, burning) that worsens with bladder filling and improves with emptying, for at least 3 months, In the absence of other diagnoses that explain the symptoms.
Basic tests:
- Detailed anamnesis including documentation of urinary frequency, urgency, location and severity of pain
- Physical examination including a brief neurological examination
- Urinalysis and urine culture (negative for infection)
- Documentation of dyspareunia and menstrual relationship in women
Advanced tests (not required for direct diagnosis):
- Cystoscopy with hydrodistension - recommended in suspected Hunner lesions or when the diagnosis is in doubt
- Urodynamic tests - not a test required for diagnosis except in cases where there is suspicion of uromechanical obstruction or detrusor dysfunction
Treatment
The treatment of IC/BPS is multimodal and individualized:
Conservative treatments:
- Dietary changes and fluid restriction
- Pelvic floor physiotherapy
- Treatment Cognitive-behavioral
- Oral drug therapy:
Pentosan polysulfate sodium (PPS) - the only drug approved by the FDA, but attention should be paid to the risk of pigmentary maculopathy
Amitriptyline - proven efficacy in reducing pain and discomfort
Cyclosporine A - highly effective in studies, especially in reducing pain and discomfort
Hydroxyzine (antihistamine)
Certolizumab pegol - in clinical development
- Intravesical therapies:
Dimethyl sulfoxide (DMSO) - the only intravesical therapy approved by the FDA
Botulinum toxin A - high probability of being the best treatment according to GRA
Chondroitin sulfate, Heparin, Lidocaine
Invasive therapies:
- Sacral or pudendal neuromodulation
- Pulguration or triamcinolone injection (electrical or chemical burn) For Hunner lesions
- Surgery (ileocystoplasty) - as a last resort
Prognosis
The prognosis is variable but more encouraging than commonly thought
- Long-term improvement: Approximately 47% of patients report an improvement of more than 50% in symptoms, and 12% are completely symptom-free at an average follow-up of 16.6 years
- Response to treatment: Approximately 80% of patients report significant to moderate improvement at long-term follow-up
- Positive prognostic factors: mild IC/BPS at baseline, high bladder capacity (≥760 ml), low glomerular filtration rate (few petechiae after hydrodistension)
- Negative prognostic factors: presence of Hunner lesions (improvement rate of only 36.8%), concomitant chronic fatigue syndrome
- Pregnancy: does not affect the course of the disease
Gynecological considerations
It is important to recognize the diseases Common gynecological comorbidities:
- Endometriosis/adenomyosis: Prevalence of up to 70% in women with IC/BPS
- Pelvic floor dysfunction: Prevalence of 50-87%
- Vulvodynia/vestibulodynia: Affects 25% of women with IC/BPS
- Sexual dysfunction
- Hormonal changes in the urogenital region
A multidisciplinary approach including a urologist, gynecologist, pelvic floor physiotherapist, and pain specialist is optimal for comprehensive treatment.
