|
|
Interstitial Cystitis |
|
Interstitial cystitis (IC) is a chronic inflammatory condition
of the bladder that causes frequent, urgent, and painful
urination and pelvic discomfort. The natural lining of the
bladder (epithelium) is protected from toxins in the urine by
a layer of protein called glycoaminoglycan (GAG). In IC this
protective layer has broken down, allowing toxins to irritate
the bladder wall. The bladder then becomes inflamed and tender
and does not store urine well.
Unlike inflammation of the bladder caused by bacterial
infection (cystitis), which is associated with urinary tract
infections (UTI) and usually treated with antibiotics, no
infectious agent has been found in IC. Though not curable, IC
is treatable and most patients find some relief with treatment
and lifestyle changes.
Incidence and Prevalence
According to the National Institutes of Health (NIH), IC
affects about 700,000 people in the United States, 90% of
which are women. The average age of onset is 40 years.
Although only 25% of cases involve people under age 30, the
number of children affected by IC may be greater than commonly
believed. IC is often misdiagnosed, and sufferers may see
several doctors over the course of years before a diagnosis is
made. Increasing awareness of the disease is helping to speed
diagnosis and treatment.
Causes and Risk Factors
IC is a poorly understood disease with unknown causes.
Although no bacteria or viruses (pathogens) have been found in
the urine of IC sufferers, an unidentified infectious agent
may be the cause. Others believe that IC occurs with ischemia
(tissue death) or a deficiency of GAG in the epithelium. It
may be an autoimmune disease, in which the immune system
attacks healthy cells, perhaps following a bladder infection.
Spasms of the pelvic floor muscles may also contribute to the
IC symptoms. It is likely that several factors cause the
condition.
Other conditions associated with IC include the following:
 |
Asthma
|
|
|
Endometriosis
|
|
|
Food
allergies
|
|
|
Hay fever
(pollen allergy)
|
|
|
Incontinence
|
|
|
Irritable
bowel syndrome
|
|
|
Lupus
|
|
|
Migraine
|
|
|
Rheumatoid
arthritis
|
|
|
Sinusitis
|
The connection between IC and these
conditions is not understood.
IC may occur following gynecological surgery. Some evidence
suggests an increased risk for IC in Jews; and studies of
mothers, daughters, and twins who suffer from it suggest a
hereditary risk factor.
Signs and Symptoms
Interstitial cystitis manifests differently in patients. For
instance, some people experience chronic pelvic pain, while
others do not. Symptoms may intensify as the bladder fills and
diminish after urination. Classic symptoms include the
following:
|
|
Frequency—
urination may exceed 60 times in a 24-hour period
|
|
|
Pain —
chronic pelvic, vulvar, urethral, or abdominal discomfort
during urination and sex
|
|
|
Urgency—
sensation of having to urinate immediately, often
accompanied by bladder pain, pressure, or spasm
|
Symptoms usually worsen within the first 5
years and then level off. Patients with IC typically
experience periods of symptom flare, or intensification,
followed by periods of remission, when symptoms abate.
For men, symptoms may include pain and inflammation of the
prostate (prostatitis). Women may suffer increased vulvar
pain. Both men and women may experience pain in the perineum
(space between the vagina or scrotum and the anus) and painful
or uncomfortable sex, including intercourse and touching. For
some men, ejaculation may be painful.
Complications
Because of its chronic nature, frequently delayed diagnosis,
and the lack of a cure, IC causes psychological and social
problems that can affect family, work, and lifestyle:
|
|
Anxiety
|
|
|
Depression
|
|
|
Difficulty
traveling
|
|
|
Fatigue
|
|
|
Inability to
enjoy usual activities
|
|
|
Insomnia
|
|
|
Panic
|
|
|
Weight
fluctuation and eating disorders
|
Diagnosis
To diagnose IC, diseases that cause similar symptoms must be
ruled out. Urine culture and urinalysis are performed to test
for bacteria and signs of infection. In men, prostatic fluid
may also be cultured.
A cystoscopy with hydrodistention, performed under general
anesthesia, is the standard diagnostic procedure for IC. The
bladder is filled to capacity with water (commonly) or gas.
This allows a urologist to examine the epithelium with a
small, telescopic fiber-optic camera, or scope, that is
inserted through the urethra to the bladder. Glomerulations
(tiny hemorrhages that are the telltale sign of IC) are
revealed only while the bladder is distended. These
hemorrhages are present in 95% of IC cases.
Less frequently, epithelial ulcerations (Hunner’s ulcers),
lesions, and scars are found. Hunner’s ulcers are indicative
of IC, though hydrodistention is not needed to see them. A
biopsy, in which a tissue sample is removed and analyzed, is
performed to distinguish between ulcers and cancer and to
evaluate the presence of mast cells, which are sometimes seen
in abundance in IC-affected bladders. Some IC sufferers do not
have epithelial glomerulations or ulcers. Cystoscopy may also
reveal bladder stones, which can cause symptoms similar to IC.
Cystoscopy and hydrodistension are performed under anesthesia
because distending the bladder of an IC sufferer is painful
and otherwise causes urgent urination. However,
hydrodistension may have therapeutic effects. Some patients
repeat the procedure occasionally as treatment for IC because
it may temporarily alleviate pain and pressure.
The potassium chloride (KCl) sensitivity test (Parsons test)
is an experimental procedure used occasionally to test for IC
and evaluate a patient's potential response to treatments such
as Elmiron® that work on the bladder lining. A catheter is
used to instill the bladder with a potassium chloride
solution. The KCl solution is thought to reveal deficiencies
in the GAG layer of the bladder wall. The test is painful and
may be only 60% to 75% accurate. It is not yet widely accepted
as a diagnostic test for IC.
Differential Diagnosis
Several diseases and conditions have symptoms similar to IC.
They may be ruled out, diagnosed instead of IC, or found to be
coexistent:
|
|
Bladder
stones (urolithiasis)
|
|
|
Carcinoma of
the bladder in situ
|
|
|
Gynecological
disorders (endometriosis, ectopic pregnancy, fibroids,
ovarian tumor)
|
|
|
Inflammation
of the bladder (caused by chronic low-grade bacterial
cystitis, cyclophosphamide cystitis, tuberculosis
cystitis, radiation cystitis)
|
|
|
Kidney
disease (renal tuberculosis)
|
|
|
Neurological
disorders (multiple sclerosis)
|
|
|
Pelvic floor
dysfunction (PFD)
|
|
|
Prostatitis
(men)
|
|
|
Sexually
transmitted diseases (e.g., genital herpes, chlamydia)
|
|
|
Surgical
adhesions
|
|
|
Urethrocele
(bladder hernia into the vagina) or cystocele (tissue
growth arounthe urethra)
|
Treatment
There is no cure for IC; the goal of treatment is to relieve
symptoms. Often, treatment effectiveness wanes and a
replacement must be found through trial and error. Most
patients who suffer from IC find relief, usually with
multiple, complementary treatments.
Types of treatment include the following:
|
|
Biophysical
techniques – behavioral changes, stress management,
dietary changes
|
|
|
Medications
|
|
|
Surgery
|
|
|
Biophysical
Techniques
|
Biophysical techniques used to control IC
symptoms include bladder retraining, transcutaneous electrical
nerve stimulation (TENS), stress reduction with biofeedback,
diet modification, and exercise. Physical therapy for the
pelvic floor muscles may help decrease pain and spasms.
Bladder retraining is a self-help process in which patients
learn to control their urge to urinate. The theory behind
bladder retraining is that the bladder muscle actually weakens
with frequent urination because it is not allowed to distend
fully. Patients with IC experience the impulse to urinate
frequently because they have pain or urgency as the bladder
fills. Bladder retraining programs vary. Generally, the
patient schedules times for urination (a voiding schedule) and
uses a series of relaxation techniques and distractions to
help keep the schedule. The interval is progressively
lengthened, thus strengthening the bladder muscle. Bladder
retraining may be complicated by severe pain.
Transcutaneous electrical nerve stimulation (TENS)
TENS involves the application of mild electric pulses to the
body for minutes or hours a day. It is believed that the
electric pulses increase blood flow to the bladder, strengthen
pelvic muscles that aid in control, and trigger the release of
pain-blocking hormones. TENS therapy may help with IC pain,
though it may take a couple of months before any benefit is
realized. A TENS device is worn outside of the body, usually
near the sacral nerve.
Sacral Nerve Stimulation
The InterStim® device, used traditionally to treat
bladder-control problems, is being used experimentally in
preclinical trials to evaluate its effects on IC. It is
implanted under the skin of the lower back, near the sacral
nerve, where it delivers electrical pulses to the nerves
involved in bladder function. It may help control frequency
and urgency associated with IC, although the Food and Drug
Administration (FDA) has not approved it for IC therapy.
Stress reduction techniques, biofeedback, and exercise may
reduce the occurrence of flares by strengthening the muscles
of the pelvic floor. For some, exercise exacerbates symptoms
by irritating an already tender bladder or sore abdomen.
Diet
Many people find that eliminating acidic, spicy, and sugary
foods, as well as dairy products from their diet helps to
control symptoms. The Interstitial Cystitis Association (ICA)
provides a list of foods that may be problematic:
|
|
Beverages —
hard liquor, beer, wine, carbonated drinks, coffee, tea,
cranberry juice
|
|
|
Carbohydrates
and grains — rye and sourdough bread
|
|
|
Condiments —
seasonings, mayonnaise, miso, soy sauce, salad dressings,
vinegar
|
|
|
Dairy
products — aged cheese, sour cream, yogurt, chocolate,
milk
|
|
|
Fruits —
apples, apricots, avocados, bananas, cantaloupes, citrus
fruits, cranberries, grapes, nectarines, peaches,
pineapples, plums, pomegranates, rhubarb, strawberries,
fruit juices
|
|
|
Meats and
fish — aged, canned, cured, processed, or smoked meats and
fish, anchovies, caviar, chicken liver, corned beef, meats
containing nitrates or nitrites (e.g., ham, bacon)
|
|
|
Nuts
|
|
|
Others
substances — tobacco, caffeine, diet pills, junk food,
cold and allergy medication containing ephedrine or
pseudoephedrine, vitamins that contain fillers (especially
aspartate), tofu
|
|
|
Preservatives
and additives — benzol alcohol, citric acid, monosodium
glutamate, aspartame (Nutrasweet®), saccharine, artificial
ingredients and colors
|
|
|
Vegetables —
favabeans, lima beans, onions, tomatoes
|
Most IC patients have the least amount of
trouble with rice, potatoes, pasta, vegetables, and chicken.
Foods from the above groups that may be tolerable include the
following:
|
|
Beverages —
decaffeinated and acid-free coffee and tea, certain herbal
teas
|
|
|
Carbohydrates
and grains — breads other than rye and sourdough, rice \
|
|
|
Condiments —
garlic
|
|
|
Dairy
products — cottage cheese, white chocolate
|
|
|
Fruits —
melon other than cantaloupe, pears
|
|
|
Nuts —
almonds, cashews, pine nuts
|
|
|
Vegetables —
fresh, homegrown potatoes and tomatoes
|
Some find that over-the-counter dietary aids
such as Prelief®, which helps to make food less acidic, allow
them to eat many foods that would otherwise be intolerable.
Smoking worsens symptoms for some people; symptoms improve for
many after quitting.
Surgery
Surgery is typically performed only when other treatments fail
to provide relief. It may be ineffective and may worsen IC
symptoms.
Laser burning (fulguration) and surgical removal
(resection) are two methods used to remove Hunner’s ulcers
from the bladder in ulcerative IC. They are performed with a
cystoscope inserted through the urethra under general
anesthesia.
Urostomy involves creating a tube in the abdomen from
intestinal tissue, rerouting the tubes that carry urine from
the kidneys (ureters) to the tube, and connecting it to an
opening (stoma) in the abdomen. Urine then drains continuously
into a collection bag that can be emptied as necessary.
Alternatively, an internal pouch, known as a Koch, Florida, or
Indiana pouch, may be constructed from intestinal tissue to
hold urine from the ureters. The patient periodically drains
the pouch through the stoma with a self-administered catheter.
Bladder removal (cystectomy) may be performed with
urostomy and internal pouch procedures.
Augmentation cytoplasty is performed rarely in cases
where heavily scarred portions of the bladder need to be
removed, though it is not considered a standard treatment. A
section of intestinal tissue may be cut and shaped to replace
the damaged portion of the bladder. It is attached to the
remainder of the natural bladder so that urine can be stored
and expelled through the urethra.
A relatively new procedure known as orthotopic diversion
involves the removal of the entire bladder and the creation of
a new one from intestinal tissue. The new bladder is connected
to the urethra and works like a natural bladder. This allows
people to urinate through the urethra without the use of
catheters or collection devices.
Urgency, frequency, and phantom pelvic pain may remain
following surgery, even if the bladder is removed. Possible
risk factors and side effects, combined with the irreversible
nature of these procedures make many surgeons reluctant to
perform them and many patients wary of their effects. There is
a risk for IC to develop in transplanted intestinal tissue,
including that used to create an internal pouch. Normal
urination may be impossible or difficult and
self-catheterization may be necessary. Also, there is a risk
for urinary incontinence (involuntary urination), especially
with orthotopic diversion.
Some research suggests that putting urine in contact with
intestinal tissue is risky. Infections, disturbances in
metabolism, and problems with the mucosal lining of the bowel
tissue may occur. Long-term kidney damage is also associated
with these procedures.
Interstitial cystitis (IC) is a chronic
inflammation of the urinary bladder. Naturopathic treatment
involves inhibiting the inflammatory process by removing
inflammatory and irritating foods from the diet, taking
nutritional supplements, and using herbal support.
Nutrition
The importance of nutrition cannot be overstated and changing
to a healthy diet may help relieve symptoms.
Eliminate food sensitivities, which are often the cause of
chronic inflammatory conditions. To determine food
sensitivities, use an elimination and challenge diet.
Eat whole, fresh, unrefined, and unprocessed foods. Include
fruits, vegetables, whole grains, beans, seeds, nuts, olive
oil, and cold-water fish (salmon, tuna, sardines, halibut, and
mackerel).
Avoid sugar, dairy products, refined foods, fried foods, junk
foods, some beans (fava, lima, black, soy) and caffeine.
Coffee, chocolate, alcohol, carbonated drinks, citrus fruits,
and tomatoes often worsen symptoms.
Drink ½ of your body weight in ounces of water daily (e.g., if
you weigh 150 lbs, drink 75 oz of water daily).
Supplements
Calcium citrate alkalinizes the urine, which decreases
irritation to the bladder.
Bromelain provides anti-inflammatory action. Take away from
food.
Herbal Medicine
Herbal medicines usually do not have side effects when used
appropriately and at suggested doses. Occasionally, an herb at
the prescribed dose causes stomach upset or headache. This may
reflect the purity of the preparation or added ingredients,
such as synthetic binders or fillers. For this reason, it is
recommended that only high-quality products be used. As with
all medications, more is not better and overdosing can lead to
serious illness and death.
The following herbs may be used to treat IC:
Gotu kola (Centella asiatica) — Take 30 mg
standardized extract triterpenes 3 times a day. It enhances
the integrity of connective tissue by stimulating production
of glycosaminoglycans, which are an integral component of the
protective mucous layer in the bladder.
Herbs to consider as a tea:
|
|
Buchu (Barosma
betulina) — A soothing diuretic and antiseptic for the
urinary system.
|
|
|
Cleavers (Galium
aparine) — Traditionally used as a urinary tract tonic.
|
|
|
Corn silk (Zea
mays) — Has soothing and diuretic properties.
|
|
|
Horsetail
(Equisetum arvense) — An astringent and mild diuretic with
tissue
healing properties.
|
|
|
Marshmallow
root (Althea officinalis) — Has soothing demulcent
properties. It is best taken as a cold infusion; soak the
herb in cold water for several hours, strain, and drink.
|
|
|
Usnea (Usnea
barbata) — Has soothing and antiseptic properties.
|
Homeopathy
A trained homeopathic practitioner is needed to diagnose and
prescribe a deep-acting, constitutional remedy. The standard
dosage for acute symptom relief is 3 pellets of 30C every 4
hours until symptoms resolve. Lower potencies, such as 6X, 6C,
30X, may be given every 2 to 4 hours. If the right remedy is
chosen, symptoms should improve shortly after the second dose.
If there is no improvement after 3 doses, a different remedy
is given.
The following remedies may be effective in treating IC:
Apis mellifica — Indicated for stinging pain that is
worse with heat.
Cantharis — Indicated for intolerable urgency with burning,
scalding urination.
Staphysagria — Indicated for a urinary tract infection
that is the result of sexual intercourse.
Sarsaparilla — Indicated for pain that burns after
urination has stopped.
Physical Medicine
Castor oil packs can be applied for IC that has associated
bladder cramping or pelvic discomfort.
|
|
|
