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Interstitial Cystitis

Interstitial cystitis can be frustrating and difficult to deal with. I have found that the biggest benefit of learning about interstitial cystitis is better treating patients who have been told that they have endometriosis and they have negative laparoscopies and poor responses to Lupron. If you look even at advertisements for chronic pelvic pain in our usual green and gray journals, they will show very nicely demonstrated Lupron as an empiric therapy for endometriosis and pelvic pain is basically eighty percent endometriosis and everything else is insignificant. Whether that is true or not, it does not mean that we have the problem solved. It also means that there are other factors contributing to pelvic pain.

The diagnostic criteria is simple: urgency, frequency, negative urine culture, pain or discomfort of the pelvic bladder, perineum and dyspareunia. Symptoms will also be prominent in patients who have seasonal allergies and at the times of flares of their allergic rhinitis, they will also potentially notice a flare of their interstitial cystitis.

Here is a description of the pathophysiology that makes sense to me and this is the basis for our treatment as well. We see here an interrupted bladder mucosa with the GAG layer (the glycosaminoglycan superficial cell layer on the superficial cells of the mucosa) fairly intact here, but showing quite a bit of disruption. To me, at least in terms of pathology, that could easily be

So we have this nerve overdrive brought on by potassium and literally damage to the tissues from the free radical effect of the potassium itself. Clinically, the patient has flares and remissions. You will give them some doxycycline and they will feel great and they will think that was the cure, when in fact that was the placebo. As I said, perimenstrual flares are common. Intercourse will frequently result, even if it is tolerable, in a flare after intercourse or direct dyspareunia against the bladder neck. Diet is an extremely good indicator in picking up patients, especially younger patients who have sensitivity to certain foods.

Here is a way of measuring symptom severity that correlates very well to disease. It is a simple questionnaire. People who score highly on the symptom index are very different from the controls who don't have the clinical diagnosis of interstitial cystitis and even having them take this history and asking those questions can be a predictor of disease. You do a pelvic exam to rule out other causes of pelvic pain.

Treatment includes dietary modification; there are some specific diets that are easily available to reduce the offending agents. Bladder retraining, just as you do to help somebody retrain to get normal bladder capacity is important. Drug intervention includes intravesical as well as oral administration. Cystoscopy and hydrodistention are an initial surgical therapy. We won't talk about augmentation or substitution. Intravesical treatment with DMSO once a week for 

This is frequently combined with an anti-inflammatory, such as Kenalog and a local anesthetic. I have had patients do self catheterization and administer heparin to themselves on a daily basis; it can be done as few as three times a week as a means of managing their problem.

Nowadays we hear a lot about Elmiron; this is a drug that actually helps build up the lining to help protect the deep tissue of the vaginal wall from potassium - at least, that is purportedly how it works. It is a large molecular weight product that is almost entirely excreted into the urine.

The problem is that it takes three months to see a decent effect. Dr. Parsons would say that this is the only drug that has ever been clinically shown to have an objective optimal outcome in a placebo controlled trial for interstitial cystitis. DMSO, I believe, is the only drug that is FDA-approved for interstitial cystitis. Seventy-four percent of patients report a greater than fifty percent improvement in their pain after three months. If you continue the therapy longer, you start picking up more patients with relief and more of a positive response. So it is kind of a chronic therapy to allow the bladder to heal after the insult.

Antihistamines are another option, specifically Atarax, which is a mast-cell stabilizer rather than the typical Claritin or other antihistamines.