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Interstitial Cystitis

By

Patrick J. Shenot

, MD, Thomas Jefferson University Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
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Interstitial cystitis is noninfectious bladder inflammation that causes pain (suprapubic, pelvic, and abdominal), urinary frequency, and urgency with incontinence. Diagnosis is by history and exclusion of other disorders clinically and by cystoscopy and biopsy. With treatment, most patients improve, but cure is rare. Treatment varies but includes dietary changes, bladder training, pentosan, analgesics, and intravesical therapies.

Incidence of interstitial cystitis is unknown, but the disorder appears to be more common than once thought and may underlie other clinical syndromes (eg, chronic pelvic pain). Whites are more susceptible, and 90% of cases occur in women.

Cause is unknown, but pathophysiology may involve loss of protective urothelial mucin, with penetration of urinary potassium and other substances into the bladder wall, activation of sensory nerves, and smooth muscle damage. Mast cells may mediate the process, but their role is unclear.

Symptoms and Signs of Interstitial Cystitis

Interstitial cystitis is initially asymptomatic, but symptoms appear and worsen over years as the bladder wall is damaged. Suprapubic and pelvic pressure or pain occurs, usually with urinary frequency Urinary Frequency Urinary frequency is the need to urinate many times during the day, at night (nocturia), or both but in normal or less-than-normal volumes. Frequency may be accompanied by a sensation of an... read more (up to 60 times/day) or urgency. These symptoms worsen as the bladder fills and diminish when patients void; in some people, symptoms worsen during ovulation, menstruation, seasonal allergies, physical or emotional stress, or sexual intercourse. Foods with high potassium content (eg, citrus fruits, chocolate, caffeinated drinks, tomatoes) may cause exacerbations. Tobacco, alcohol, and spicy foods may worsen symptoms. If the bladder wall becomes scarred, bladder compliance and capacity decrease, causing or worsening urinary urgency and frequency.

Diagnosis of Interstitial Cystitis

  • Clinical evaluation

  • Cystoscopy with possible biopsy

Treatment of Interstitial Cystitis

  • Lifestyle modification

  • Bladder training

  • Drugs (eg, pentosan polysulfate sodium, tricyclic antidepressants, nonsteroidal anti-inflammatory drugs [NSAIDs], dimethyl sulfoxide instillation)

  • Surgery as a last resort

Lifestyle modification

Up to 90% of patients improve with treatment, but cure is rare. Treatment should involve encouraging awareness and avoidance of potential triggers, such as tobacco, alcohol, foods with high potassium content, and spicy foods.

Choice of treatment

In addition to lifestyle modification, bladder training, drugs, intravesical therapies, and surgery are used as needed. Stress reduction and biofeedback Biofeedback For biofeedback, a type of mind-body medicine, electronic devices are used to provide information to patients about biologic functions (eg, heart rate, BP, muscle activity, skin temperature... read more (to strenghten pelvic floor muscles, eg, with Kegel exercises) may help. No treatment has been proved effective, but a combination of 2 nonsurgical treatments is recommended before surgery is considered.

Drug therapies

The most commonly used drug is pentosan polysulfate sodium, a heparin-like molecule similar to urothelial glycosaminoglycan; doses of 100 mg orally 3 times a day may help restore the bladder’s protective surface lining. Improvement may not be noticed for 2 to 4 months. Intravesical instillation of 15 mL of a solution containing 100 mg of pentosan or 40,000 units of heparin plus 80 mg of lidocaine and 3 mL of sodium bicarbonate may benefit patients unresponsive to oral drugs. Tricyclic antidepressants (eg, imipramine 25 to 50 mg orally once a day) and NSAIDs in standard doses may relieve pain. Antihistamines (eg, hydroxyzine 10 to 50 mg once before bedtime) may help by directly inhibiting mast cells or by blocking allergic triggers.

Dimethyl sulfoxide instilled into the bladder through a catheter and retained for 15 minutes may deplete substance P and trigger mast cell granulation; 50 mL every 1 to 2 weeks for 6 to 8 weeks, repeated as needed, relieves symptoms in up to one half of patients. Intravesical instillation of bacille Calmette-Guérin (BCG) and hyaluronic acid are under study.

Surgical and other procedures

Bladder hydrodistention, cystoscopic resection of a Hunner ulcer, and sacral nerve root (S3) stimulation help some patients.

Surgery (eg, partial cystectomy, bladder augmentation, neobladder, and urinary diversion) is a last resort for patients with intolerable pain refractory to all other treatments. Outcome is unpredictable; in some patients, symptoms persist.

Key Points

  • Interstitial cystitis is noninfectious bladder inflammation that tends to cause chronic pelvic pain and urinary frequency.

  • Diagnosis requires exclusion of other causes for symptoms (eg, UTIs, pelvic inflammatory disease, chronic prostatitis or prostatodynia, diverticulitis), cystoscopy, and biopsy.

  • Cure is rare, but up to 90% of patients improve with treatment.

  • Treatments can include diet modification, bladder training, and drugs (eg, pentosan polysulfate sodium, tricyclic antidepressants, NSAIDs, dimethyl sulfoxide instillation).

  • Surgery is a last resort for patients with intolerable pain refractory to all other treatments.

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