INTERSTITIAL
CYSTITIS
Interstitial cystitis, a chronic inflammatory condition of
thebladder wall, frequently remains undiagnosed. The cause is un-known and no
treatment is effective for all patients, although sev-eral treatments are
available and most patients obtain some relief. More than 700,000 Americans
have interstitial cystitis. It can occur at any age and in all ethnic groups
and both genders, al-though 90% of those affected are women. The average age at
onset is 40, although one in four people affected is under age 30 at onset of
symptoms. Preliminary results of studies of men with nonbacterial prostatitis
indicate that many of them may also have interstitial cystitis (Interstitial
Cystitis Association, 2001).
Although
no single theory can explain the disorder, several pathophysiologic mechanisms
may cause it, including changes in epithelial permeability, pelvic floor
dysfunction, mastocyto-sis, activation of C-fibers, increase of nerve growth
factors, and bradykinin. A decrease in the glycosaminoglycan (GAG) layer on the
urothelium is thought to be a possible cause (Doggweiler-Wiygul, Blankenship
& MacDiarmid, 2001).
Interstitial
cystitis is characterized by severe, irritable voiding symptoms (day and night
frequency, nocturia, urgency), pain and discomfort (suprapubic pressure, pain
with bladder filling, supra-pubic or perineal pain and pressure), and a
markedly diminished bladder capacity. Some patients void more than 60 times a
day. Sexual intercourse is often painful (Doggweiler-Wiygul et al., 2001).
Patients
commonly present with multiple health problems that may be difficult to
diagnose and may be associated with changes in the immune system. Patients with
chronic fatigue syn-drome, fibromyalgia, and temporomandibular disorder share
many clinical illness features such as myalgia, fatigue, sleep dis-turbances,
and impaired ability to perform activities of daily living as a consequence of
these symptoms. Research findings suggest that various other chronic illnesses
and pain syndromes may be associated with interstitial cystitis, including
irritable bowel syndrome and chronic tension-type headache (Aaron, Burke &
Buchwald, 2000).
The
diagnosis is made by excluding other causes of the symp-toms. Diagnosis is
complicated because there are no definitive di-agnostic criteria. As a result,
several years may pass and patients see an average of four or five physicians
before the definitive di-agnosis is made. The lack of more specific diagnostic
criteria does not mean that interstitial cystitis is psychologically based;
rather, it is a physical disorder with psychological consequences. Many
patients have difficulty coping with the lack of a diagnosis, the in-ability of
health care professionals to provide an explanation for their symptoms, and the
persistence of symptoms.
Treatment
strategies include use of medications that target pain and discomfort. Other
therapies are used with the goal of repair-ing the bladder wall or their
anti-inflammatory effects.
In
1996, the FDA approved the use of a bladder protectant, pen-tosan polysulfate
sodium (Elmiron), which is given orally. Since its introduction, Elmiron has
been the most effective agent; it is the only oral agent in its class.
Intrabladder instillation of various compounds (eg, silver nitrate, dimethyl
sulfoxide, oxychlorosene [Clorpactin]) may provide relief. About 50% of
patients respond favorably to intravesicular instillation of dimethyl
sulfoxide. Anti-spasmodic agents, such as oxybutynin (Ditropan), and urinary
mucosal anesthetic agents, such as phenazopyridine (Pyridium), may be useful.
Intravesicular heparin has some effect in decreas-ing symptoms in half of
patients. Patients must be able to self-catheterize to instill the heparin on a
daily basis initially, then three or four times weekly. Tricyclic
antidepressant medications (doxepin and amitriptyline), which have central and
peripheral anticholinergic actions, may decrease the excitability of smooth
muscle in the bladder and reduce pain and discomfort.
Other
treatments include transcutaneous electrical nerve stimula-tion (TENS) and
destruction of ulcers with laser photoirradiation. Percutaneous sacral nerve
stimulation is a means of neuromodu-lation to decrease the pelvic area pain and
irritable bladder symp-toms. Some women with intractable interstitial cystitis
respond favorably to percutaneous sacral stimulation, with a significant
im-provement in pelvic pain, daytime frequency, nocturia, urgency, and average
voided volume. Permanent sacral implantation can be an effective treatment
modality in refractory interstitial cystitis; further long-term evaluation is
required, although initial results are promising (Interstitial Cystitis
Association, 2001).
Often,
the patient has experienced symptoms for a prolonged time. These symptoms
prevent the patient from carrying out nor-mal activities of daily living. The
patient has usually been treated by a number of health care providers, often
with little relief of symptoms. As a consequence, the patient may feel
depressed, anx-ious, distrustful, and skeptical about proposed treatments
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