Interstitial Cystitis - Urinary Tract Disorders

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).

Pathophysiology

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).

Clinical Manifestations

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).

Assessment and Diagnostic Findings

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.

Medical Management

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.

PHARMACOLOGIC THERAPY

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 THERAPY

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).

Nursing Management

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