When to suspect interstitial cystitis
The symptom profile and comorbidities associated with this painful condition can make it difficult to diagnose—unless you know what to look for.
Hydroxyzine is an H1 RA with mild anxiolytic and antiallergy properties. In an open-label study of IC/BPS patients with allergies (n=37), it was found to reduce symptoms by 55%.39
Is there a role for dietary supplements? In developing its new recommendations for IC/BPS, the AUA did not review studies of dietary supplements.31 The Interstitial Cystitis Association (ICA), however, includes information on its Web site about a number of dietary supplements that may be helpful in controlling symptoms (https://www.ichelp.org/Page.aspx?pid=635).
One such product contains aloe vera, which the ICA describes as having anti-inflammatory actions that have been found to reduce IC/BPS symptoms.40 Another is a dietary supplement that the author (TCT) developed, which contains quercetin, a flavonoid with anti-inflammatory properties, as well as chondroitin and hyaluronate—components of the glycosaminoglycan protective layer in the bladder that may be damaged in patients with ICS. In an open label study of 127 patients with refractory symptoms of IC/BPS, this supplement produced a 51% response rate (P<.0001).41
Pain management is particularly challenging
Intense chronic pain is the most difficult aspect of IC/BPS to treat. Tramadol, an opioid with weaker addiction potential and fewer adverse effects than morphine, is often helpful. Gabapentin, an antiseizure drug, and pregabalin, a similar drug recently approved for fibromyalgia, may also be useful. A fentanyl patch, as well as belladonna and opium suppositories, may be used under the care of a pain management specialist.
If these pain regimens fail, urologists often try intravesical approaches, such as bladder hydrodistension under anesthesia, which has been found to provide short-term (up to 5.3 months) symptom relief in 30% to 50% of patients.4,42,43 Intravesical treatments, in which medication is directly instilled into the bladder, are frequently used, especially in patients with severe symptoms.44
Intravesical dimethylsulfoxide (DMSO) may be given once a week for 6 weeks, but instillation often hurts and DMSO causes the patients to smell of garlic, which severely limits compliance. In one randomized double-blind study involving 11 patients with classic IC/BPS (ie, with Hunner’s ulcers) and 10 IC/BPS patients without Hunner’s ulcers, DMSO reduced urinary frequency and pain only in those with classic cases.45
Intravesical hyaluronate sodium, given in weekly instillations for 4 weeks, resulted in some pain reduction in 2 open-label studies,4 but in a subsequent randomized, double-blind, placebo-controlled, multicenter study, instilling 10 times the amount of hyaluronate failed to show any benefit and was terminated by the sponsor (Seikagaku Corp., written correspondence, March 2004). In one small study, intravesical hyaluronate and chondroitin, given weekly for 20 weeks and then monthly for 3 months, led to significant improvement in frequency, urgency, and pain.46
In a multicenter trial, intravesical instillation of lidocaine, together with sodium bicarbonate, led to 30% improvement, compared with the controls.47 (Such intravesical “cocktails” are often supplemented with other agents, such as heparin or hydrocortisone.)
Other options for refractory pain include intravesical laser ablation, fulguration of bladder lesions, intravesical injections of botulinum toxin, and neuromodulation of the sacral or pudendal nerve via an implanted impulse generator.
CASE After the urologist confirmed Jan’s diagnosis, she returned to your office for treatment. Jan was started on dietary modification, hydroxyzine (50 mg at bedtime), and physical therapy. She had a 50% reduction in symptoms after 3 months of therapy.
CORRESPONDENCE
Theoharis C. Theoharides, MD, PhD, FAAAAI, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111; theoharis.theoharides@tufts.edu
