Clinical Review

The generalist’s guide to interstitial cystitis

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How to diagnose and treat all but refractory cases of this not-so-uncommon disease


 

References

The typical patient voids 16 times a day and 2 or more times at night. In later stages of the disease, she may urinate as often as 60 times a day and every half hour at night, severely eroding her ability to hold a job, travel, or lead a normal life. In fact, her quality of life may be impaired as much as that of a person with end-stage renal disease.1,2 She sees an average of 4 doctors and endures irritative voiding symptoms for 4 years before her disease is identified. The cause is unknown.

Interstitial cystitis produces a wide spectrum of symptom severity, occurring episodically with spontaneous flare-ups and remission, or with continuous, intractable urinary urgency and pain. Until recently, women presenting with urinary urgency, frequency, and pain were presumed to have a urinary tract infection (UTI) or overactive bladder, and were often treated—to no avail—with multiple courses of antibiotics or anticholinergics.

Fortunately, interstitial cystitis is gaining recognition, and effective treatments are emerging. Usually the ObGyn—often the first physician a woman consults—need refer only the refractory cases to a specialist. This article describes the components of diagnosis and the most effective treatments, including use of the first-line agents amitriptyline (Elavil) and pentosan polysulfate sodium (Elmiron).

CASE Is overactive bladder the cause of stubborn symptoms?

“R.H.,” a healthy 48-year-old G2P2 with a 5-year history of urinary urgency and frequency, reports that she voids “at least 15 times per day.” She denies any urge incontinence, but says she experiences occasional stress incontinence if she has a bad cold. Four years ago, she saw a urologist for these symptoms, after her husband said he was tired of having to stop the car so she could go to the bathroom. The urologist diagnosed a “small bladder,” performed urethral “stretching,” and prescribed oxybutynin.

Her symptoms improved for about 6 months, but then progressed and have now worsened. She began taking tolterodine, 4 mg daily, 2 months ago, as prescribed by her primary care physician. The sensation of painful urgency has eased, but there has been no change in frequency. R.H. used to wake as often as 4 times a night with the urge to urinate, but since she began taking zolpidem tartrate (Ambien) as a sleep aid, she now wakes only 2 times every night.

Why are her symptoms so persistent?

This woman’s case is a classic example of interstitial cystitis masquerading as overactive bladder. Treatment with anticholinergic drugs may ease urgency symptoms slightly, but has no real effect on frequency.

This case has 5 hallmarks of the syndrome of interstitial cystitis:

  1. Urgency
  2. Frequency (more than 8 voids/day, taking fluid intake into account)
  3. Bladder pain
  4. Nocturia (more than twice)
  5. Absence of a genitourinary tract infection

Patients show signs of “battle fatigue”

Women with interstitial cystitis may be anxious, depressed, angry, and sleep-deprived. In some women, stress exacerbates the urinary symptoms and pain (as do certain common foods and beverages, especially citrus, tomatoes, and caffeine).

Approximately 60% of patients report dyspareunia, and many report chronic pelvic pain. In fact, 75% of women who report chronic pelvic pain also have irritative voiding symptoms. Therefore, it is important to ask about lower urinary tract symptoms whenever a woman presents with pelvic pain.3,4

Pain may be suprapubic, vaginal, perineal, or originate in the groin or lower back. Although 16% of patients present solely with pain, and 30% have only urinary frequency, most patients suffer from both symptoms.

Approximately 40% report premenstrual or ovulatory exacerbation of symptoms, although symptoms may improve during pregnancy.5 Voided volumes are usually small, despite the strong urgency, which does not always resolve. Pelvic pain may ease after voiding but recurs shortly.

Insidious, worsening course

Symptoms appear insidiously and worsen to a “final” stage within 5 to 15 years, at which point a plateau is reached with little further progression.6 Some experts suggest that the disease be classified as “early non-ulcerous” or “classic ulcerous.”

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