Clinical Review

When treating interstitial cystitis, address all sources of pain

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Dietary modification, oral and intravesical agents, and even physical therapy may be necessary to render the pain of interstitial cystitis and painful bladder syndrome manageable


 

References

Dr. Howard is a speaker and consultant for Ortho Women’s Health and Urology and a consultant for Ethicon Women’s Health and Urology.

In Part 1 of this article, I discussed an actual case of interstitial cystitis and painful bladder syndrome (IC/PBS) that was diagnosed in our clinic. That diagnosis was challenging, made over a period longer than 1 year. Regrettably, such a delay is not unusual—especially in patients who already have another diagnosis, such as endometriosis, as was true in that case.

Once a diagnosis of IC/PBS has been made, the first, crucial step is educating and involving the patient in her diagnosis and treatment, as she is more likely to accept the need for chronic, multimodal therapy. As I mentioned in Part 1, early diagnosis may be especially important. Response to treatment in patients who have a short duration of symptoms (less than 2.5 years) is 75% to 80%, and treatment often leads to clinical remission.

Here, I lay out the numerous treatment modalities the clinician can draw from to manage this complex disease. Therapy generally involves dietary manipulation, urothelial therapy such as intravesical heparin or oral pentosan polysulfate sodium (PPS), and a tricyclic antidepressant for its neurolytic properties. Second-line therapies include mast-cell stabilization with antihistamines and other neurolytic agents.

The only FDA-approved treatments, however, are intravesical dimethylsulfoxide (DMSO) and oral PPS.

Eliminate as many sources of pain as possible

IC/PBS is a complex chronic pain syndrome, so it is critical to identify all potential sources of pain, or pain generators, and to eliminate or treat as many of them as possible. The goal of this approach is to decrease the volume of nociceptive input to the dorsal horn. Although we lack substantial supporting evidence, the hope is that this approach may allow the dorsal horn and central nervous system to “down-regulate” and potentially normalize, or at least allow pain-modulating mechanisms to “gate” the noxious stimuli arriving at the dorsal horn and decrease the intensity of pain. This approach leads to a need for multimodal therapy in most patients.

Dietary changes may help

Patients who have IC often report exacerbation of symptoms with the intake of certain foods or fluids, suggesting that dietary modification or restriction may be therapeutic (TABLE). More than 50% of patients report exacerbation of symptoms with acidic foods, carbonated drinks, alcoholic beverages, and caffeine. The elimination of these foods and beverages often results in significant improvement of symptoms. Calcium glycerophosphate (Prelief) prevents food-related exacerbation in about 70% of patients.

TABLE

Foods that may irritate the urinary tract

Alcoholic beverages
Apple and apple juice
Cantaloupe
Carbonated drinks
Chili and similar spicy foods
Chocolate
Citrus fruit
Coffee
Cranberry and cranberry juice
Grape
Guava
Peach
Pineapple
Plum
Strawberry
Sugar
Tea
Tomato and tomato juice
Vinegar
Vitamin B complex

DMSO may ease symptoms, but treatment can be painful

DMSO (RIMSO-50) was the first drug approved by the FDA for treatment of IC. It is approved for intravesical instillation, which can be performed in the office. A small urethral catheter (8–12 French) is inserted, and the bladder is emptied. A 50-mL volume of 50% DMSO is instilled, and the catheter is removed. After waiting 15 to 30 minutes, the patient voids. Treatments are usually repeated at 1- to 2-week intervals.

Some patients find DMSO treatment painful. In that case, a pretreatment dose of ibuprofen (800 mg orally), naproxen sodium (550 mg orally), or ketorolac tromethamine (10 mg orally) may be considered.

Some patients complain of significant irritation and burning of the urethra with DMSO. For them, the urethra may be anesthetized with 2% topical lidocaine. In addition, the catheter may be left inside the urethra and clamped during the 15 to 30 minutes of treatment, allowing emptying of the DMSO via the catheter before removal. In the 10% of patients who experience painful bladder spasms, anticholinergic medications or belladonna and opium suppositories may provide relief.

All patients note a garlic-like odor of breath and taste in the mouth for 24 to 48 hours after DMSO therapy, due to excretion via the respiratory system as dimethylsulfide. This can be personally and socially unpleasant for the patient, so it is critical that she be counseled about this side effect beforehand.

DMSO has very low systemic toxicity. However, it has been reported to be teratogenic in animal studies, so its use in pregnancy is contraindicated.

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