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Bladder Pain Syndrome (Interstitial Cystitis): Understanding and treating

Pain, General, Women's Health | July 23, 2014 | Author: The Super Pharmacist

Pain, women's health

Bladder Pain Syndrome (Interstitial Cystitis): Understanding and treating

Bladder pain syndrome, or interstitial cystitis (BPS/IC), is a condition characterised by pain and/or other abnormalities in the course of bladder function, i.e. urination. The symptoms may be variable between patients, and may vary for an individual patient over time. These may include:

  • Pain in the bladder area, with or without radiation outward into the rest of the pelvic region
  • Urinary urgency (i.e. extreme pressure or drive to urinate)
  • Urinary frequency
  • Pain before urinating
  • Urinary hesitancy (i.e. difficulty initiating a stream of urine)
  • Nocturia, i.e. sleep interruptions caused by the need to urinate
  • Pain during sexual intercourse

BPS/IC is often considered a chronic illness, and can be recurrent, i.e. the symptoms may recede and then return in 'waves'. The condition is associated with a significant decrease in the quality of life of the individuals affected. Women are approximately ten times more likely to develop this condition, which affects people of all ages and socioeconomic groups.

What Causes Bladder pain syndrome, or interstitial cystitis?

Bladder pain syndrome, or interstitial cystitis is diagnosed when all other common explanations for bladder pain and dysfunction have been ruled out; in other words, it is an exclusion diagnosis.

Therefore, BPS/IC may be a syndrome caused by a combination of factors - or by a single factor that has somehow eluded scientific detection to this day.

BPS/IC is not strongly associated with microbial infection, although patients may have had a history of urinary tract infection. However, symptom 'waves' are not associated with the presence of bacteria.

Other criteria for BPS/IC include a positive response to a diagnostic bladder distention (see below). Essentially, the precise cause of this condition is not currently defined or understood. There are a number of prominent theories under investigation by the research community that may explain the illness.

These include:

Hyper-reactive Bladder

This theory is based on observations of an overlap of symptoms between BPS/IC and other similar conditions that involve abnormally frequent bladder function, e.g. overactive bladder syndrome (OAB).

Therefore, the condition may be based on abnormalities in the neurological regulation of this organ.

This is supported by the presence of increased nerve growth factor (NGF) - an important protein with a central role in the regulation of neural activity - in the urine of BPS/IC patients, and a possible link between this and the intensity of pain symptoms.

In addition, nerve damage and other types of neurological dysfunction are associated with BPS/IC.

Bladder Lining Damage/Dysfunction

A number of cell layers make up the surface of the bladder. Damage to the innermost layers of these - known as the bladder lining - is strongly associated with BPS/IC (this is the basis of the term 'interstitial cystitis'). Again, the cause of this has not been conclusively defined. Some researchers conclude that the damaged tissue may then come into contact with certain chemicals found in urine, which results in irritation, thus explaining BPS/IC symptoms. This damage may be associated with ulceration of the lining but again it is not clear whether this is a cause or a symptom of BPS/IC.

Autoimmune Component

An increasing body of evidence supports the theory of BPS/IC as an autoimmune disorder. This is a condition in which the immune system of the body attacks its own tissues, causing damage and disease. Mast cells, an immune cell type that releases histamine to destroy its targets, have been detected in the course of attacking bladder lining cells in samples taken from patients.

Psychological Component

BPS/IC is also commonly associated with psychiatric or psychological conditions, such as stress, anxiety and depression. Therefore, the condition may be comorbid with, or a symptom of, some similar mental health disorders. On the other hand, life quality impairments may be associated with depressive symptoms (such as the tendency to react to pain with disproportionate negativity) - i.e. the presence of a psychological disorder may simply influence the effects of BPS/IC.

Genetic Factors

There is some evidence that BPS/IC may be associated with specific mutations or changes in certain genes. 

In addition, BPS/IC accompanied with anxiety disorders may be associated with other specific genetic factors. 

In addition, certain foods or beverages have been identified as probable risk factors for BPS/IC development or persistence.

Possible risk factors

  • Beverages containing caffeine, e.g. coffee, tea
  • Carbonated beverages
  • Alcoholic beverages
  • Citrus fruits
  • Artificial sweeteners
  • Chili peppers

As there is no consistent aetiology of BPS/IC, treatment is mainly based on interventions that are associated with the management of symptoms.

Treatment Options

There are many treatments available for BPS/IC, which are recommended systematically based on the severity and persistence of an individual patient's symptoms. These include:

Patient Education. The education of patients about their BPS/IC, the most probable risk factors and how to avoid them, has been shown to be beneficial and to improve life quality in many cases. Patient education is often recommended in conjunction with behavioural modifications.

Behavioural Modifications. These are a range of lifestyle changes a patient may make in order to combat their symptoms. They may include avoiding dietary triggers, anxiety or stress. These are also associated with successful reduction of BPS/IC symptoms, and the concomitant effects on life quality.

Physical Therapy. This may include massage or manipulation therapy of the bladder or pelvic region. This can significantly improve BPS/IC symptoms by regulating pain, urinary frequency and/or urinary urgency.

Pharmacotherapy. These are drug therapies associated with the effective treatment of BPS/IC symptoms.

PharmacotherapyPharmacotherapy options include:

  • Amytriptiline
  • Pentosan polysulphate sodium,
  • Hydroxyzine
  • Cyclosporine A (via injection into the bladder (or intravesical injection), which inhibits abnormal function)
  • Botulinum toxin-A (i.e. Botox), which is currently under investigation as another intravesical application
  • Triamclinone injections
  • Dimethyl sulphoxide (DMSO), via instillation (i.e. A type of injection into the bladder so that the drug coats the inner lining of the organ)

Neurological Interventions. Some treatments are based on the stimulation or modulation of affected nerves, to disrupt or modify signals they transmit to the brain, which processes and perceives these as pain. Electrical nerve stimulation has been applied to BPS/IC treatment (i.e. to important nerves in the region that control bladder function and/or pain perception, e.g. the sacral nerve) with promising results. In addition, sacral neuromodulation (devices surgically implanted in the body, which emit consistent electrical modulation to a nerve) has demonstrated significant reductions in symptoms, and improvements in quality of life for BPS/IC patients. There are several advantages to neuromodulation, such as the fact that it is minimally invasive and demonstrates long-term success. Therefore, it may be a viable treatment option for patients with recurrent symptoms who have not responded to the conventional treatments mentioned above.

Bladder Distention. This is an artificially-induced increase of bladder capacity, usually done under general anaesthesia. Bladder distention is associated with medium-term pain relief in BPS/IC patients, although it is not clear how the procedure treats the condition. It is possible that distention somehow alleviates pressure or damage to nerves in the area.

Surgery. Bladder surgery is usually the last line of treatment for patients with very severe, intransigent symptoms. This may take the form of surgical denervation (i.e. to permanently inhibit pain or urinary urgency), bladder reconstruction, or urinary diversion (in which case the bladder may be removed). Reconstruction is achieved using tissue from the gastrointestinal tract. Surgery may reduce pain and urgency significantly, and also increase bladder capacity.

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