Interstitial cystitis

Question 1

What is it?

Answer 1

Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called bladder pain syndrome and hypersensitive bladder syndrome.

There is no simple explanation for the symptoms, and the pathophysiology is likely a complex combination of various factors, including dysfunction of the blood vessels, nerves, immune system and epithelium.

It is much more common in women than men. It can have a significant impact on quality of life and mental health.

Question 2

Presentation

Answer 2

The symptoms are similar to a lower urinary tract infection, but are more persistent.

The typical presentation is more than 6 weeks of:

Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
Frequency of urination
Urgency of urination
Symptoms may be worse during menstruation

Question 3

Investigations

Answer 3

Other causes of symptoms need to be excluded, with:

Urinalysis for urinary tract infections
Swabs for sexually transmitted infections
Cystoscopy for bladder cancer
Prostate examination for prostatitis, hypertrophy or cancer

Hunner lesions, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

Granulations are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall.

Question 4

Management

Answer 4

Supportive management is used initially:

Diet changes such as avoiding alcohol, caffeine and tomatoes
Stopping smoking
Pelvic floor exercises
Bladder retraining
Cognitive behavioural therapy
Transcutaneous electrical nerve stimulation (TENS)

Oral medications may be helpful, including;

Analgesia
Antihistamines
Anticholinergic medications (e.g., solifenacin or oxybutynin)
Mirebegron (beta-3-adrenergic-receptor agonist)
Cimetidine (histamine-2-receptor antagonist)
Pentosan polysulfate sodium
Ciclosporin (an immunosuppressant)

Intravesical medication may be helpful, given directly into the bladder:

Lidocaine
Pentosan polysulfate sodium
Hyaluronic acid
Chondroitin sulphate

Hydrodistention involves filling the bladder with water, to high pressure, during a cystoscopy. It requires a general anaesthetic. This can give a temporary (3-6 month) improvement in symptoms.

Surgical procedures may be used, including:

Cauterisation of Hunner lesions during cystoscopy
Butulinum toxin injections during cystoscopy
Neuromodulation with an implanted electrical nerve stimulator
Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
Cystectomy (removal of the bladder)