Interstitial Cystitis Flashcards
1
Q
Interstitial cystitis definitions
A
- An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, assoc. w/ lower urinary tract symptoms of more than 6wks duration, in the absence of infection or other identifiable causes
- Bladder pain syndrome/intersititial cystitis (BPS/IC) is a condition diagnosed on a clinical basis and consists of chronic pelvic pain often exacerbated by bladder filling and assoc. w/ urinary freq.
- IC is a chronic, yet manageable, inflammatory bladder condition characterized by recurring discomfort or pain in the bladder and/or pelvic region
2
Q
Interstitial cystitis diagnosis
A
- Diagnosis of exclusion
- There is no specific test or marker that is diagnostic
3
Q
Interstitial cystitis symptoms
A
- Complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night time freq., in the absence of proven urinary infection or other obvious pathology
- Recurrent UTIs w/ neg. cultures
4
Q
Most common comorbidity among interstitial cystitis pts.
A
- Allergies and irritable bowel
5
Q
Difference b/w IC and an overactive bladder?
A
- IC presents w/ pain
6
Q
IC physical exam findings
A
- Bladder neck tenderness
- Suprapubic tenderness
- Levator ani tenderness
- Cervical motion tenderness
- Posterior vaginal tenderness
- Rectal tendernesse
7
Q
IC initial work-up
A
- Initial assessment consits of a freq/volume chart, focused physical exam, urinalysis, and urine culture
- Cytology and cystoscopy are recommended if clinically indicated
8
Q
Mast cells and IC
A
- Have freq been reported to be assoc. w/ IC, both as a pathogenetic mechanism and as a pathognomonic marker
- Mast cells are strategically localized in the urinary bladder close to blood vessels, lymphatics, nerves and detrusor smooth muscle
- Studies strongly suggest that IC is a syndrome w/ neural, immune, and endocrine components in which activated mast cells play a central, although not primary, pathogenetic role in many pts.
9
Q
O’Leary-Sant IC symptom and Problem Index Questionnaire and the Pelvic Pain and Urgency/Frequency (PUF) Questionnaire
A
- Assess the pt. for the likelihood of IC
- Consider IC if O’Leary score is >6
- Consider IC if PUF score is >10
10
Q
Glomerulations and IC
A
- The finding of glomerulation on hydrodistention is variable and not consistent w/ clinical presentation
- Absence of glomerulation can lead to false neg. assessment of pts who present w/ clinical findings consistent w/ IC/BPS
- Seen in many clinical situations
*radiation therapy, defunctionalized bladders, bladder cancer, chemotherapeutic or toxic drug exposure, normal bladders
11
Q
Hunner’s Ulcer
A
- A pos. finding that can confirm the diagnosis of IC in pts who meet the definition criteria
- Are very painful
- Acute phase (inflamed, friable, denuded area)
- Chronic phase (blanched, non-bleeding area)
- Provides a therapeutic option
*can cauterize or inject them w/ steroids
12
Q
Antiproliferative Factor
A
- Frizzle-related peptide growth inhibitor
- Produced by the urothelium of pts w/ IC
- Found in bladder urine but not in renal pelvic urine
- May prove to be the most accurate marker of PBS/IC when confirmed by other centers
- Appears to have the highest sensitivity and specificity of the variety of possible markers tested and fits nicely into an etiologic schema
*94% and 95% respectively
13
Q
Antiproliferative factor physiological function
A
- Seems to have role in increasing cell permeability
- Induces reversible inhibition of HBEGF production and normal bladder epithelial cell proliferation
14
Q
KCl (potassium chloride) challenge
A
- An intravesical injection of KCl comparing the sensory nerve provocative ability of sodium vs. potassium
- Pain and provocation of symptoms constitutes a pos. test
- Used as a diagnostic test for IC, the KCl test is not valid
- Too painful for pts. so has been done away w/
15
Q
IC conservative treatment options
A
- Pt. educ. and reassurance
- Timed voiding, voiding diary, behavioral therapy where freq. primary symptom
- Stress reduction
- Biofeedback, pelvic massage
16
Q
IC diet
A
- Diet composed of foods to avoid to help ameliorate symptoms of IC
Avoid:
- Caffeine
- Alcohol
- Spicy foods
- Artificial sweeteners
- Foods high in citric acid
17
Q
Second line IC treatments
A
- Manual physical therapy
- Multimodal pain management
- Oral medications
- Intravesical medications
18
Q
Oral medications for IC
A
- Amitriptyline
- Cimetidine
- Hydroxyzine
- Pentosanpolysulfate
19
Q
Intravesical medications for IC
A
Medications are instilled into the bladder via catheter
- DMSO
- Heparin
- Lidocaine
-
20
Q
Amitriptyline
A
- Has become a staple of oral treatment for IC
- Central and peripheral anticholinergic actions at some sites (inhibiting neural activation)
- Block the active transport system in the presynaptic nerve ending that is responsible for the reuptake of the released amine neurotransmitters serotonin and noradrenaline
- They are sedative, an action that occurs presumably on a central basis but perhaps is related to their antihistaminic properties
21
Q
Sodium pentosanpolysulfate
A
- Trade name: Elmiron
- Heparin analogue, oral formulation
- Usage based on theory of epithelial permeability barrier in IC pts.
- Targets the glycosaminoglucan layer of the urothelium
- Proposed MOA: correction of a glycosaminoglycan dysfunction, thus presumable reversing the abnormal epithelial permeability
- Marginally effective ~30% of pts. vs placebo
- 6% of ingested dose is excreted in urine
- 100mg TID
- Most studied oral drug used in IC
22
Q
Sodium pentosan polysulfate side effects
A
- GI effects: nausea, diarrhea
- Patchy hair loss
23
Q
Hydroxizine
A
- Antihistamine used for IC
- H1-receptor antagonist that blocks neuronal activation of mast cells
- Studies show moderate efficacy at 50-75mg daily
- Efficacy highest (55%) in pts w/ hx of allergies
24
Q
Analgesics for IC
A
- Critical part of IC treatment: a chronic pain syndrome
- Nonopiod analgesics:
*acetaminophen
*nonsteroidal anti-inflammatory agents
*aspirin
*gabapentin
- Nonopiods all reach a ceiling of max analgesic effect
25
Third line IC treatments
- Cystoscopy + hydrodistention under anesthesia; short duration, low pressure distention
- If Hunner lesion present: fulgeration (laser or electrocautery) or triamcinolone injection into lesion
26
Hydrodestention in IC
- Not yet standardized in terms of pressure, solution or time of distention
- Cystoscopic examination and distention of the bladder for 1 to 2 min. at a pressure of 80 cm H2O
- Bladder is emptied and then refilled to look for glomerulations or ulcerations
- Therapeutic hydraulic distention follows for another 8min
- Biopsy, if indicated, is performed after the 2nd distention
-
27
Fourth line IC treatments
- Rarely get to
- Neurostimulation
\*permanent implantation if tiral is successful
\*consider if other therapies have not provided adequate symptom control
28
Direct sacral nerve stimulation
- 4th line treatment for IC
- New treatment for refractory IC
- Percutaneous trial followed by permanent implantation or staged procedure
- S3 electrode wire placemnt
- Initial studies suggest 40% intent to treat success, higher in recent studied
29
Fifth line IC treatments
- Cyclosporine A
\*administerd orally if other treatments have not provided adequate symptom control
- Intradetrusor botulinum toxin A
\*pt must be willing to accept possibility of need for intermittent catheterization for unknown period of time after treatment
30
Sixth line IC treatments
- Major surgery (substitution cystoplasty, urinary diversion w/ or w/o cystectomy) may be undertaken in carefully selected pts. for whom all other therapies have failed to provide adequate symptom control and quality of life
31
Therapies to avoid in IC
- Standard: long-term antibiotic admin
- Standard: intravesical bacillus Calmette-Guerin
- Standard: intravesical resiniferatoxin
- Recommendation: high pressure, long duration hydrodistention
- Recommendation: systemic (oral) long-term steroid administration
