According to recent data, interstitial cystitis/ bladder pain syndrome (IC/BPS) is more common than previously thought. The most up-to-date data suggest that 2.7% to 6.5% of adult women (about 3 to 8 million) in the United States have compatible symptoms. Of all patients with the condition, approximately 20% are male. IC/BPS has been linked to pain and discomfort that affects physical and psychosocial function, as well as quality of life. Compounding the problem is that IC/BPS is challenging to diagnose and treat, and no cure has been identified.
In 2011, the American Urological Association (AUA) created the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. The document comes 12 years after the AUA first set out to develop IC/BPS guidelines. “After pulling together 300 or 400 articles in 1998, we decided we didn’t have enough information about the condition,” says Philip M. Hanno, MD, MPH, who chaired the group that created the AUA guideline. “In the last decade, researchers have found that IC/BPS is much more prevalent, and the time was right to provide clinicians with a framework to help treat these individuals.”
IC/BPS symptoms are much like those of a urinary tract infection, but they are seen in people with negative urine cultures who do not experience improvement with antibiotic treatment and harbor no other gynecologic or confusable disease that would explain the symptoms. “Patients complain of pain that they perceive to be related to the bladder that is associated with at least one other symptom, which is most often urinary frequency or urgency,” explains Dr. Hanno. “IC/BPS pain is sometimes described by patients as pressure or discomfort in the area of the bladder.” Clinicians should be suspicious of IC/BPS in patients with these symptoms when they last longer than 6 weeks.
“Treatment strategies for IC/BPS should start with more conservative therapies first and then move to less conservative therapies if symptom control is inadequate for acceptable
quality of life.”
Distinguishing IC/BPS from recurrent urinary infection or overactive bladder (OAB) is key to making a diagnosis (Table 1). “It’s important that physicians avoid making faulty diagnoses,” adds Dr. Hanno. “In BPS, the frequency is secondary to discomfort, pressure, or pain that is perceived to be related to the bladder. With OAB, patients get a sudden urgency because they feel that they’re going to be wet if they don’t void right away.”
Treatment Recommendations for IC/BPS
With just two FDA-approved agents to treat IC/BPS (oral sodium pentosan polysulfate and intravesical dimethyl sulfoxide), management of the condition can be complicated. Anticholinergics are indicated for OAB, but the AUA guidelines suggest avoiding them in IC/BPS. In addition, antibiotics are generally ineffective due to the lack of any infection. Amitriptyline, an old tricyclic antidepressant, is potentially useful in doses slowly titrated from 10 mg to 50 mg nightly. However, amitriptyline has significant side effects to be concerned about and is contraindicated in patients with a history of cardiac arrhythmia or severe heart disease. “Ideally, medications should be reserved for those who don’t respond to more conservative therapies,” Dr. Hanno says. “Treatment strategies for IC/BPS should start with more conservative therapies first and then move to less conservative therapies if symptom control is inadequate for acceptable quality of life.”
First-line therapy recommendations in the guidelines include patient education and diet changes (Table 2). “Patients should avoid food or beverages that trigger symptoms, like tomato-based products, citrus juices, hot and spicy foods, caffeinated beverages, and alcohol,” Dr. Hanno says. “Stress reduction, warm baths, and alkalinization of the urine with calcium carbonate or sodium bicarbonate can provide symptom relief. Following initial conservative management, pelvic floor therapy in the hands of an experienced physical therapist can also be effective in alleviating some symptoms. Patients diagnosed with IC/ BPS should be co-managed with gynecologists or urologists because long-term management and multiple therapeutic modalities are required.”
Many patients will experience symptom improvement over time with the aforementioned treatment methods, meaning major surgical procedures can be avoided in most patients. “Only about 10% of patients require any major surgery for severe symptoms,” says Dr. Hanno. “Some patients with IC/BPS have a true ulcer in the bladder, which can be treated with fulguration.”
Continuously Improving the AUA Guidelines
The AUA guidelines are a work in progress. Dr. Hanno says adjustments will be made annually on the basis of new information from the literature. “Future research should address why patients with IC/BPS tend to have certain associated disorders, such as IBS and fibromyalgia, and to the effect of treatment of associated disorders. It is thought that some of these patients have a chronic generalized pain syndrome rather than a primary bladder problem. The key is for physicians to utilize the AUA guidelines to ensure that patients truly have IC/BPS. After making the proper diagnosis, they can then take a logical approach to treatment and provide appropriate therapies that are aimed at improving bladder function.”
Readings & Resources (click to view)
Hanno PM, Burks DA, Clemens JQ, et al; for the American Urological Association. Guideline on the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. March 1, 2011. Available at:http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=ic-bps.
Hanno PM, Landis JR, Matthews-Cook Y, Kusek J, Nyberg L Jr. The diagnosis of interstitial cystitis revisited: lessons learned from the National Institutes of Health Interstitial Cystitis Database study. J Urol. 1999;161:553-557.
Clemens JQ, Meenan RT, Rosetti MC, Gao SY, Calhoun EA. Prevalence and incidence of interstitial cystitis in a managed care population. J Urol. 2005;173:98-102.
Clemens JQ, Meenan RT, Rosetti MC, Kimes T, Calhoun EA. Costs of interstitial cystitis in a managed care population. Urology. 2008;71:776-780.