Interstitial cystitis/Painful bladder syndrome: A review

A 45 year old lady came to us with recurrent complaints of pain while passing urine,suprapubic discomfort,urgency lasting for more than 1 years.She had been investigated extensively and was given antibiotics/bladder spasmolytics/antimuscarinic agents/NSAIDs with no relief.Her all the investigations were normal.She was taken up for cystoscopy which revealed bladder capacity of 250 ml with glomerulations on emptying the bladder.The bladder biopsy was done after a therapeutic distension for 8-10 minutes.The patient was started on amitryptiline,Comfora(sodium pentosan polysulphate 100 mg three times a day)and gabapentin(TRIPLE THERAPY).She had temporary remission after the institution of the therapy and now relatively free of the symptoms.We are planning to repeat the distension after a period of 6 months.

REVIEW OF LITERATURE:
The interstitial cystitis is a chronic condition which comprimses of a constellation of symptoms-bladder pain, suprapubic/pelvic pressure, urgency, dysuria etc. The all above symptoms may occur together or the patient may suffer each one of them in isolation.
This is diagnosis of exclusion and requires a high level of suspicion on the part of the treating urologist. Any patient having unexplained irritative bladder symptoms without relief and the all investigations showing no culprit then we must doubt painful bladder syndrome.
The condition has been seen as debility because its effect on patients quality of life. A Harvard medical scholl guide states that the impact of this condition on the patient can be compared with chronic cancer pain /or renal dialysis.
The International Continence Society (ICS) reserves the diagnosis of IC for patients with “typical cystoscopic and histological features,” without further specifying these. In the absence of clear criteria for “IC,” this chapter will refer to PBS/IC and IC interchangeably, because all but recent literature terms the syndrome “IC.”(Campbells Book of Urology)
National Institute of Diabetes and kidney Diseases(NIDDK) diagnostic criteria:It’s a cystoscopic and histological diagnosis.Cystoscopy should demonstrate glomerulations(with or without Hunners ulcer)-diffuse on distension of bladder.

There are some conditions which must be excluded:-UTI/vaginitis/prostatitis
-Urinary tuberculosis
-Stone disease
-Radiation/cyclophosphamide cystitis
-malignancy
-herpetic affections(less than 3 months duration)
-urethral instrumentation(recent)
-stricture urethra
Urodynamically-the pain should be elicited after filling the bladder for 100-150 ml and the capacity should not be more than 350 ml.There should be any presence of uninhibited bladder contractions.
The typically age of the patient should be more than 18 years and the symptoms should be present for more than 9 months. There should not be a relief on institution of anticholinergics /antibiotics.
A patient who fulfills these criteria can be termed to be a patient of interstitial cystitis.
This condition is more common in women especially menopausal women. Although all the people irrespective of age, socioeconomic status, menopausal status do suffer from this syndrome.

The patient of IC/PBS may have associated illnesses like-allergic conditions,Inflammatory bowel diseases,Fibromyalgia and focal vulvitis etc.
Aetiology:The IC as such is a complex condition with no direct etiological agent to attribute this condition to. Neurological/allergic/autoimmune/stress-psychological conditions have been supposed to be playing a role in these conditions. Presence of MAST cells in the bladder is supposed to be a pathognomonic marker of the disease. The association of mastocytosis, IC and inflammatory bowel disorders is intriguing. The bladder permeability defect due to lack of surface bladder glycosaminoglycans can lead to aggravation of the condition. The treatment now also is aimed at restoring this protective layer of the bladder.

Diagnosis:
The cystoscopic visualization of glomerulations is not a specific for diagnosis. Potassium chloride sensitivity test although not a specific again but can hint to success of pentosan polysulphate.
Management:
1. Behavioural modification: May help in patients having predominant frequency but less pain.

2. Diet: Certain foods can aggravate the condition like banana, cranberries, tea, coffee, alcoholic beverages, ketchups, Mayonnaise, carbonated drinks, junk foods, onion etc..


3.Medications: Antihistaminics to control mast cell proliferations,amitryptiline to fight with neurogenic inflammation,oral pentosan polysulphate to restore the protective layer of the bladder have been used in this condition with variable success rates.In india it is available as Comfora 100 mg three times a day for 3 months and then re-evaluate the patient.The side effects like nausea,diarrhea,rashes and reversible alopecia have been reported.Tachyphylaxis is also reported.
4.Bladder instillation therapies:DMSO – a wood pulp extract is the only agent FDA approved for the instillation.25% or 50% solutions have been used for the instillation.
With its ease of administration, lack of side effects, and dependable symptomatic results, DMSO has been a treatment of choice with many treating doctors. Some people add triamcinolone, 40,000 units of heparin, and sodium bicarbonate for better success.
5. Bladder distension:
Bladder distension stretches the bladder and gives a temporary relief for few months. It is done under general anesthesia. The bladder is distended for 2 minutes with 80 cm of H20 and then deflated again to see the glomerulations. Once it is done a therapeutic distension is done for 8 minutes followed by bladder biopsy for mast cells detection.
6. Radical surgical options are sometimes chosen like subtotal cystectomy with augmentation or ileal diversion with or without cystectomy. The results are somewhat positive. But as the underlying condition of neurogenic inflammation may not go -phantom bladder pain may persist.