Interstitial Cystitis/Painful Bladder Syndrome

Alis Kolter Panzera, MSN, CRNP

Disclosures

Urol Nurs. 2007;27(1):13-19. 

In This Article

Management

Initially, patients with PBS/IC may be anxious, sleep deprived, and frustrated. Most have suffered with symptoms for 2 to 7 years and have visited several health care providers before receiving a diagnosis. Although no cure currently exists, many treatment options are available to ease the symptoms (Bradley & Singh, 2000). Treatment success is often very patient dependent. It is important that the clinician be familiar with the repertoire of treatments so that a variety of strategies can be used alone or in combination to provide the maximum benefit for the patient. There is great therapeutic value simply in being a concerned clinician who understands PBS/IC and takes the patient seriously. For example, in my experience, extending kindness and understanding toward these long-suffering patients is enormously beneficial. I have also observed benefits as patients understand the nature of the disease and develop a realistic, goal-oriented, treatment plan. Most treatment regimes are multifactorial; thus, optimal symptom relief most often occurs as a result of combining treatment options (Erickson & Davies, 1998).

Conservative Therapies

Conservative treatments for PBS/IC are numerous. Initially, dietary changes or restrictions should be implemented. A variety of foods have been implicated in causing or exacerbating symptoms of PBS/IC. For some patients, this pattern is very clear as symptoms flare within hours of eating the offending food (see Table 1 ). First, patients can be encouraged to try a restricted diet for 1 to 2 weeks; this involves avoiding all of the offending foods. If symptoms improve, this suggests that potential offending foods have been eliminated from the diet. Next, the patient is instructed to slowly begin adding foods back into the diet one by one and carefully paying attention to PBS/IC symptoms. If a symptom flare is going to occur it usually will happen within 1 day of eating the offending food (Erickson & Davies, 1998).

Added benefit may be obtained by coupling diet with a urinary alkalinization protocol. To decrease urine acidity, clinicians may prescribe potassium citrate (Urocit-K®) taken twice daily with meals (Moldwin, 2000). An additional urinary alkalinization protocol that does not require a prescription includes drinking a glass of water mixed with one-half teaspoon of baking soda (with a maximum of three glasses per day). This can also be beneficial by increasing the pH of the urine, and therefore, decreasing pain. This regime should not be recommended for patients on a salt-restricted diet (Moldwin, 2000). Patients who desire some leniency in the diet can use Prelief®, an over-the-counter, calcium glycerophosphate containing dietary supplement, before ingesting any potentially irritating food or beverage. Cigarette smoking can also be a source of bladder irritation; thus, a smoking cessation program should be encouraged when applicable.

Behavioral changes such as timed voiding or bladder retraining may be useful for patients with urinary frequency and urgency, but not pain (Whitmore, 2002). Bladder retraining requires the patient to prolong intervals between voids, often beginning with just 5 minutes until comfortable and then gradually increasing the time interval. Alternative therapies such as acupuncture, massage, relaxation, and stress reduction can be used alone or may complement conventional treatment modalities and can improve the patient's quality of life (Whitmore, 2002). To promote relaxation and stress reduction, patients can also try meditation tapes, visualization, self-hypnosis, massage, and psychotherapy (ICA, 2005a)

Other noninvasive therapies may be useful in reducing PBS/IC symptoms. For example, many patients with PBS/IC, and even those with severe symptoms, report feeling better physically and psychologically as a result of beginning a gentle exercise program. Some activities include low-impact aerobics, walking, yoga, swimming, and pelvic floor muscle exercises (ICA, 2005a).

For partial pain relief, simple strategies can be implemented at home. Placing a cold pack or heating pad directly on the perineum or area of pain, taking warm sitz bathes, placing knees against the chest (fetal position), reclining with spread legs or assuming the squatting position may help to decrease symptomatology (ICA, 2005b).

Wearing comfortable clothes can also help provide basic relief for patients with PBS/IC. For example, patients should be advised to wear loose clothing and avoid belts or clothing that put pressure on the waist and abdomen. Patients should be encouraged to wear cotton leggings or tights instead of nylons, and thigh-high stockings and white cotton underwear instead of nylon or colored undergarments. Wearing low-heeled shoes or slippers to relieve lower-back pain is also advised (ICA, 2005b).

Some resourceful patients have even seen improvement by using special products to help themselves during symptomatic phases. Examples include a heated mattress pad; a foam mattress pad (egg crate style); cotton or flannel sheets; white, unscented toilet tissue; and white washcloths with mild, unscented white, soap (ICA, 2005b).

Patients with PBS/IC frequently have a concomitant diagnosis of high tone pelvic floor dysfunction. These patients have spasms and tenderness in the levatorani muscle group (Lukban & Whitmore, 2005). Treatment to restore normal pelvic floor muscle tone may achieve pain relief. Referral for physical therapy and home exercises to realign the pelvis and minimize tension in the pelvic floor musculature is recommended.

Pharmacologic Therapies

Several oral medications have been used to relieve the symptoms of PBS/IC. Pentosan polysulfate sodium (PPS; Elmiron®) is the only oral medication with Food and Drug Administration (FDA) approval for treating PBS/IC. Elmiron appears to repair the defect in bladder mucosal GAG layer that occurs as a result of PBS/IC. By rebuilding the mutinous barrier the medication prevents irritating urinary solutes from reaching the nerves that cause pain (Hanno, 1997). Side effects are rare but can include gastrointestinal upset, headache, and hair loss. Three to 6 months of therapy or more may be needed to achieve symptom relief (Thomson Healthcare, 2005).

Because mast cell activation may contribute to PBS/IC symptoms, antihistamines are a reasonable treatment option, particularly if the patient also suffers from allergies. Hydroxyzine hydrochloride (Atarax®) in doses of 25 mg to 50 mg at night works best when used for at least 2 to 3 months (Parsons, 1996a). Side effects are minimal and include sedation; however, this can be helpful for patients suffering from sleep deprivation secondary to nocturia.

Antidepressants such as amitriptyline (Elavil®) or fluoxetine (Prozac®) have several actions beneficial to patients with PBS/IC. These include antihistaminic, anticholinergic, and sedative effects as well as inhibition of nociception in the central nervous system. Because PBS/IC causes long-term symptoms, antidepressants may also be useful in treating chronic pain associated with this disorder. Tricyclic antidepressants facilitate pain relief by inhibiting histamine secretion by mast cells and decreasing norepinephrine and serotonin re-uptake in the peripheral nervous system. For example, low-dose amitriptyline may be prescribed, beginning with 10 mg to 50 mg at bedtime and titrating up or down as tolerated. Side effects may include sedation, constipation, and dry mouth (Erickson & Davies, 1998).

The use of anticonvulsants, such as gabapentin, has also been proposed. Although not specifically indicated, anticonvulsants act to relieve neuropathic pain commonly found in patients with PBS/IC. A beginning dose of 100 mg at bedtime can be titrated up to 3,600 mg daily in three divided doses (Hansen, 2000). Side effects may include dizziness, somnolence, and gastrointestinal upset.

Urinary analgesics such as phenazopyridine (Pyridium®) and Urised® as well as narcotics and other pain relievers (nonsteriodal anti-inflammatory drugs) may be used during a symptom flare. Although these medications are not indicated as long-term treatment options, they are often beneficial for short-term pain relief (Bradley & Singh, 2000).

Intravesical therapy is another type of pharmacologic treatment option. Dimethyl sulfoxide (DMSO) is the only FDA-approved intravesical medication for PBS/IC. DMSO is an organic liquid with anti-inflammatory, analgesic, mast cell activation, and muscle-relaxant properties. The usual dose is 50% DMSO, 50 ml intravesically every 1 to 2 weeks for 4 to 8 weeks. The medication can be mixed in combinations with heparin, hydrocortisone, and sodium bicarbonate to increase its effects. The drawback to this treatment is the garlic-like taste or odor on the skin that can last for up to 48 hours. DMSO is teratogenic in animals and must be avoided in pregnancy (Tchetgen et al., 2005).

Intravesical heparin has been used "off-label" and acts as a mucosal surface protector as it is a synthetic GAG. Used intravesically, heparin has anti-inflammatory benefits, surface protective actions, and inhibitory effects on bladder scarring (Parsons, 2004). Finally, a variety of intravesical rescue "cocktails" have been described which can provide quick relief of bladder flares. For example, combinations of heparin or PPS together with local anesthetics such as a 50 cc vial of 5% marcaine and sodium bicarbonate are instilled and retained in the bladder for 20 to 30 minutes. Treatments are usually given 1 to 3 times a week over a 2 to 6-week period (Parsons, 2004).

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