Interstitial Cystitis: Enhancing Early Identification in Primary Care Settings

Brittany N. Heck, FNP, MSN

Disclosures

Journal for Nurse Practitioners. 2007;3(8):509-519. 

In This Article

Management and Treatment

As with any chronic disease, the management of IC focuses on initiating treatment interventions early on in the disease process to restore function, minimize symptoms, and improve quality of life. As the cause reflects a multifactorial process, the management of IC and PBS consists of a multimodal approach. Primary care providers begin with more conservative measures in the beginning stages of the disease, incorporating more aggressive treatments in patients who are unresponsive to initial efforts. A number of treatment options exist for the management of IC and PBS, and primary care providers should be familiar with these options.

Nonpharmacologic Treatments

Conservative approaches to treatment in patients with IC and PBS focus on initiating appropriate dietary and behavioral modifications in the early stages of disease. A low-potassium and low-acidic diet, over the course of several weeks, is recommended; foods that are acidic and contain potassium ( Table 1 )[39] were identified in the exacerbation of symptoms in 50% of patients with the syndrome.[22] Patients may reintroduce the offending foods one by one, paying particular attention to symptom changes in relation to foods recently ingested. Symptom flares generally occur 1 hour to 24 hours after the ingestion of irritating foods, so food diaries can be useful in helping distinguish which foods are most problematic in patients with IC and PBS.[40]

Behavioral modifications such as physical therapy and bladder retraining exercises are two other early treatment interventions that may provide symptomatic relief in patients with IC and PBS. Physical therapy exercises in patients with IC and PBS are aimed at correcting underlying pelvic floor dysfunction.[41] Pelvic floor dysfunction, a condition characterized by abnormal relaxation and contraction patterns within the pelvic muscles, often exacerbates voiding disturbances in women with IC and PBS. One investigation examining the effectiveness of intravaginal massage in patients with IC found that 90% of patients reported reduction in urinary frequency, urgency, and pelvic pain.[42]

In many early cases of IC and PBS, patients do not routinely exhibit a reduction in bladder capacity.[18] However, frequent urination in response to painful bladder filling may lead to an overall reduced bladder capacity as the disease progresses. Bladder retraining exercises that focus on slowly increasing the length of time between voids was shown to decrease pain and frequency in patients with IC and PBS.[33] Consequently, bladder-retraining techniques are recommended in the early stages of disease, because this may prevent a reduction in bladder capacity from occurring.

Intravesical Treatments

Intravesical treatments are generally reserved for patients who have advanced stages of disease or who have failed to adequately respond to conservative and oral treatments.[9] To date, dimethylsulfoxide (DMSO) is the only FDA-approved drug for routine bladder installation in patients with IC and PBS. DMSO decreases urgency, frequency, and pain in patients with IC and PBS because of its anti-inflammatory, analgesic, and antispasmodic activity within the bladder.[49] Treatments can be performed in the clinical setting once every week or 2 weeks, for a total of 6 to 8 weeks. Patients who have undergone DMSO treatments typically report moderate symptom relief; however, pain frequently returns, warranting additional treatments.[44] Because symptom recurrence is so prevalent in patients treated with DMSO, its use over the past several years has decreased.

Heparin is another agent that can be used as an intravesical treatment intervention in patients with IC and PBS. Heparin is structurally similar to the GAG layer of the bladder wall and produces anti-inflammatory effects that assist in restoring function within the mucous lining.[49] A study by Kuo[50] found that more than 50% of patients with IC and PBS who received 25,000 IU of heparin twice a week for 3 months showed significant improvements in symptom scores.

Oral Medications

The first-line pharmacologic therapy in patients with IC and PBS focuses on restoring integrity and function to the GAG layer within the bladder wall. Pentosan polysulfate sodium (Elmiron) is the only oral form of treatment approved by the Food and Drug Administration (FDA) to relieve bladder pain and discomfort in patients with IC and PBS.[43] Elmiron relieves symptoms in patients with IC and PBS by correcting injuries throughout the GAG layer, which in turn inhibits urinary contents from entering into the underlying tissues and causing damage. Elmiron is prescribed as 100 mg three times a day, and symptom relief is expected during 4 to 6 months. However, patients treated in the early stages of the disease with Elmiron have reported experiencing pain relief in 4 weeks.[44] A recent study by Nickel et al[45] assessed the efficacy of three separate dosages of Elmiron (300, 600, and 900 mg daily) during a 32-week period in patients with IC and PBS. The dose–response relation was not statistically significant, yet patient improvement ratings increased from 21.1% at 4 weeks to 49.6% by the end of the study.[45] The duration of therapy, rather than dosage of Elmiron, may be a more important variable in symptom improvement. This finding is communicated to patients, because it may affect adherence.

The use of tricyclic antidepressants is another treatment option for patients with IC and PBS. Amitriptyline is thought to exert therapeutic effects in patients with IC and PBS by promoting central and peripheral anticholinergic activity and producing antihistamine properties.[9] The anticholinergic properties decrease frequency and urgency symptoms, whereas the antihistamine effects can improve pain by inhibiting mast cell degranulation. Dosing ranges from 25 to 100 mg every night in patients with IC and PBS.[9] A recent study investigating the efficacy and safety of long-term administration of amitriptyline in patients with IC found that 64% of patients receiving therapy reported symptom improvements; 46% reported the improvements to be excellent or good.[46] However, 84% of patients experienced significant anticholinergic side effects such as weight gain and dry mouth, leading to discontinuation of the drug.[46] Although amitriptyline may be an effective treatment option for patients with IC and PBS, significant side effects may hinder its use in the clinical setting.

As previously stated, mast cells were found to play an integral role in the development of IC and PBS symptoms. Antihistamines are an important component to treatment therapy, because these medications impede the inflammatory response that results from mast cell degranulation. Hydroxyzine, a histamine 1 antagonist, has been identified as the only drug in its class to contain properties that affect mast cell degranulation.[47] Hydroxyzine is taken in a dose of 25 to 75 mg once a day, and it usually is taken at nighttime because of its sedative effects.[9] Findings suggest that hydroxyzine administered in combination with Elmiron, as opposed to each drug alone, provided symptom relief in 40% of patients; however, statistically significant results were not obtained.[48] Because many patients with IC and PBS experience symptom flares in relation to allergy exacerbations, hydroxyzine therapy may be most effective in patients with a concurrent allergy diagnosis.

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