Kembara Xtra - Medicine - Interstitial Cystitis

Kembara Xtra - Medicine - Interstitial Cystitis 
An ailment characterized by pressure, pain, or discomfort in the pelvic area and one or more of the following urine symptoms: increased nocturia, urgency, or frequency
A chronic inflammatory condition with unknown cause that has urinary symptoms for longer than 6 weeks without showing any other symptoms of an infection or other pathology

Many patients' symptoms are subtle, and the disease sometimes advances for years with relapsing and remitting symptoms before a diagnosis is made.

Types include nonulcerative and ulcerative (classic).
System(s) impacted: urologic and renal
Synonym(s): Hunner ulcer, chronic cystitis, IC/bladder pain syndrome, and urgent frequency syndrome
pregnant women's issues
Unpredictable changes in symptom severity or improvement throughout pregnancy; may be linked to an increased risk of preeclampsia and preterm birth, but more prospective research is required; common issues with drugs taken during pregnancy that have uncertain effects on the fetus

Epidemiology 
Patients of color are disproportionately affected
Most prevalent in people older than 30 years old, and diagnostic rates rise with age. Predominant sex: female over male (5:1) in patients 25 to 80 years old.
Incidence
Due to varying diagnostic standards and regional variations, an estimate is difficult to make, however the 1-year incidence has been recorded as: 21 per 100,000 female patients 4 per 100,000 male patients
Prevalence
When referring to the US:
Variable prevalence exists.
Affected individuals range from 82,000 men to 1.2 million women, however many cases are likely undiscovered.
0.052%, but it might go up to 10%

Pathophysiology and Etiology 
Uncertain etiology; likely complex pathophysiology; potential causes include: - Urothelial disruption; antiproliferative factor production; and decreased glycosaminoglycan layer
Pelvic floor dysfunction, afferent nerve plasticity, mast cell infiltration, and bladder nitric oxide
- Autoimmune - Reduced vascularization - Neurogenic inflammation

Risk Elements 
Unknown, although several concerns have been listed as being: female; recent UTI; IBS; allergies; and history of sexual abuse.


Accompanying Conditions 
Chronic fatigue syndrome, allergies, depression, panic disorder, vulvodynia, syncope, dyspepsia, chronic prostatitis, chronic pelvic pain, and pelvic floor dysfunction, as well as IBS, trauma, and autoimmune diseases like SLE and Sjögren syndrome are just a few of the conditions that can cause chronic pain.

Numerous diagnostic standards are based on patient symptoms and the exclusion of overlapping pathologies when making a diagnosis.

In simple cases, symptoms that have persisted for more than six weeks without being caused by an infection or another condition can be used to make a clinical diagnosis.
- The presence of at least one of the following urinary symptoms along with pain, pressure, or discomfort in the pelvic or bladder area.
Increased frequency, urgency, or nocturia during the day
Cystoscopy with hydrodistension or urodynamic tests shouldn't be utilized to make a diagnosis, but they can be taken into account if the diagnosis is murky or the patient's case is complicated.


History Detailed history including urinary symptoms (including voiding patterns) and bladder/pelvic pain; Variable symptoms that may worsen over time
Urgency and frequency are typical signs of urine incontinence at presentation.
Symptoms appear during flare-ups and remission.
Menstruation, stress, sexual activity, IBS, endometriosis, vulvodynia, fibromyalgia, chronic fatigue syndrome, and autoimmune diseases can all cause episodes.
Caffeine, sodas and other carbonated beverages, alcohol, and acidic foods (citrus, tomatoes) are common food triggers.



Clinical Evaluation 
Exams can be nonspecific, but the most typical findings are dysphoria, suprapubic discomfort, levator ani soreness, and bladder neck tenderness.
Examine your abdomen to rule out any lumps or hernias. Tenderness in the costovertebral region and above the pubis are two symptoms of interstitial cystitis.

When inspecting the anterior vaginal wall, pelvic floor spasms, suprapubic soreness, rectal spasms, urethral pain, and bladder base tenderness can all be signs of interstitial cystitis in women.
A male digital rectal exam may reveal tenderness in the prostate, which could misdiagnose the condition as chronic prostatitis. Sphincter spasms can be a sign of interstitial cystitis, according to some findings.


Differential diagnosis: Urinary tract infection (UTI), acute and chronic prostatitis, overactive bladder, urge incontinence, bladder or ureteral stone, chronic pelvic pain, urogenital prolapse, urethral diverticulum, neurologic bladder disease, nonurinary pelvic disease (STIs, endometriosis, pelvic relaxation, pudendal neuralgia), bladder neoplasm, neurologic bladder disease, and neurologic bladder

Laboratory Results 
Initial Tests (Lab, Imaging) Keeping a symptom diary to document symptoms and establish a baseline for comparison with therapy Urinalysis and urine culture to rule out infection
Testing for gonorrhea and chlamydia in those with pyuria or who are at high risk for STIs
The use of urine biomarkers is not advised.
Urine cytology is not advised for routine assessment. 
In addition to the advised work-up for malignancy, testing might be taken into consideration in patients at high risk for urologic malignancy.


Other/Diagnostic Procedures

The diagnosis of interstitial cystitis should not be made with cystoscopy with hydrodistension; however, it can be utilized to help separate other disease.

Urodynamic investigations can be utilized to distinguish various concurrent illnesses such overactive bladder, stress urine incontinence, or voiding dysfunction that can alter management but are not advised for routine evaluation.

In individuals with pelvic pain, intravenous lidocaine (anesthetic bladder challenge) can be used to identify the bladder as the pain's primary source.
The potassium sensitivity test is not advised for clinical usage because it is uncomfortable, vague, and does not alter the course of treatment.
Although a bladder biopsy is not advised for the diagnosis, it is carried out if a cancer is suspected.
Interpretation of Tests
High numbers of mast cells and/or nonspecific chronic inflammation are discovered during bladder biopsies.
Negative for dysplasia and neoplasia on urine cytology

Management
Symptom control and improving the patient's quality of life should be the main objectives of treatment. There is no single therapy that works for everyone. Additionally, there is little proof that any therapy works, necessitating the need for larger studies. However, all patients may be given the benefit of cautious general measures, such as:
- Patient education on the normal function of the bladder, the course of the disease, the lack of a cure, expectant management, and treatment options
- A shift in diet
 Elimination diets that concentrate specifically on avoiding common triggers including caffeine, alcohol, sodas and other carbonated beverages, meals high in citrus, tomatoes, and bananas.
- Stress management, therapy, and meditation
- Consistent exercise - Pelvic floor relaxation - Steer clear of activities that make the pain worse

Medication

The majority of interstitial cystitis drugs have shown modest efficacy in randomized controlled studies when compared to placebo; there is no way to anticipate who may benefit from a particular medication. Educate the patient on the possibility of trial-and-error during treatment.
Antidepressants, pentosan polysulfate sodium, and neuromuscular blockade are among the therapy alternatives that have been thoroughly reviewed, but no concrete evidence has been found to support their efficacy in treating symptoms.

Conservative treatments are to be tried out initially, and then more aggressive treatments might be started based on the patient's symptoms and quality of life.

Treatments ought to be determined by the presence, degree, and preferences of the patients' symptoms.

If it is in the patient's best interest and their symptoms are closely monitored and evaluated, multiple concurrent treatments might be thought about.
Initial Line
Note: According to AUA agreement, the first line of treatment should involve patient education, pain management, general relaxation, stress reduction, behavior change, and self-care.
Next Line
On which medications should be taken initially, there is no agreement. Based on the patient's symptoms and preferences, decisions should be made. By the AUA (1)[C], the following therapeutic modalities are regarded as second line:
Amitriptyline: 25 to 100 mg per day; larger dosages (around 50 mg per day) are most beneficial; however, start with lower levels to reduce side effects.
400 mg of Cimetidine BID. Rare side effects exist.



 25–75 mg HS hydroxyzine. Drowsiness and xerostomia are frequent adverse effects.
Pentosan polysulfate, the only FDA-approved treatment for interstitial cystitis, 100 mg TID on an empty stomach; may take 3 to 6 months to take effect. Headache, nausea, diarrhea, lightheadedness, rash, edema, and hair loss are examples of possible side effects. Routine eye exams are advised for people who use often due to an increased risk of developing a rare atypical maculopathy.
 Intravesical therapy- Dimethyl sulfoxide (DMSO), the only intravesical treatment approved by the FDA, every 1–2 weeks for 3–6 weeks, followed by PRN. Instillation pain, a disagreeable odor, and an aggravation of chronic pain are all side effects.
- Lidocaine 1% 20 to 30 mL is regarded as a short-term therapeutic option. - Heparin 10 to 20,000 units in 2 to 5 mL of solution, three times per week
Fourth Line
 Low-pressure hydrodistention during a cystoscopy performed under anesthesia.
Laser, electrocautery, and/or triamcinolone injections may be used to treat Hunner lesions if they are discovered.
If prior treatments have failed to improve the patient's symptoms or quality of life, a permanent neurostimulation device may be implanted as a fourth line of treatment




Referral 

A clear diagnosis is necessary before surgical intervention.


Advanced Therapies 
The AUA  classifies targeted pelvic, hip girdle, and abdominal trigger point massage as a second-line therapy.
If the various medicines listed above have failed to improve symptoms and quality of life, a therapy option such as intravesical hyaluronic acid, intravesical chondroitin sulfate, or oral cyclosporine A may be suggested (1)[C].
 A short, randomized trial with sildenafil 25 mg showed improvement in urinary symptoms at 3 and 6 months.
SURGICAL AND OTHER PROCEDURE
Sacral neuromodulation, transurethral electro- or laser fulguration (useful for Hunner lesions), and hydraulic distention of the bladder under anesthesia are all options. Pain alleviation could last for several months or even years.
 Augmentation cystoplasty, which can be combined with or without partial cystectomy, to improve bladder capacity and reduce pressure.
Expected outcomes in severe cases: greatly better, 75%; discomfort still present, 20%; unchanged, 5%
 Total cystectomy with urinary diversion only in cases where the disease is wholly resistant to medical treatment


Alternative Medication 

Glycerophosphate and acupuncture have both been proposed as treatments, however there have been no conclusive clinical studies proving their effectiveness.
One short study with 21 patients who received hyperbaric oxygen therapy revealed a 28% reduction in pain after three months.
Follow Up 
patient observation
 tailored to the degree, timeframe, and outcome of the intervention

Diets
– Dietary modification, elimination diet – Caffeine, chocolate, citrus, tomatoes, fizzy drinks, foods high in potassium, soybeans, spicy meals, acidic foods, and alcohol are examples of common irritants

Prognosis 
Patients frequently complain about a lower quality of life.
After about five years of symptoms, there may be a potential symptom plateau.
 Mild: remissions and exacerbations of symptoms; may not advance; not a risk factor for other disorders
Severe: ongoing issues that frequently call for surgery to alleviate symptoms