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Guidelines Introduced for Interstitial Cystitis/Bladder Pain Syndrome

For the first time ever, a clinical guideline on the diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) has been established.

The full text of the evidence-based guideline, issued by American Urological Association, is available on AUA’s website.  An executive summary will be published in an upcoming issue of the Journal of Urology.

“IC/BPS affects a significant number of patients whose quality of life is severely diminished by this complicated, frustrating condition,” said Philip Hanno, MD, who chaired the multidisciplinary panel that developed the guideline.

“This population has historically been both under-recognized and under-served, and it is our hope that this guideline provides physicians with a much-needed road map to help treat these patients,” he noted.

A previous attempt had been made in 1999 to develop a guideline for IC/BPS, “but after doing a literature search, we realized we didn’t have enough data to put a guideline together,” explained Dr. Hanno.  Now enough research is available.

“Over time,” Dr. Hanno explained, “interest in the disorder exploded, and the prevalence seemed to be increasing because of better epidemiology studies, and we felt that there was a lot of mismanagement of the symptom complex and failure to recognize it.  We felt it was really important to put together a guideline for clinicians, and luckily at this time there was enough data to do it.”

Here are the key recommendations:

  1. The basic assessment should include a careful history, physical examination, and laboratory examination to rule in characteristic IC/BPS symptoms (including sensations of pain, pressure and discomfort perceived by the patient to be related to the bladder, and absence of infection, as well as marked urinary urgency and frequency), and rule out easily mistakable disorders (such as overactive bladder or, specifically in men, chronic prostatitis).
  2. Baseline voiding symptoms and pain levels should be obtained to measure subsequent treatment efficacy.
  3. Cystoscopy and/or urodynamic studies should be considered as an aid to diagnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations.  Although there are no existing cystoscopic or urodynamic findings specific for IC/BPS, the guideline states that these tests can be valuable in identifying lesions or alterations (Hunner’s lesions) in the bladder in patients with symptoms, and in ruling out other entities such as bladder cancer or urethral diverticula.

One major concern of Dr. Hanno’s is that IC/BPS is often misdiagnosed as overactive bladder or prostatitis in men, which delays correct diagnosis and treatment.  “Some patients are treated as if they have recurrent urinary tract infections, and they will be on antibiotics for months or years without proper diagnosis, or on anticholinergics for years if it is diagnosed as overactive bladder and they don’t get better.  Identifying IC/BPS early and treating it early can certainly impact a patient’s quality of life,” Dr. Hanno said.

Currently, no cure exists for IC/BPS, and oftentimes no single treatment works well over time for the individual patient.  Despite the fact that the best treatment remains unclear, the following points are given for guidance for overall management of IC/BPS:

  1. Strategies should start with the most conservative treatments first before moving to less conservative therapies.
  2. Initial treatment type and level should be related to symptom severity, clinical judgment, and patient preferences.   Patients should be counseled with regard to reasonable expectations for treatment outcomes.
  3. Some patients may benefit from multiple, concurrent treatments; baseline symptom measurement and regular assessment are critical to document the efficacy of combined vs. single treatments.
  4. Ineffective treatments should be stopped once a clinically meaningful interval has elapsed.
  5. Pain management and its effect on a patient’s quality of life should be regularly assessed and considered.  If pain management is inadequate, then consideration should be given to a multidisciplinary approach, and the patient referred appropriately.
  6. If no improvement in symptoms occurs after multiple treatment approaches, the diagnosis of IC/BPS should be reconsidered.

The authors of the guideline indicate that patient education is the first-line treatment:

  1. “Patients should be educated about normal bladder function, what is known and unknown about IC/BPS, the benefits vs. risks/burdens of available treatment alternatives, the fact that no single treatment has been found effective for most patients, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved,” the authors write.
  2. Patients should be counseled on how certain self-care practices, behavioral modifications, and coping techniques such as stress management may help manage their IC/BPS symptoms.
  3. The guideline also outlines second-, third-, fourth-, fifth-, and sixth-line treatment options and includes an algorithm outlining a hierarchy of physical and medical therapies, as well as surgical options for IC/BPS.  “There is a lot of leeway in the guidelines, so people have the ability to do what they think is right,” Dr. Hanno said.

The guideline discusses several treatments that should not be offered because of lack of efficacy and/or unacceptable adverse effects.  These treatments are:

  1. Long-term oral antibiotics
  2. Intravesical instillation of bacillus Calmette-Guerin outside of a study setting
  3. Intravesical instillation of resiniferatoxin
  4. High-pressure, long-duration hydrodistension
  5. Systemic (oral) long-term glucocorticoid administration

“This guideline will improve the ability of primary care physicians and specialty physicians (urologists, gynecologists) to diagnose IC/BPS, and then it will aid them in treatment options, as well as avoid certain treatments that have been proven to not be worthwhile,” Dr. Hanno notes.

“It’s directed at all physicians,” he emphasized, noting that “primary care physicians need to recognize this condition and then make the appropriate referrals to physicians who have some expertise in managing it.”

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Acupuncture and Interstitial Cystitis

Interstitial cystitis (IC), also known as painful bladder symptom is a chronic condition characterized by pelvic pain, urinary frequency, urgency and sexual dysfunction.

Both men and women can get IC, although it occurs mostly in women.  People with IC can have symptoms similar to a urinary tract infection, but without an infection.  Often, there is painful, frequent, urgent, inhibited, or incomplete urination.    Sometimes there may be blood in the urine.  There may be a dull feeling of fullness in the lower abdomen and bladder.   The pain in the bladder can be intense or dull, and sometimes it is located in the pelvis, or on the pelvic floor.

No simple treatment exists to eliminate the signs and symptoms of interstitial cystitis, and no one treatment works for everyone. One may need to try various treatments or combinations of treatments before it can find an approach that relieves the symptoms.

One complementary and alternative therapy that has shown some promise in treating interstitial cystitis is acupuncture.

During an acupuncture session, a practitioner places numerous thin needles in the skin at specific points on the body.

Traditional Chinese medicine works by identifying specific imbalances in the body and using acupuncture to correct them. The exact pattern and degree of imbalance is unique to each individual. The traditional acupuncturist’s skill lies in identifying the precise nature of the underlying disharmony and selecting the most effective treatment. The choice of acupuncture points will be specific to each patient’s needs.

Physiologically, acupuncture helps to reduce the symptoms of interstitial cystitis by decreasing inflammation, releasing pain relieving chemicals in the nervous system, and decreasing muscle spasm.  Correcting the imbalance does not just treat the symptoms or mask the condition, but rather corrects the root of the problem by encouraging self-healing of the body and rebalancing the flow of life energy.

The results of acupuncture are cumulative over a series of treatments.  Once the imbalance is corrected, the body can work to heal itself and can result in long lasting benefit.

Western medical practitioners tend to believe that acupuncture boosts the activity of your body’s natural painkillers. From a biomedical viewpoint, acupuncture is believed to stimulate the nervous system, influencing the production of the body’s communication substances – hormones and neurotransmitters. The resulting biochemical changes activate the body’s self-regulating homeostatic systems, stimulating its natural healing abilities and promoting physical and emotional well being.

This treatment has not been well-studied for interstitial cystitis, so be sure to discuss the use of this therapy with your doctor.

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Overly Restrictive Diets May Not be Necessary for Interstitial Cystitis Sufferers

The results of a recent survey revealed that the diets of interstitial cystitis/bladder pain syndrome (IC/BPS) patients may not have to be so restrictive.

The aim of the study was to survey IC/BPS patients using an online questionnaire to determine which foods, drinks, supplements/spices, and general food categories truly lead to symptom flare ups.

In order to conduct the study, the Interstitial Cystitis Association posted an online study for ICA’s members to participate.  Members were asked their experiences/effects after consuming 344 different foods, drinks, supplements, condiments/spices, and general food categories.  Mainly, the researchers were interested in the effects on urinary frequency, urgency, and/or pelvic pain symptoms.  Members were asked to score the resulting symptoms due to the consumption of the noted foods using the Likert scale of 0 to 5.  Questions on ethnicity, education, symptom duration, seasonal allergies, irritable bowel syndrome, and specific diets were also included.

Out of the 598 complete responses to the questionnaire, 95.8% relayed that certain foods and beverages do affect their IC/BPS symptoms; however, most items on the list had no effect on the symptoms.

Some items that made symptoms worse were citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C.

Only two items on the list were reported to help alleviate the symptoms:  calcium glycerophosphate (Prelief) and sodium bicarbonate (baking soda).

Although it is recommended that patients with IC/BPS avoid citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C, the study’s results suggest that interstitial cystitis diets do not have to be overly restrictive.  Further, the use of calcium glycerophosphate or sodium bicarbonate before consumption of the known irritants may also help reduce the symptoms of IC/BPS.

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Bladder Health Diet – Top Seven Foods to Avoid IF You Have IC

Diet is the foundation of care for most patients.  What you eat has the ability to soothe or irritate your bladder.  The daily irritation that food provokes is devastating to an IC bladder and sets back the patient a week in tissue growth.

IC patients can eat so many enjoyable foods but there are foods and drinks that are notorious for causing IC flares. Even one small serving a day can make your night sleepless and painful.  These are the first foods that should be eliminated from your diet –

1. Coffee – By far, coffee – regular or decaf, is the most irritating to an IC bladder not just for the caffeine but also for the very high acid level.  If you are symptomatic, it is strongly suggested that you avoid coffee.  When your bladder has improved and you want to incorporate coffee in your diet again, try herbal coffees first then try a low acid regular coffee.

2. Teas – Tannic acid is what gives tea their flavors which is also an irritant to the bladder.  If you want tea in your diet, try a plain herbal chamomile or peppermint tea, these teas are calming and soothing to the muscle of the bowel. Avoid powdered sugar free instant iced teas which are filled with artificial sugars and other irritating preservatives.

3. Soda – The citric acid, preservatives and flavorings in the soda are highly irritating.  Even diet sodas are irritating especially with the added artificial sugar.  If you want soda in your diet, try an organic root beer.

4. Fruit Juices – Cranberry, orange, lemon and tomato juices are very acidic. Each glass carries acid of not just one fruit but of several fruits that have been squeezed to make that juice. If you want to drink juice, try apple or pear juice and preferably a “baby” version. Baby juices use much less acid and are easier for an IC bladder to tolerate.

5. Multivitamins – Our body cannot use the massive amount of vitamins found in supplements, thus they are quickly excreted out of the body through our urine. Avoid Vitamin C (Ascorbic Acid) and Vitamin B6 as these are notorious to cause IC flares.

6. Artificial Sugars – In the IC bladder, artificial sugars create profound irritation. These artificial sugars are metabolized into a very strong acid and basically scour the bladder. It is strongly suggested that artificial sugars are removed from your diet.

7. Chocolate – Chocolates can cause irritation and pain to the bladder.  To satisfy your sweet tooth, try carob candies. You can also try white chocolate or a very dark, semisweet chocolate.

Sensitivity to various foods can vary among individuals, it is important to determine your personal trigger foods.

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New Drug Delivery System for Bladder Disease

If you have interstitial cystitis or IC you are not alone.  This bladder disease affects at least a half million people in the United States, mostly women, with perhaps an equal number undiagnosed.  Currently treatment for IC is an infusion of lidocaine into the bladder through a catheter which only provides brief relief and needs to be repeated frequently.

Researchers at MIT have developed a device which they think is a better solution for the drug delivery system.  Using a laser beam, they drill a tiny hole in a small medical-grade silicone tube with the solid drug. A shape memory wire made of nitinol is threaded through the tube, which is then straightened out, placed in a catheter and inserted into the bladder.  As soon as it is released in the bladder, the nitinol wire causes the device to spring back into a pretzel-like shape which prevents it from being expelled from the bladder during urination and thus it can slowly, steadily release the drug over a two week period which is typically long enough to treat an IC flare-up, which can occur three times a year.

Although the device is in its phase-1 clinical trials and initially being tested specifically for IC, the same delivery system could also be used to deliver drugs for other bladder diseases, including chemotherapy for bladder cancer, which has the highest recurrence rate of all, in part because it is so difficult to deliver drugs to the bladder in a sustained way.

The major problem with these treatments is the patients don’t get the drug long enough that’s why doctors try to make up for this shortcoming by using very high concentrations of drugs. The new device could potentially lead to smaller dosages, thus reducing side effects and adverse reactions. Also, compared to the discomfort of having a catheter left in place for an hour under the present standard treatment regime, this device inserted quickly and patients could not even tell that the device had been left in place.

If all goes well the device could become an approved medical product by 2014.

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New Treatment for Bladder Disease

Interstitial cystitis, or IC, is a painful condition of the bladder and is caused by inflammation of bladder wall tissue.  The condition generally affects mostly women aged 30 to 40, yet younger people are diagnosed with IC.  With similar symptoms to a urinary tract infection, many women are commonly misdiagnosed with a UTI.  In fact, many IC patients experience a four-year delay between the time the first symptoms occur and the correct diagnosis is made.  Common symptoms include pain during intercourse, pelvic pain, urinary discomfort, urinary frequency (sometimes up to 60 times a day in severe cases), and urinary urgency.

No cure exists for IC today and no standard treatment has been universally agreed upon.  Currently, Elmiron is the only medication taken by mouth that is approved for treating IC.  Other medicines include opiod painkillers, tricyclic antidepressants (to relive pain and urinary frequency), and Vistaril, which is an antihistamine that causes sedation and helps reduce urinary frequency.  Other therapies include bladder hydrodistention, bladder training, instilled medications that are placed directly into the bladder, physical therapy, and surgeries ranging from cystoscopic manipulation to bladder removal.

The treatment options for IC patients are few and only provide brief relief.  But researchers at Massachusetts Institute of Technology think they have found a much better solution using a much better device.  First, a small medical-grade silicone tube is filled with a solid drug.  Then, a small hole is drilled into the tube using a laser beam.  A shape-memory wire made of nitinol is threaded through the tube, which is then straightened out, placed in a catheter, and inserted into the bladder.  As soon as it is released there, the nitinol wire causes the device to spring back into a pretzel-like shape, which prevents it from being expelled from the bladder during urination and, instead, can slowly, steadily release the drug over a two-week period—which would be long enough to treat an interstitial cystitis flare-up, something that occurs about three times a year.

The device was developed by Heejin Lee and Michael Cima and is currently undergoing phase-1 clinical trials.  Though it is initially being tested specifically for interstitial cystitis, the developers believe that the same delivery system could be used to deliver drugs for other bladder diseases, including chemotherapy for bladder cancer.  This new system is an amazing development for those who suffer from bladder cancer and other diseases as it is so difficult to deliver drugs to the bladder in a sustained way.

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Alternative Treatments for Interstitial Cystitis

Nearly 1.3 million Americans suffer from interstitial cystitis (IC), and more than 1 million of these victims are women.   This common urological condition causes recurring discomfort or pain in the bladder and the surrounding pelvic region.  Symptoms vary from case to case and may span from mild to severe, but most patients experience discomfort, pressure, tenderness, intense pain in the bladder and pelvic area, or an urgent, frequent need to urinate.  The severity of the pain varies, depending on how full the bladder is.  And many women experience more pain during menstruation and vaginal intercourse.

Given the prevalence of such a frustrating, painful condition, it is no wonder physicians and researchers have spent years trying to find a solution to IC.  As a result, naturopathic treatment has emerged, providing alleviation to IC sufferers.

Naturopathic treatment involves inhibiting the inflammatory process associated with the condition by removing inflammatory and irritating foods from the diet, taking nutritional supplements, and using herbal support.

A healthy diet is important in relieving symptoms.  Foods that cause sensitivities must be eliminated.  Food sensitivities are often the cause of chronic inflammatory conditions.  The diet must also include whole, fresh, unrefined, and unprocessed foods.  This includes fruits, vegetables, whole grains, beans, seeds, nuts, olive oil, and cold-water fish (such as salmon, tuna, sardines, halibut, and mackerel).  Avoid sugar, dairy products, refined foods, fried foods, junk foods, some beans (like fava, lima, black, and soy) and especially caffeine.  Coffee, chocolate, alcohol, carbonated drinks, citrus fruits, and tomatoes often worsen symptoms.  Finally, drink 50% of your body weight in ounces of water daily in order to flush out any gathered bacteria and maintain a clean system.

Natural supplements are also highly recommended.  Calcium citrate alkalinizes the urine, which decreases irritation to the bladder.  And bromelain provides anti-inflammatory action.  Both of these supplements may be found naturally in foods, but supplements are designed to give the correct doses of these healthy ingredients to successfully alleviate IC symptoms.

In addition to a healthy diet and natural supplements, herbal medicines are also recommended by those practicing naturopathic medicine.  Herbs do not have side effects when used appropriately and at suggested doses.

Gotu kola is suggested to enhance the integrity of connective tissue by stimulating production of glycosaminoglycans, which are an integral component of the protective mucous layer in the bladder.  The recommended dosage is 30 mg of standardized extract triterpenes three times a day.

If you are a tea drinker, then several herbs should be considered.  Buchu is a soothing diuretic and antiseptic for the urinary system.  Cleavers are traditionally used as a urinary tract tonic.  Corn silk has soothing and diuretic properties.  Horsetail is an astringent and mild diuretic with tissue-healing properties.  Usnea has soothing and antiseptic properties.  And marshmallow root has soothing demulcent properties—it is best taken as a cold infusion by soaking the herb in cold water for several hours, straining it, and then drinking.

Only high-quality products should be used if herbal medicine is considered.  Take the recommended dosages for maximum effect, but do not overdose as it can lead to serious illness and death.  Consult your physician or a naturopathic practitioner before beginning any treatment.

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Relief for Painful Bladder Syndome/Interstitial Cystitis is on the Way

Urigen Pharmaceuticals, Inc., announced on Wednesday, August 18, 2010, that the company and the FDA will begin discussing its program URG101.  Urigen Pharmaceuticals is a pharmaceutical company that develops special programs, therapies, and machines to treat painful urological disorders, including Painful Bladder Syndrome and Interstitial Cystitis.

According to Lowell Parsons, MD, Urigen’s Chief Medical Officer, “We are pleased the FDA has agreed to meet to discuss our URG101 program.  Since Painful Bladder Syndrome/Interstitial Cystitis occurs in a discrete region of the body, there is a definite role for a regional therapy such as URG101, and it may also provide the safest approach.”  Dr. Parsons believes that this treatment is the most significant advancement in the treatment of such painful urological diseases, and will improve both the quality of the patients’ lives and the quality of care in the field of urology.

URG101 is a urological therapy designed specifically for Painful Bladder Syndrome/Interstitial Cystitis and is currently patented by Urigen Pharmaceuticals.  The URG101 treatment is instilled into the bladder and works with lidocaine and heparin.  Lidocaine recues the sensations of pain, urgency, and muscle spasms, while heparin coats the bladder wall and augments the natural heparinoids.  Clinical studies have been conducted on the therapy, and each study was a multi-center, double-blind, placebo-controlled, crossover trial.  The results were clear:  an improvement in average daytime pain.

In the field of urology, Painful Bladder Syndrome is sometimes referred to Interstitial Cystitis.  This painful condition is increasingly being diagnosed by urologists across the country.  It is characterized by pain the bladder, urgency to urinate, and disrupted sleep due to the urge to urinate at night.  Approximately 10.5 million women and men in the United States alone suffer from Interstitial Cystitis.  Unfortunately, few treatments exist for this condition, and no urological therapies have been approved yet, which makes URG101 such a cutting-edge program and why urologists such as Dr. Parsons are excited at the FDA’s agreement to meet.

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Interstitial Cystitis and Diet

What is Interstitial Cystitis? Interstitial Cystitis (IC), also known as hypersensitive bladder syndrome (HBS), bladder pain syndrome (BPS) or painful bladder syndrome (PBS) is a condition that results in ongoing pain or discomfort in the bladder and pelvic region. Common symptoms include urinary urgency (feeling a strong need to go), and urinary frequency (needing to go often). Many women also report pain during vaginal intercourse, and worsening symptoms during menstruation.

Although IC affects men, women and children of all ages and ethnicities, it is most commonly found in women.  IC affects about 5% of the general population, and up to 12% of women may show early symptoms.

What should I eat? Changing your diet and increasing your water consumption can significantly reduce your discomfort. Although triggers vary from person to person, acidic foods and diuretics are generally the worst offenders. Maintaining an alkaline-rich diet can help tremendously. Many doctors recommend keeping a food diary to keep track of which foods bother you the most.

Foods to avoid or eliminate:

Tobacco and Alcohol – IC sufferers should avoid smoking and alcohol consumption. Both substances constrict the bladder’s blood vessels, and inhibit the natural cleansing process.

Coffee – The caffeine and acid in coffee may cause intense pain for IC patients, and also act as a diuretic. We recommend eliminating coffee from your diet.

Tea – Avoid any tea containing black or green tea leaves, and most herbal teas. Instead, try hot water with grated ginger and honey, or mint teas containing only spearmint or peppermint leaves.

Cranberry and other acidic fruits– Although cranberry juice is good for treating urinary tract infections, it’s too acidic for IC patients. Choose more alkaline varieties such as blueberry, pear, or apple juices.

Diet Soda – Diet sodas contain citric and phosphoric acids, artificial sweeteners, acidic carbonation and caffeine — all of which will irritate an IC bladder. Opt for a non-caffeinated, non-diet root beer diluted with ice or water.

Tomatoes – These healthy fruits are unfortunately high in potassium and acid. Low-acid varieties may be substituted as an infrequent treat.

Artificial sweeteners, flavors and food colorings (dyes) – These bladder irritants are frequently found in processed foods.

Yeast-promoting foods – Many women with IC have systemic yeast issues. Vinegar, sugar, and other foods that promote yeast overgrowth should be avoided.

Gluten – Found naturally in grains and other foods through contamination and additives, gluten is an inflammation-causing protein. Some IC sufferers are gluten sensitive, and should eliminate gluten from their diet.

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