New Trends in the Management of Interstitial Cystitis
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationships to this field of study.
Synopsis: A series of diagnostic and therapeutic suggestions is offered, each of which helps to make interstitial cystitis more manageable for the busy practitioner.
Source: Mishell DR Jr, et al Evolving trends in the successful management of interstitial cystitis/painful bladder syndrome. J Reprod Med 2008;53:651-656.
The authors provide a mini-primer on interstitial cystitis (IC), a condition that is known to be poorly diagnosed and treated in many circumstances. If the astute clinician remains mindful of the subtle ways in which IC presents, then relatively effective therapeutic options are available. The presentation (pelvic pain, urgency, frequency, nocturia, and dyspareunia) can be subtle and may be confused with the symptoms related to coexisting conditions such as vestibulitis and endometriosis. In fact, the presentation may be so subtle that pain is not one of the chief complaints.
Diagnostic tools include a careful history, a urinanalysis and culture, a physical examination that focuses on the presence/absence of tenderness of the bladder and urethra, the Pelvic Pain and Urgency/Frequency (PUF) questionnaire, the Potassium Sensitivity Test (PST), and, ultimately, cystoscopy/hydrodistention. Treatments listed include dietary modification, FDA-approved pentosan polysulfate sodium and intravesical instillation of dimethyl sulfoxide, tricyclic antidepressants, antihistamines, and physical therapy for pelvic floor dysfunction.
Key points in managing this condition include having a positive attitude in support of the patient, training the support staff to work with the patients, and also having patience, as therapies often take several months to have an effect. Ongoing follow-up to provide both medical and emotional continuity are also stressed.
This is the most obvious industry-supported article that I have ever reviewed for this readership. The lead author is an icon, but certainly not in the area of IC. The second and third authors are more identified with urogynecology as a clinical field, but this article adds nothing new. The article correctly discloses that the "…study was supported by …" (which happens to be the pharmaceutical firm that markets the only FDA-approved oral treatment for IC, pentosan polysulfate sodium). The study design states that "Experts discussed the literature surrounding IC, focusing on diagnostic tools and currently available treatment modalities." By no means was this a comprehensive review or a meta-analysis. Bottom line: It's surprising to me that this article made it through the peer-review process.
Having said that, however, it's a good article. How could that be? It's good because it basically collates the ideas that the authors want to get across, i.e., that IC really exists and there really are ways to diagnose and treat it. If the reader already knew that, then at least the lists that I summarized previously help the clinician make sure that he/she is not missing a trick or two in managing the patients. It is also a useful article to be distributed to office staff, as it helps them put these difficult cases in perspective.
Allow me to add my personal management "tips" to those in the article. Let me warn you, though, none is FDA-approved for IC. Some patients have benefited from the use of InterStim® placement (sacral neuromodulation therapy). Although primarily done by urogynecologists, urologists, and neurosurgeons, the gynecologist/women's health care provider can use this technique for selected cases. Short of that, a product called Urgent PC®, which is a percutaneous tibial nerve stimulation device used for urinary urgency and overactive bladders, sometimes helps. It is done as a series of in-office treatments. The article refers to tricyclic antidepressants, and I have found imipramine (Tofranil®), amitryptyline (Elavil®), and nortriptyline (Pamelor®) to be the most useful.
It is not uncommon for these folks to have pain. As a result, prudent use of analgesics should be strongly considered. I must admit that I felt the article let the reader down when it did not more strongly address the reality that many of these patients need pain medication. Unfortunately, where there is pain medication use, there is the potential for abuse. I find that, too often, the clinician is scared off from the use of analgesics for fear of addiction, drug-seeking behavior, etc. I strongly recommend the reader either prescribe the medication or work closely with an experienced provider who can keep the patient out of trouble in this regard.
Accompanying pain is often nausea and vomiting. This is a natural extension of the pain experience. Prescribing anti-emetics such as promethazine (Phenergan®) or ondasetron (Zofran®) is certainly appropriate as management of pain is considered.
As a summary, let me just strongly encourage each clinician reading this to be vigilant. Patients with disturbance of their voiding pattern, patients with nonspecific pelvic pain and/or dyspareunia, patients with any symptom complex related to the pelvis all should be considered an IC candidate. No, we don't want IC over-diagnosed (which, unfortunately has occurred in some practices, where patients are labeled without a work-up), but we certainly don't want it forgotten. IC is not "in her head." It's real, but, as the old saying goes "You see what you look for … you look for what you know." This article can help you "know" IC so that you can look for it more effectively.