What Are the Treatments for IC?
Scientists have not yet found a cure for IC, nor can they predict who
will respond best to which treatment. Symptoms may disappear without
explanation or coincide with an event such as a change in diet or
treatment. Even when symptoms disappear, they may return after days,
weeks, months, or years. Scientists do not know why.
Because the causes of IC are unknown, current treatments are aimed at
relieving symptoms. Most people are helped for variable periods by one or
a combination of treatments. As researchers learn more about IC, the list
of potential treatments will change, so patients should discuss their
options with a doctor.
Bladder Distention
Because many patients have noted an
improvement in symptoms after a bladder distention done to diagnose IC,
the procedure is often thought of as one of the first treatment attempts.
Researchers are not sure why distention helps, but some believe that it
may increase capacity and interfere with pain signals transmitted by
nerves in the bladder. Symptoms may temporarily worsen 24 to 48 hours
after distention, but should return to predistention levels or improve
after 2 to 4 weeks.
Bladder Instillation
During a bladder instillation, also
called a bladder wash or bath, the bladder is filled with a solution that
is held for varying periods of time, averaging 10 to 15 minutes, before
being emptied.
The only drug approved by the U.S. Food and Drug Administration (FDA)
for bladder instillation is dimethyl sulfoxide (DMSO, RIMSO-50). DMSO
treatment involves guiding a narrow tube called a catheter up the urethra
into the bladder. A measured amount of DMSO is passed through the catheter
into the bladder, where it is retained for about 15 minutes before being
expelled. Treatments are given every week or two for 6 to 8 weeks and
repeated as needed. Most people who respond to DMSO notice improvement 3
or 4 weeks after the first 6- to 8-week cycle of treatments. Highly
motivated patients who are willing to catheterize themselves may, after
consultation with their doctor, be able to have DMSO treatments at home.
Self-administration is less expensive and more convenient than going to
the doctor's office.
Doctors think DMSO works in several ways. Because it passes into the
bladder wall, it may reach tissue more effectively to reduce inflammation
and block pain. It may also prevent muscle contractions that cause pain,
frequency, and urgency.
A bothersome but relatively insignificant side effect of DMSO
treatments is a garlic-like taste and odor on the breath and skin that may
last up to 72 hours after treatment. Long-term treatment has caused
cataracts in animal studies, but this side effect has not appeared in
humans. Blood tests, including a complete blood count and kidney and liver
function tests, should be done about every 6 months.
Oral Drugs
Pentosan polysulfate sodium (Elmiron), the first
oral drug developed for IC, was approved by the FDA in 1996. In clinical
trials, Elmiron improved symptoms in 38 percent of patients treated.
Doctors do not know exactly how it works, but one theory is that it may
repair defects that might have developed in the lining of the bladder.
The FDA-recommended dosage of Elmiron is 100 mg, three times a day.
Patients may not feel relief from IC pain for the first 2 to 4 months. A
decrease in urinary frequency may take up to 6 months. Patients are urged
to continue with therapy for at least 6 months to give it an adequate
chance to relieve symptoms.
Elmiron's side effects are limited primarily to minor gastrointestinal
discomfort. A small minority of patients experienced some hair loss, but
hair grew back when they stopped taking the drug. Researchers have found
no negative interactions between Elmiron and other medications.
Elmiron may affect liver function, which should therefore be monitored
by the doctor.
Because Elmiron has not been tested in pregnant women, the manufacturer
recommends that it not be used during pregnancy, except in the most severe
cases.
Other Oral Medications
Aspirin and ibuprofen are easy to
obtain and may be a first line of defense against mild discomfort. Doctors
may recommend other drugs to relieve pain.
Some patients have experienced improvement in their urinary symptoms by
taking antidepressants or antihistamines. Antidepressants help reduce pain
and may also help patients deal with the psychological stress that
accompanies living with chronic pain. In patients with severe pain,
narcotic analgesics such as Tylenol with codeine or longer acting
narcotics may be necessary.
All drugs--even those sold over the counter--have side effects.
Patients should always consult a doctor before using any drug for an
extended time.
Transcutaneous Electrical Nerve Stimulation
With
transcutaneous electrical nerve stimulation (TENS), mild electric pulses
enter the body for minutes to hours two or more times a day either through
wires placed on the lower back or just above the pubic area, between the
navel and the pubic hair, or through special devices inserted into the
vagina in women or into the rectum in men. Although scientists do not know
exactly how TENS works, it has been suggested that the electric pulses may
increase blood flow to the bladder, strengthen pelvic muscles that help
control the bladder, or trigger the release of substances that block pain.
TENS is relatively inexpensive and allows the patient to take an active
part in treatment. Within some guidelines, the patient decides when, how
long, and at what intensity TENS will be used. It has been most helpful in
relieving pain and decreasing frequency in patients with Hunner's ulcers.
Smokers do not respond as well as nonsmokers. If TENS is going to help,
improvement is usually apparent in 3 to 4 months.
Diet
There is no scientific evidence linking diet to IC, but
many doctors and patients find that alcohol, tomatoes, spices, chocolate,
caffeinated and citrus beverages, and high-acid foods may contribute to
bladder irritation and inflammation. Some patients also note that their
symptoms worsen after eating or drinking products containing artificial
sweeteners. Patients may try eliminating various products from their diet
and reintroducing them one at a time to determine which, if any, affect
symptoms. It is important, however, to maintain a varied, well-balanced
diet.
Smoking
Many patients feel that smoking makes their symptoms
worse. Because smoking is the major known cause of bladder cancer, one of
the best things smokers can do for their bladder is to quit.
Exercise
Many patients feel that gentle stretching exercises
help relieve IC symptoms.
Bladder Training
People who have found adequate relief from
pain may be able to reduce frequency by using bladder training techniques.
Methods vary, but basically patients decide to void (that is, empty their
bladder) at designated times and use relaxation techniques and
distractions to keep to the schedule. Gradually, patients try to lengthen
the time between scheduled voids. A diary that records voiding times is
usually helpful in keeping track of progress.
Surgery
Many approaches and techniques are used, each of
which has its own advantages and complications that should be discussed
with a surgeon. Surgery should be considered only if all available
treatments have failed and the pain is disabling. Most doctors are
reluctant to operate because the outcome is unpredictable--some people
still have symptoms after surgery.
Those considering surgery should discuss the potential risks and
benefits, side effects, and long- and short-term complications with a
surgeon and with their family, as well as with people who have already had
the procedure. Surgery requires anesthesia, hospitalization, and weeks or
months of recovery, and as the complexity of the procedure increases, so
do the chances for complications and failure.
To locate a surgeon experienced in performing specific procedures,
check with your doctor.
Two procedures--fulguration and resection of ulcers--can
be done with instruments inserted through the urethra. Fulguration
involves burning Hunner's ulcers with electricity or a laser. When the
area heals, the dead tissue and the ulcer fall off, leaving new, healthy
tissue behind. Resection involves cutting around and removing the ulcers.
Both treatments are done under anesthesia and use special instruments
inserted into the bladder through a cystoscope. Laser surgery in the
urinary tract should be reserved for patients with Hunner's ulcers and
should be done only by doctors who have had special training and have the
expertise needed to perform the procedure.
Another surgical treatment is augmentation, which makes the bladder
larger. In most procedures, scarred, ulcerated, and inflamed sections of
the patient's bladder are removed, leaving only the base of the bladder
and healthy tissue. A piece of the patient's bowel (large intestine) is
then removed, reshaped, and attached to what remains of the bladder. After
the incisions heal, the patient may void less frequently. The effect on
pain varies greatly; IC can sometimes recur on the segment of bowel used
to enlarge the bladder.
Even in carefully selected patients--those with small, contracted
bladders--pain, frequency, and urgency may remain or return after surgery,
and the patient may have additional problems with infections in the new
bladder and difficulty absorbing nutrients from the shortened intestine.
Some patients are incontinent, while others cannot void at all and must
insert a catheter into the urethra to empty the bladder.
Bladder removal, called a cystectomy, is another surgical
option. Once the bladder has been removed, different methods can be used
to reroute urine. In most cases, ureters are attached to a piece of bowel
that opens onto the skin of the abdomen; this procedure is called a
urostomy, and the opening is called a stoma. Urine empties through the
stoma into a bag outside the body. Some urologists are using a second
technique that also requires a stoma but allows urine to be stored in a
pouch inside the abdomen. At intervals throughout the day, the patient
puts a catheter into the stoma and empties the pouch. Patients with either
type of urostomy must be very careful to keep the area in and around the
stoma clean to prevent infection. Serious potential complications may
include kidney infection and small bowel obstruction.
A third method to reroute urine involves making a new bladder from a
piece of the patient's bowel and attaching it to the urethra. After
healing, the patient may be able to empty the newly formed bladder by
voiding at scheduled times or by inserting a catheter into the urethra.
Few surgeons have the special training and expertise needed to perform
this procedure.
Even after total bladder removal, some patients still experience
variable IC symptoms in the form of phantom pain. Therefore, the decision
to undergo a cystectomy should be undertaken only after testing all
alternative methods and after seriously considering the potential outcome.
A surgical variation of TENS, called saccral nerve root stimulation,
involves permanent implantation of electrodes and a unit emitting
continuous electrical pulses. Studies of this experimental procedure are
now under way.
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