Cystitis, Interstitial

Essentials of Diagnosis

• Pain with bladder filling or urinary urgency

• Submucosal petechiae or ulcers on cystoscopic examination

• Diagnosis of exclusion

General Considerations

• Etiology unknown

• Most likely several diseases with similar symptoms

• Associated diagnoses include severe allergies, irritable bowel syndrome, or inflammatory bowel disease

Demographics

• Prevalence of between 18 and 40 per 100,000 people

• Both sexes, but majority of patients are women

• Mean age at onset of 40 years

Symptoms and Signs

• Pain, pressure, or discomfort with bladder filling that is relieved with urination

• Urgency, frequency, and nocturia

• Physical examination should exclude genital herpes, vaginitis, or urethral diverticulum

Differential Diagnosis

• Up to 40% of patients referred to urologists for interstitial cystitis are found to have a different diagnosis after careful evaluation

• Exposure to radiation (radiation cystitis) or cyclophosphamide (chemical cystitis)

• Bacterial vaginitis

• Genital herpes

• Urethral diverticulum

• Urethral carcinoma

• Bladder carcinoma

• Eosinophilic cystitis

• Tuberculous cystitis

Laboratory Tests

• Urinalysis and urine culture to exclude infectious causes

• Urinary cytology to exclude bladder malignancy

Diagnostic Procedures

• Urodynamic testing can be done to assess bladder sensation and compliance and to exclude detrusor instability

• Cystoscopy may reveal glomerulations (submucosal hemorrhage) with hydrodistention of the bladder

• Total bladder capacity should be determined

• Biopsy of any suspicious lesions should be performed to exclude other causes, such as carcinoma, eosinophilic cystitis, and tuberculous cystitis

Diet

• Avoid foods that exacerbate symptoms (eg, tomatoes)

Medications

• Amitriptyline (10–75 mg/day orally) is often used as first-line medical therapy

• Nifedipine (30–60 mg/day orally) and other calcium channel blockers have also demonstrated some activity

• Pentosan polysulfate sodium (Elmiron)—an oral synthetic sulfated polysaccharide—helps restore integrity to the epithelium of the bladder

• Intravesical instillation of dimethyl sulfoxide (DMSO) or heparin

• Intravesical bacillus Calmette-Guérin is not beneficial

Surgery

• Cystourethrectomy with urinary diversion in extreme cases

Procedures

• Transcutaneous electric nerve stimulation (TENS)

• Acupuncture

• Stress reduction

• Exercise

• Biofeedback

• Massage

• Pelvic floor relaxation

Prognosis

• No cure, but most patients achieve symptomatic relief

When to Refer

• Persistent and bothersome symptoms in the absence of identifiable cause