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How is Interstitial Cystitis Treated?

Interstitial Cystitis infographic

In part one we discussed what IC is, then in part two we discussed symptoms/diagnosis, and for the final part of this blog, we will cover the treatment options for IC patients and what post-treatment looks like for these patients. 

Treatment Options & Post Treatment

It’s important to remember that there isn’t a one size fits all treatment option for IC patients. Treatment plans must be customized to each patient depending on their symptoms. Patients usually try different treatments, or different combinations of treatments, until they experience symptoms relief. 

Unfortunately, none of the treatment options provide immediate relief and it usually takes weeks, or even months, before symptoms improve. Once a successful treatment plan is developed, it’s important for patients to remember their condition cannot be cured. Symptoms subsiding simply means the condition is in remission but it doesn’t mean the patient is cured. Even though IC cannot be cured, most IC patients can get significant symptom relief and live a normal life with treatment.  

Symptom control is the goal of most IC treatment plans. These treatments are typically done in phases with the doctor monitoring their pain and quality of life. It’s important for patients to talk to their doctor about the effectiveness of their treatment plan so the doctor can continue to customize their plan. 

The different phases of IC treatment are:

1. Behavioral Therapy

2. Prescription Drugs

3. Neuromodulation Therapy, Ulcer Cauterization & Injections

4. Cyclosporine

5. Surgery

First Phase: Behavioral Therapy

Behavioral therapy, or lifestyle changes, is often the first round of treatment for IC patients. Lifestyle changes involve the patient making adjustments to their day to day life. This could include changing their diet or practicing methods to help combat their symptoms. Most patients aren’t able to mitigate all of their symptoms with lifestyle changes alone but many patients report a reduction in symptoms once they adopt behavioral therapy.

Manipulative Physical Therapy

IC patients often have pelvic area pain and/or tenderness, and manipulative physical therapy can sometimes reduce these symptoms. There is medical research that suggests that pelvic floor strengthening exercises, like Kegels, can worsen symptoms and are not recommended by IC patients.

Limiting Stress

Different types of stress can also worsen symptoms for IC patients. Patients are encouraged to work on developing coping mechanisms to help manage their stress and pain. If a patient feels like they need additional help managing their stress, they can also seek out the support of a professional like a therapist. 

Limiting Certain Foods and Drinks

Some IC patients have reported that certain foods can make their symptoms worse. There are 4 foods that patients most often find irritating to their bladder: Citrus fruits, tomatoes, chocolate, and coffee are the four most common foods that IC patients report irritate their bladder. Spicy foods and certain beverages (that are alcoholic, caffeinated, or carbonated) can also irritate an IC patient’s bladder.

Elimination Diet

The list of foods that could potentially impact an IC patient is quite long and these foods don’t always impact the patients in the same way. Every individual patient will need to figure out how and what foods affect their bladder. The simplest way to accomplish this is to implement an elimination diet for a week or two. With an elimination diet, the patient will stop eating all of the foods that could be potentially irritating their bladder. These food lists are readily available from a variety of online sources including IC Help and IC Network.

If bladder symptoms improve while the patient is on the elimination diet, this means that at least one of the foods was irritating their bladder. The next step is then to figure out which of these foods is causing the irritation. This can be accomplished by adding one food from the list back into the patient’s diet every 24 hours. It’s important for the patient to go through the entire list one at a time so that the culprit can be accurately determined. Whenever the patient experiences an increase in symptoms after adding back another item on the list, that food item will be added to the patient’s list of foods to avoid in the future. 

Second Phase: Prescription Drugs

If lifestyle changes don’t make a big enough impact on the patient’s symptoms, the healthcare provider may recommend the patient try an oral or intravesical prescription drug. Drugs can be taken alone or in combination with behavioral therapy. There are different types of drugs with different potential side effects that the patient should thoroughly discuss with their doctor. Drugs can be taken orally or intravesically through a catheter placed directly into the bladder.

The two types of medications that are approved by the FDA to treat IC are: 

1. Oral Pentosan Polysulfate

It’s unknown exactly how pentosan polysulfate treats IC patients. It’s been theorized that it decreases swelling, or it builds/restores the protecting coating of the bladder tissue, along with many other theories. Side effects aren’t common but can include nausea, diarrhea, or gastric distress. A small number of patients have also reported temporary hair loss. It typically takes three to six months of treatment before patients report a reduction in symptoms and the treatment is effective for relieving pain for about 30% of IC patients who try the medication.

2. Intravesical Dimethyl Sulfoxide (DMSO)

The second FDA approved treatment is the intravesical placement of dimethyl sulfoxide (DMSO) into the bladder with a catheter. This treatment is usually performed on the patient once a week for six weeks. Some patients keep using it occasionally as a form of maintenance therapy. Similar to the pentosan polysulfate, it’s unknowingly exactly how this medication treats IC patients. It’s theorized that it might block swelling, decrease pain sensation, or remove toxins that can cause tissue damage. It’s recommended for some patients to combine DMSO with other drugs, such as steroids or heparin, to decrease inflammation. Unfortunately, there is no research if these combinations are more effective than DMSO alone. The main side effect of DMSO is a garlic-like odor that lasts for several hours after the treatment. For some patients, the catheter used to distribute the DMSO can be painful, however, this pain can often be mitigated with a local anesthetic.

Other types of medications that are used to treat IC but are not FDA approved are as follows:

Hydroxyzine

Hydroxyzine is an antihistamine that may be helpful in treating IC. It is prescribed to patients because of the theory that IC patients have an excessive amount of histamines in their bladder and this can lead to pain, as well as, other symptoms. The main side effect of hydroxyzine is drowsiness. However, this is a benefit for certain patients because it helps them sleep better, as well as, get up less frequently to urinate. Hydroxyzine and, more recently, cimetidine has been specifically studied for IC. It’s unknown whether or not other antihistamines can also help treat IC.

Amitriptyline

Amitriptyline is technically an antidepressant, but it actually has many effects that may help IC patients. It’s widely used to treat other types of chronic pain like cancer and nerve damage. It has antihistamine properties, it can decrease bladder spasms, and slow the nerves that carry pain messages through the body. The most common side effects of this medication are drowsiness, constipation, and increased appetite.

Heparin

Heparin is similar to oral pentosan polysulfate and it’s theorized that it helps the bladder using similar mechanisms. However, heparin must also be placed into the bladder with a catheter the way DMSO is distributed. Complications and side effects are rare with this medication because it stays in the bladder and doesn’t usually impact the rest of the body.

Third Phase: Neuromodulation, Ulcer Cauterization and Injections

Neuromodulation Therapy 

If behavioral therapy and prescription drugs don’t improve symptoms enough, the healthcare practitioner might recommend more advanced therapies. If the patient is interested in going this route, they will likely be referred to an IC specialist. After reviewing the patient’s IC treatment history, the specialist might suggest a form of neuromodulation therapy. This type of therapy is a group of treatments that deliver safe electrical impulses to the nerves in order to alter how the nerves function.   

Bladder Ulcer Cauterization

If the patient has a bladder ulcer, having it cauterized under anesthesia or having steroid injections could give them long-term relief (up to a year or more). This treatment can also be repeated if necessary.

Injections

If other treatments haven’t worked, some injections of Botox® can be given. Small doses of Botox® can paralyze muscles and when injected into the bladder muscle, Botox® has the potential to reduce IC pain. This treatment may wear off, and the patient may need to have a second treatment six to nine months after their first treatment. The patient’s healthcare provider should closely monitor the patient for complications after treatments, including difficulty passing urine. 

Fourth Phase: Cyclosporine

If other treatments have not been successful, the fourth phase, cyclosporine can be used.  Patients should thoroughly discuss this drug with their healthcare provider to decide if their symptoms justify the risks. There are many side effects with this medication, and because it is an immunosuppressant, it can reduce the patient’s ability to fight disease.

Fifth Phase: Surgery

The final phase, major surgery, should be reserved for patients with severe or unresponsive cases of IC, who are willing to accept the dangers and potential complications that are associated with surgery. Surgery can only be offered to patients that have a severely limited bladder capacity or other acute symptoms that are not responding to other therapies. Most patients do not get to the fifth phase and IC is not typically treated with surgery.

Post-Treatment

After Initial Treatment

The majority of patients continue their treatment plan indefinitely or at least until their symptoms return. Some patients still experience symptom flare-ups even while on treatment. For others, symptoms gradually improve and sometimes even disappear completely. 

Some patients don’t respond to any kind of therapy and rely on pain management to improve their quality of life. Pain management can include acupuncture, drugs, and other non-drug therapies. Professional pain management is typically recommended for the most severe cases.

Most patients will find that their symptoms improve with treatment, however, not all patients experience full symptom relief. Some patients may still need to urinate more frequently than the average person, have some degree of discomfort, and/or have to avoid certain foods/drinks/activities that can worsen their symptoms.

Can Interstitial Cystitis be Cured?

It’s possible for symptoms to come back after a long period of remission. It’s unknown what triggers these recurrences and there isn’t a guaranteed way to prevent them from happening. Patients can try to prevent symptoms from returning by keeping up with their treatment after remission, avoiding certain foods/beverages that may irritate the bladder, and avoiding certain activities/stresses that might make IC symptoms worse. Since the foods and activities that trigger symptoms are different for each person, each patient has to create their own plan with their doctor.

If you are an IC patient who wants additional resources or if you’re concerned that you might have a gynecological problem that is undiagnosed, please contact Mangrove Women’s Health at 530-332-9703, extension 281 to set up an appointment.

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