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Treating interstitial cystitis

Interstitial cystitis is a chronic inflammation of the bladder that causes people to urinate -- sometimes painfully -- as often as 40, 50, or 60 times a day. Their quality of life, research suggests, resembles that of a person on kidney dialysis or suffering from chronic cancer pain. Not surprisingly, the condition is officially recognized as a disability.

There's no cure for interstitial cystitis, but many treatments offer some relief, either on their own or in combination.

Treatment (see chart) is aimed at relieving pain and reducing inflammation. The two main approaches are oral medications and bladder instillations -- drugs that are introduced into the bladder by catheter and held for 15 minutes. The procedure usually takes place in a physician's office, but in some cases these drugs can be self-administered at home.

Common treatments for interstitial cystitis

Treatment Comment
Oral drugs

Tricyclic antidepressants

Taken at low doses, tricyclic antidepressants relax the bladder and interfere with the release of neurochemicals that can cause bladder pain and inflammation. They may also improve sleep. Amitriptyline is the medication most commonly prescribed for interstitial cystitis.

Pentosan polysulfate sodium (Elmiron)

Elmiron is the only oral drug approved by the FDA specifically for interstitial cystitis. It improves the bladder lining, making it less leaky and therefore less inflamed and painful. The full effect may take three to six months. Side effects, which are rare, include reversible hair loss, diarrhea, nausea, and rash.

Antihistamines

Antihistamines such as hydroxyzine (Atarax, Vistaril) interfere with the mast cells' release of histamine, helping to relieve bladder inflammation and pain, urinary frequency, and nighttime voiding. Because antihistamines can cause drowsiness, they are usually best taken at bedtime.

Painkillers

Nonsteroidal anti-inflammatory drugs (aspirin, naproxen sodium, ibuprofen) and acetaminophen can help relieve mild to moderate pain. Check with your clinician about possible side effects of long-term use of these over-the-counter medications. Opioid analgesics, such as oxycodone or hydrocodone combined with acetaminophen, may be used to treat severe pain when other forms of therapy have not worked. Because these medications can be addictive, anyone taking them should be followed carefully, for example, at a pain clinic.

Bladder instillations

Dimethyl sulfoxide (DMSO)

DMSO is the only FDA-approved bladder instillation drug for interstitial cystitis. It helps relax the bladder and alleviate pain and inflammation. Some research suggests that more than half of patients improve after six weeks of once-a-week treatments. It may cause a burning sensation during and after instillation and can cause a garlicky odor on the skin and breath for up to three days following treatment. DMSO is sometimes combined with other medications.

. Bacillus Calmette-Guerin (BCG)

. Hyaluronic acid (Cystistat)

These instillation drugs are still under study and not yet widely available. BCG is a bacterium that is thought to block inflammation and stimulate a protective immune response. Cystistat may help repair the bladder lining.

No single treatment alleviates all symptoms, and some may stop working over time, so finding what works is often a matter of trial and error. The good news is that in 50% of cases, the disease will disappear on its own.

Other options

In a procedure called transcutaneous electrical nerve stimulation (TENS), pain pathways are modified by a device worn on the body. The device produces electrical impulses, which pass through electrodes that are attached to the body with small adherent pads. Patients can adjust the level of electrical stimulation themselves. Good results have been reported in about one-quarter of those using TENS.

An implantable device called InterStim directly stimulates the sacral nerve in the lower back. Already approved for treating bladder control problems, it's now under study as a potential treatment for interstitial cystitis pain.

Some people report that stress reduction, exercise, biofeedback, or warm tub baths improve their symptoms, but no research has evaluated the effectiveness of these strategies. Bladder training -- that is, learning to urinate only at specific times (despite the urge to go) -- can help reduce urinary frequency. There's no scientific evidence linking diet to interstitial cystitis, but many people believe that their symptoms are made worse by tomatoes, chocolate, caffeine, alcohol, and beverages that acidify the urine, such as cranberry juice.

Surgery is usually a last resort and undertaken only when the pain is crippling. The surgical procedure typically involves removal of the bladder and the creation of a new one (a neobladder) using intestinal tissue. Most people need to catheterize the neobladder themselves in order to empty it.

Scientists seeking a diagnostic test have begun to identify substances unique to the urine of interstitial cystitis patients. They've also found that certain factors required for healthy cell growth appear to be missing from the urine, a discovery that could lead to a new therapy.

January 2004 Update

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