Breaking Down Interstitial Cystitis

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Esther Han, a FPMRS physician specializing in bladder and pelvic floor health, discuss diagnosis and management of interstitial cystitis in women.

Firstly, Dr. Han explains her workup of patients with suspected interstitial cystitis (IC). Because an accurate diagnosis of IC is so rare, she sends out multiple questionnaires to her patients before their appointments and performs thorough physical exams. Upon physical examination, other conditions may appear to be more likely than IC, such as genitourinary syndrome of menopause (GSM), lichen sclerosus, vaginal atrophy, or vulvodynia. She always assesses the pelvic floor to look for hypertonicity and knots. Another common cause of bladder pain is overactive bladder (OAB) and recurrent urinary tract infections (UTI), for which she can prove with a positive bacterial culture. Aside from the physical exam, she also gets a post-void residual urine test and a urinalysis. IC falls into two subtypes–IC with Hunner’s lesions and IC without Hunner’s lesions. The latter subtype is more common and is rarely seen in younger patients and patients with frequency symptoms. For this reason, Dr. Han does not regularly perform cystoscopies on young patients. Additionally, many patients with bladder pain will not be able to tolerate a cystoscopy procedure, so she relies on the physical exam and a health history to make a diagnosis.

Treatment for bladder and pelvic pain is multimodal–many of her patients will work with physical therapists and pain management physicians for their chronic pain. Her first-line therapy for bladder pain is pelvic floor physical therapy, although the pain may get worse before it improves with therapy. She also recommends suppository vaginal Valium if needed, but thinks that more research should be done on suppository CBD. She does not prescribe opioids for pain management. If the patient has vulvodynia, hormone therapy with estrogen/testosterone creams is her chosen treatment. She notes that it is important to explain to patients that local application of estrogen does not increase their chance of developing breast cancer.

Her second-line therapy includes amitriptyline, for anxiety-driven IC, and IC cocktails, which should only be continued if the patient’s symptoms are improving. Her third-line therapy is repetitive hydrodistention, but she only performs this procedure in patients with Hunner’s lesions. Additionally, Cyclosporin A should only be used exclusively in patients with Hunner’s lesions. If the patient is experiencing concurrent pudendal pain, Stimwave pudendal neuromodulation is a possibility. Dr. Han uses clues, such as pain while sitting down, excessive standing, and pain relief when laying down to diagnose patients with pudendal pain. Her last resort to bladder pain is a cystectomy, or complete removal of the bladder. She notes that this method is not very effective, as patients may experience phantom pain. For this reason, she makes sure to explore all other options and thoroughly counsel her patients before performing this procedure.

Finally, Dr. Silva and Dr. Han discuss the evidence-based correlation between bladder pain and sexual abuse. Dr. Han encourages urologists to create a safe space for their patients to share their experiences and get quality referrals to counselors.