1. Interstitial cystitis/painful bladder syndrome
Michelle Fanning-Hursh
Nursing 870, Spring 2016

2. Definition
Interstitial cystitis (IC) also known as painful bladder syndrome (PBS) is “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes”.
(American Urological Association, 2016, p. 6)

3. Pathogenesis
The exact cause of IC/PBS is unknown, but evidence is growing that urothelial dysfunction is the primary etiology.
a protein molecule called glycosaminoglycans that is in the urothelium of the bladder that functions to prevent bacteria from sticking to the bladder wall and they secrete mucous that forms a barrier between the urine and bladder wall.
dysfunction with the glycosaminoglycans allows the bladder wall to absorb urea and potassium which in turn affects nerves in the bladder wall and release of mast cells which cause inflammation.
Martin, Sheaves, and Childers (2015) & McCance and Huether (2014)
Urothelial tissue is specific to the urinary tract and it is highly elastic. This urothelial tissue has a thick layer of protective glycoprotein.
Dysfunction with the glycosaminoglycans allows the bladder wall to absorb urea and potassium which in turn affects nerves in the bladder wall and release of mast cells which cause inflammation.
Hydrodistention– saline is instilled into the bladder during a cystoscopy and you are able to visualize small petechial hemorrgages (aka glomerulations) in patients with interstitial cystitis.
If larger damaged, hemorrhagic areas known as Hunner’s Ulcers are seen then the more severe “ulcerative” type of interstitial cystitis is diagnosed. These ulcers can lead to fibrosis and shrinkage of the bladder with decreased bladder volume.

4. Clinical Manifestations
pain/discomfort with bladder filling and relief with emptying bladder (pain is the hallmark symptom)
Frequency
Urgency
Nocturia
(Cash & Glass, 2014)

5. Other Signs and Symptoms
Pain during vaginal intercourse
Low back pain with bladder filling
Increase in symptoms during menstruation
Pain/pressure/discomfort of suprapubic area, urethra, vulva, vagina, rectum, lower abdomen, and back
(Cash and Glass, 2014 & Goroll and Mulley, 2014 & Rovner, Goudelocke, and Ellett (2015) )

6. SUBJECTIVE DATA History, history, history…
Review onset, frequency, duration, and severity of symptoms
Is pain relieved by voiding?
Is voiding done to relieve pain or to avoid incontinence?
Are there any dietary triggers such as citrus, alcohol, caffeinated beverages, tomatoes, spicy foods, acidic foods?
Do your symptoms increase after stress, exercise, intercourse, being seated for long periods, or during the menstrual cycle?
(Cash and Glass, 2014 & Goroll and Mulley, 2014)
Because this disease is often undiagnosed, in part due to it being a diagnosis of exclusion, the role of history taking is imperative.
Over active bladder versus IC

7. SUBJECTIVE DATA Any other chronic pain syndromes?
Any GU surgeries or cancer?
Any hx of UTIs, urinary retention, or urinary tract stones?
How much is your quality of life affected (sleep disturbance, loss of work, avoidance of activities)?
(Cash and Glass, 2014 & Goroll and Mulley, 2014)
IBS, chronic fatigue syndrome, fibromyalgia, lupus—often see with IC
Pelvic radiation or cyclophosphamide (chemo drug)

8. OBJECTIVE DATA Vitals: temperature to r/o infection
Neurological: brief exam to r/o occult neurological problem
General: note appearance for signs of depression
Palpate: back (IC can cause back pain), and percuss CVAs. Abdomen for suprapubic tendrness, masses, or hernias.
(Cash and Glass, 2014 & Butrick, C. W., Howard, F. M., & Sand, P. K. (2010)
General– often depressed due to lack of sleep from nocturia and poor quality of life
Pelvic– may have discomfort with IC

9. OBJECTIVE DATA Pelvic:
Rule out sources of possible infection (vaginitis, herpes, urethritis, tender prostate)
Palpation of external genitalia, bladder base and urethra
Pain with urethral palpation in the presence of an anterior vaginal wall mass may be a ureteral diverticulm
Palpation of pelvic floor to check for tenderness/trigger points
Cervical motion tenderness (PID)
Speculum exam finding that r/o IC= prolapse, vaginitis, herpes
(Cash and Glass, 2014 & Butrick, C. W., Howard, F. M., & Sand, P. K. (2010)
General– often depressed due to lack of sleep from nocturia and poor quality of life
Pelvic– may have discomfort with IC

10. LABS/DIAGNOSTICS
Urinalysis, urine culture, and uriary cytologies are obtained to examine for infectious causes and bladder malignancy
Complicatied cases will require a cystoscopy by a urologist. This would reveal the glomerulations (submucosal hemorrgage) or Hunner ulcers that may be seen with IC. Biopsy should be done to r/o other causes at this time.
There is no definitive test for interstitial cystitis
(Cash and Glass, 2014 & Papadakis, McPhee, & Rabow , 2016)

11. DIFFERENTIAL DIAGNOSIS
UTI
IBS
Endometriosis
Vulvodynia
BPH
Chronic prostatitis
Red Flags
Bladder cancer (smoking hx, hematuria)
Spinal tumor (incontinence, muscle weakness, loss of sensation)

12. INTERSTITIAL CYSTITIS
TREATMENT FOR
INTERSTITIAL
CYSTITIS

13. (American Urological Association, 2016)
This is the American Urological Association treatment algorithm.
An important point is that pain management is paramount throughout the course of treatment.
The algorithm allows you to treat your pt on an individualized basis d/t the varied response to treatment.
Treatment should move in a most conservative to a least conservative manner.
Multiple, simultaneous treatments can be considered.
(American Urological Association, 2016)

14. TREATMENT Behavior modification Psychosocial support, treat depression
Dietary modifications
Treat any comorbid infections
Laser or electrocautery of Hunner’s ulcers is present
*fluid restriciton, timed voids

15. TREATMENT (Cash and Glass, 2014) Pharmacologic Treatments:
Pentosan polysulfate sodium (Elmiron) 100mg PO three times daily
Amitriptyline (Elavil). Used in other pain syndromes also. Take at bedtime. Self-titrate dose of 25mg orally every night and increase in increments of 25mg every week to a maximum dose of 100mg
NSAIDs
Hydroxyzine hydrochloride (Vistaril) 25 to 75mg orally at bedtime
Gabapentin 300 to 2,400mg in divided doses with careful titration d/t sedation
(Cash and Glass, 2014)
Elmiron– only oral drug FDA approved for IC
Bladder instillations– various drugs used (DMSO, heparin, lidocaine, cocktail)

16. TREATMENT
Botulinum toxin A injections –if other treatment options fail. Can cause need for posttreatment intermittent self-catherization
LAST RESORT
SURGERY:
Cystoplasty
Urinary diversion w/ or w/out cystectomy
(Cash and Glass, 2014)
Botulinum– approx. 20 injections through the bladder via cystoscopy by a urologist.
The American Urology Association has recently updated their guidelines to reflect new research findings on this topic. This is what my journal article critique was on and the reference is included at the end of this power point presentation.

17. Outcome/Prognosis IC is a chronic condition with a variable course
It is characterized by periods of exacerbations and remissions
It is estimated that about 10% of IC patients fail to have acceptable symptom management with conservative methods
This disease can have a significant impact on quality of life with a huge psychological impact
(Borch et al., 2011)
???talk about surgery here??

18. QUESTIONS?

19. References
American Urological Association. American Urological Association (AUA) guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Retrieved April 1, 2016, from syndrome.cfm.
Cash, J. C. & Glass, C. A. (2014). Family Practice Guidelines (3rd ed.). New York, NY: Springer Publishing Company.
Goroll, A. H. & Mulley, A. G. (2014). Primary care medicine (7th ed.). Philadelphia, PA: Wolters Kluwer Health.
Butrick, C. W., Howard, F. M., & Sand, P. K. (2010). Diagnosis and treatment of interstitial cystitis/painful bladder syndrome: A review. Journal of Women’s Health, 19(6),
Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2016). Current medical diagnosis & treatment New York, NY: McGraw-Hill Education.
Rovner, E. S., Goudelocke, C. M., & Ellett, J. D. (2015). Interstitial cystitis. Retrieved April 11, 2016, from

20. References
Borch, M., Baron, B., Davey, A., Hattala, P., Kiernan, M., Rust, K., … Yovanovich, J. (2011). Management of patients with interstitial cystitis: A case study. Urologic Nursing, 31(3),