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Interstitial Cystits: A lesser known chronic pain issue

 

Today's post focuses on a little different chronic pain issue..interstitial cystitis.  I wrote this piece a few years ago when we had a patient in our hospital who suffered from this condition, and questions arose about appropriate medication therapy for the condition.  This document is mostly about the medical treatment, as the patient was an inpatient at the time.  Years later, I have been wondering about her current situation.  I am hoping that she is aware of the many non drug pain management therapies available, and if she has tried any of them.  While modern medicine is truly miraculous, a healthy lifestyle can go a long way to enhance the effectiveness of treatment.

 

 

Multi modal Therapy for Interstitial Cystitis

Marietta Ledonne, RPH

Interstitial cystitis is a poorly understood medical condition of uncertain etiology. Patients with this diagnosis experience a range of symptoms, including urgency, frequency, and pelvic pain. It is proposed that symptoms arise from a multitude of factors including epithelial dysfunction, mast cell activation, and neurogenic inflammation.
A good treatment approach to this disease is multi modal and should include the following:
1) Pentosan polysulfate sodium (Elmiron) is the cornerstone of therapy for interstitial cystitis
Therapeutically, is is similar to low molecular weight heparin drugs. Therefore there is an increase bleed risk when a patient is on this drug. From a pain management perspective this is important because some of the analgesics you might choose (such as ibuprofen/NSAIDS) also increase bleeding risk.
2) Antihistamines are used to block the effect of mast cell input into the disease process. Non sedating antihistamines such as loratadine can be used. Diphenhydramine and hydroxyzine have also been tried for this purpose; the anticholinergic effects of these agents can help to reduce the urgency and frequency that the patientmay experience. However, these agents are also more sedating than newer antihistamines and may affect the
patient's ability to function with daily activity.
3) Tricyclic antidepressants are of significant benefit to a patient with interstitial cystitis. These drugs can help reduce the chronic pain levels that the patient may experience and increase the overall quality of life. The anticholinergic effect also helps to decrease urgency and frequency symptoms and provide a better quality of sleep. Alternatively, duloxetine and venlafaxine can be used; these drugs can help improve the patient's sense of
well being However, they do not offer the anticholinergic benefits of the tricyclics.
4) Gabapentin or pregabalin can be included in the patients regimen to help modulate the chronic pain of interstitial cystitis. Including these drugs in the regimen can help to reduce the patients dependency on opioids and/or NSAIDS, aspirin, acetaminophen, etc.
5) Intermittent use of urinary analgesics and antiseptics such as phenazopyridine are useful on a short term basis when a patient has breakthrough pain, after urologic instrumentation, etc. Diazepam can help to relax the pelvic floor and ease voiding.
6) Intravesical agents have been used for disease flare ups or failure of oral therapies. DMSO is the best known agent for this procedure; hyaluronidase and BCG have also been tried.

                                                                      References 
Treatment Approaches for Interstitial Cystitis: Multimodality Therapy
Robert J. Evans. MD
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476004/
Mayo Clinic Health Information: Interstitial Cystitis
http://www.mayoclinic.com/health/interstitial-cystitis/DS00497/DSECTION=treatments-and-drugs
Drug Information for Elmiron: Drugs.com
http://www.drugs.com/mtm/elmiron.html

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