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Most of these treatment strategies we are all familiar with. What struck me though was that the success rate for oral Elmiron was only 35%. And also, they again recommend pain therapy yet so many doctors won't touch it.
•Medical therapy
◦Tricyclic antidepressants
■Hydroxyzine
◦Sodium pentosanpolysulfate
◦Analgesics
•Intravesical therapy
◦Older rarely used therapies
■Silver nitrate
■Intravesical Clorpactin WCS 90
◦Dimethylsulfoxide (DMSO)
■A product of the wood pulp industry and a derivative of lignin, DMSO has exceptional solvent properties and is freely miscible with water, lipids, and organic agents. Pharmacologic properties include membrane penetration, enhanced drug absorption, anti-inflammatory, analgesic, collagen dissolution, muscle relaxant, and mast cell histamine-release.
■Approved for use in IC, it is generally given weekly for six weeks intravesically via catheter as 50cc of a 50% solution of DMSO (Rimso-50). A garlic odor is the predominant side effect. Success rates of 60-80% have been reported, though duration of effect is generally less than 6 months.
◦Exogenous glycoaminoglycans
■Heparin
■Sodium pentosanpolysulfate
◦BCG
■Results of a National Institutes of Health trial instilling intravesical bacillus Calmette-Guerin on a weekly basis for 6 weeks should be available in early 2004.
◦Resiniferatoxin
■A specific neurotoxin that desensitizes C fiber afferent neurons. Clinical trials in bladder pain, urgency/frequency are underway.
•Nerve Stimulation
◦Transcutaneous electrical nerve stimulation (TENS)
◦Acupuncture
◦Direct sacral nerve stimulation
■Trial stimulation is performed with a percutaneous temporary electrode for a 3 to 4 day temporary stimulation period to access efficacy. The S3 nerve is most frequently used. A wire electrode is inserted into the foramen and connected to an external pulse generator (Medtronic Inc., Minneapolis, Minnesota, USA).
■If the trial is successful, the patient can be considered for implantation of a permanent neural prosthesis. Neuromodulation has been shown to be effective in treating refractory urinary urge incontinence. Studies on therapeutic potential for interstitial cystitis are underway.
•Surgical therapy
◦Transurethral resection of a Hunner's ulcer
■By electro-cautery or laser therapy, local destruction of a Hunner's ulcer can improve symptoms for 6-12 months in some patients.
◦Major surgical procedures for the therapy of interstitial cystitis provide options after all trials of conservative treatment have failed.
◦Supratrigonal cystectomy and the formation of an enterovesical anastomosis with bowel segments
◦Urinary diversion
■With continent diversion
■With ileal conduit
■With cystectomy and orthotopic neobladder or Indiana pouch
■Beware of development of pain in pouch or neobladder
◦50% overall success rate of major surgery in literature as pain may persist or reoccur months or years after surgery.
•Strategy for management
◦As a rule, in the patient who does not respond to the initial diagnostic distention, and self-help protocols, oral therapy with amitriptyline or hydroxyzine is a noninvasive way to begin treatment. Patients who fail to demonstrate a satisfactory response in 6-10 weeks can be started on oral sodium pentosanpolysulfate. The antihistamine or tricyclic antidepressant can be discontinued if no response was noted, or continued if some limited efficacy was perceived. Sodium pentosanpolysulfate can be expected to be beneficial in one-third of patients. If no response is noted in 6-9 months, there is no point in continuing it.
◦Intravesical therapies are an important second-line strategy. A consultation with a pain center and consideration of analgesic treatment should be considered before a major surgical procedure is entertained.
•Medical therapy
◦Tricyclic antidepressants
■Amitriptyline
■10mg hs increasing over 5 weeks to 50mg hs
■Maximum dose 75-100mg
■Analgesic, antihistaminic, sedative properties
■One-third of patients cannot tolerate due to tricyclic antidepressant side effects (especially sedation)
◦Antihistamines ■10mg hs increasing over 5 weeks to 50mg hs
■Maximum dose 75-100mg
■Analgesic, antihistaminic, sedative properties
■One-third of patients cannot tolerate due to tricyclic antidepressant side effects (especially sedation)
■Hydroxyzine
■The unique piperazine H1-receptor antagonist hydroxyzine can block neuronal activation of mast cells
■25mg before bed increasing over 2 weeks (if sedation not a problem) to 50mg at night and 25mg in the morning
■25mg before bed increasing over 2 weeks (if sedation not a problem) to 50mg at night and 25mg in the morning
◦Sodium pentosanpolysulfate
■A heparin analogue available in an oral formulation, 3-6% of which is excreted into the urine. It is sold under the trade name Elmiron.
■The only oral agent approved for the treatment of the pain associated with interstitial cystitis, it is a sulfated mucopolysaccharide intended to remedy the purported defect in the epithelial permeability barrier, the glycosaminoglycan (GAG) layer, that may contribute to the pathogenesis of IC.
■Given at a dose of 100mg three times daily, improvement is noted in about 35% of patients within 6 months. Side effects include a 4% chance of reversible hair loss, gastrointestinal upset and allergic rashes in some patients.
■The only oral agent approved for the treatment of the pain associated with interstitial cystitis, it is a sulfated mucopolysaccharide intended to remedy the purported defect in the epithelial permeability barrier, the glycosaminoglycan (GAG) layer, that may contribute to the pathogenesis of IC.
■Given at a dose of 100mg three times daily, improvement is noted in about 35% of patients within 6 months. Side effects include a 4% chance of reversible hair loss, gastrointestinal upset and allergic rashes in some patients.
◦Analgesics
■The long-term, appropriate use of pain medications forms an integral part of the treatment of a chronic pain condition like interstitial cystitis. Most patients can be helped markedly with medical pain management using pain medications commonly used for chronic neuropathic pain syndromes including antidepressants, anticonvulsants, and opioids.
•Intravesical therapy
◦Older rarely used therapies
■Silver nitrate
■Intravesical Clorpactin WCS 90
◦Dimethylsulfoxide (DMSO)
■A product of the wood pulp industry and a derivative of lignin, DMSO has exceptional solvent properties and is freely miscible with water, lipids, and organic agents. Pharmacologic properties include membrane penetration, enhanced drug absorption, anti-inflammatory, analgesic, collagen dissolution, muscle relaxant, and mast cell histamine-release.
■Approved for use in IC, it is generally given weekly for six weeks intravesically via catheter as 50cc of a 50% solution of DMSO (Rimso-50). A garlic odor is the predominant side effect. Success rates of 60-80% have been reported, though duration of effect is generally less than 6 months.
◦Exogenous glycoaminoglycans
■Heparin
■Sodium pentosanpolysulfate
◦BCG
■Results of a National Institutes of Health trial instilling intravesical bacillus Calmette-Guerin on a weekly basis for 6 weeks should be available in early 2004.
◦Resiniferatoxin
■A specific neurotoxin that desensitizes C fiber afferent neurons. Clinical trials in bladder pain, urgency/frequency are underway.
•Nerve Stimulation
◦Transcutaneous electrical nerve stimulation (TENS)
◦Acupuncture
◦Direct sacral nerve stimulation
■Trial stimulation is performed with a percutaneous temporary electrode for a 3 to 4 day temporary stimulation period to access efficacy. The S3 nerve is most frequently used. A wire electrode is inserted into the foramen and connected to an external pulse generator (Medtronic Inc., Minneapolis, Minnesota, USA).
■If the trial is successful, the patient can be considered for implantation of a permanent neural prosthesis. Neuromodulation has been shown to be effective in treating refractory urinary urge incontinence. Studies on therapeutic potential for interstitial cystitis are underway.
•Surgical therapy
◦Transurethral resection of a Hunner's ulcer
■By electro-cautery or laser therapy, local destruction of a Hunner's ulcer can improve symptoms for 6-12 months in some patients.
◦Major surgical procedures for the therapy of interstitial cystitis provide options after all trials of conservative treatment have failed.
◦Supratrigonal cystectomy and the formation of an enterovesical anastomosis with bowel segments
◦Urinary diversion
■With continent diversion
■With ileal conduit
■With cystectomy and orthotopic neobladder or Indiana pouch
■Beware of development of pain in pouch or neobladder
◦50% overall success rate of major surgery in literature as pain may persist or reoccur months or years after surgery.
•Strategy for management
◦As a rule, in the patient who does not respond to the initial diagnostic distention, and self-help protocols, oral therapy with amitriptyline or hydroxyzine is a noninvasive way to begin treatment. Patients who fail to demonstrate a satisfactory response in 6-10 weeks can be started on oral sodium pentosanpolysulfate. The antihistamine or tricyclic antidepressant can be discontinued if no response was noted, or continued if some limited efficacy was perceived. Sodium pentosanpolysulfate can be expected to be beneficial in one-third of patients. If no response is noted in 6-9 months, there is no point in continuing it.
◦Intravesical therapies are an important second-line strategy. A consultation with a pain center and consideration of analgesic treatment should be considered before a major surgical procedure is entertained.