Therapy of the Bladder Pain Syndrome and Interstitial Cystitis (2/2)
Conservative treatment of bladder pain syndrome/interstitial cystitis
Following interventions are used to alleviate the symptoms of bladder pain syndrome. There is only limited evidence from controlled trials availability:
- Stress reduction, warm tub baths, pelvic floor relaxation exercises with biofeedback.
- Behavioral therapy (bladder training) to increase bladder capacity: a treatment option if frequency with only minor pain is present. Some authors presented satisfactory results (halving urinary frequency, increasing the functional bladder capacity)
- Acupuncture: sometimes leads to symptomatic improvement with no change in the objective parameters.
- Dietary restrictions: avoid caffeine, alcohol, artificial sweeteners, hot spices, and beverages that might acidify the urine.
Drug therapy of the bladder pain syndrome/Interstitial Cystitis
Pentosan polysulfate (PPS):
100 mg p.o. 1-1-1, pentosan polysulfate is thought to reduce the permeability of the urothelium, the treatment effect should be assessed after six months of therapy. Only minor efficacy was demonstrated in randomized trials, after six months improvement in 30% of the patients (Sant et al, 2003).
Hydroxycine is an antihistamine (H1 antagonist), dosage is 25 mg p.o. 0-0-1 for 1 week, then the dosage is increased to the dose to 25 mg in the morning and 50 mg at night. Good results were reported in patients with evidence of allergies, however, a randomized trial could not demonstrate efficacy (Sant et al, 2003).
Amitriptyline dosage 25 mg 0-0-1 gradually increasing to 75 mg 0-0-1. Efficiency is based on anticholinergic, antihistaminic and adrenergic effects. One third of the patients reported a persistent improvement of symptoms. Sedation is the main side effect. Caution: cardiac toxicity is possible.
Pain medication is prescribed according to the WHO analgesic ladder: non-steroidal analgesic combined if necessary with an opioid.
Good responses are reported with cyclosporine. Problematic are the severe side effects of immunosuppressive drugs, thus they are only an option if an autoimmune disease is also present.
Antibiotics are used if a positive urine culture is present. One empirical course of antibiotics may be given at the onset of bladder symptoms. Low effectiveness has been reported for the use of antibiotics without proven urinary tract infection.
There are numerous studies with promising results for several drugs, however the results were never confirmed by other authors or by prospectively randomized studies: L-Arginine (NO donor), anticholinergics (only indicated for overactive bladder), misoprostol (oral prostaglandine), montelukast (leukotriene antagonist), prednisolone, nifedipine (calcium antagonist), cimetidine (H2 antihistamines).
Hydrodistention of the Bladder:
Hydrodistention of the bladder under anesthesia is usually the first treatment attempt, as it has also diagnostic significance. The bladder is filled with water to a pressure of 80–100 cm of water over 5–8 min. An improvement of symptoms can be expected in only a subset of patients (20%). The mechanisms are unclear and might involve damage to the mucosal afferent nerve endings.
Intravesical Instillations for the Regeneration of the GAG Layer:
The regeneration of the GAG layer is thought to improve the increased permeability of the urothelium. Pentosan polysulfate, heparin, chondroitin sulfate or hyaluronic acid are used for intravesical instillations individually or in combination. The instillations are usually started with weekly intervals. After treatment response, the dosing interval can be increased to monthly instillations.
Therapy is very expensive depending on the product. There are few randomized trials which have demonstrated only a limited or statistically insignificant effect (Nickel et al, 2012) (Madersbacher et al, 2012). Neither preparation has been approved for use in the United States.
Miscellaneous Drugs for Intravesical Therapy:
- Lidocaine and dexamethasone in combination with iontophoresis (EMDA), optionally followed by a hydrodistention of the bladder without anesthesia.
- Intradetrusor injections of botulinum toxin A
Surgical Treatment Options for Interstitial Cystitis
Transurethral resection or coagulation of Hunner's ulcers, with loop or with laser fulguration. Initial good improvement, but high relapse rate in 1–3 years. Prospective studies do not exist.
Sacral Nerve Stimulation:
Sacral nerve stimulation improves subjective and objective symptoms, so far there are only small uncontrolled studies with short follow-up available. This also applies to the transcutaneous electrical nerve stimulation (TENS).
Open surgical treatment for Interstitial Cystitis:
Open surgery remains the last resort after unsuccessful medical or interventional treatment. Surgical therapy is a good option for patients with agonizing urinary frequency due to diminished bladder capacity (less than 250 ml under anesthesia). Surgery is less reliable in eliminating chronic pain. Even after radical cystectomy and urinary diversion, a significant proportion of patients are not cured from their chronic pain syndrome.
Bladder augmentation (supratrigonal cystectomy):
The trigone of the bladder is kept and the bladder wall is reconstructed with bowel .
Surgical alternative to bladder augmentation. The entire bladder is removed as a possible symptom source, the disadvantage is the need for ureter-intestinal anastomosis.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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