Interstitial cystitis is a chronic pain disorder with an estimated prevalence of 3-8 million women and 1-4 million men in the United States. However, these numbers may be underestimated given the difficulties associated with diagnosis that lead to underdiagnosis, especially in men. (31)
Given the complexity of interstitial cystitis, research suggests that a multimodal, integrative treatment plan, including diet therapy, stress management, and physiotherapy, can lead to treatment success rates of over 90%. This article will discuss a holistic approach to interstitial cystitis and provide a sample treatment plan that can be implemented in clinical practice.
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What Is Interstitial Cystitis?
Interstitial cystitis (IC) is also known as painful bladder syndrome (PBS) and bladder pain syndrome (BPS). It is a chronic pelvic pain condition characterized by recurring urinary urgency and frequency and pain or pressure in the bladder and pelvic region, lasting at least six weeks without infection or other apparent cause. IC affects millions of men and women but is most common in women in their 30s or older. (40)
Interstitial Cystitis & Symptoms
The signs and symptoms of IC can vary among individuals, and some people may experience periodic remissions and flare-ups. Common signs and symptoms of IC mimic those of a urinary tract infection (UTI):
- Pelvic pain or discomfort ranging from mild to severe is described as an aching, pressure, or burning sensation in the pelvic region and the bladder. This sensation is worsened by filling the bladder and is often relieved by urinating.
- Urinary frequency and urgency: urinating more often than usual and urgently, even when the bladder is not full. Patients often wake frequently during the night to urinate (nocturia).
- Painful urination (dysuria): urinating is accompanied by pain or a burning sensation
- Pain during sexual intercourse (dyspareunia)
Root Causes of Interstitial Cystitis
The exact cause of IC remains unknown, and it is believed to be a multifactorial condition with various contributing factors leading to inflammation.
One possible cause is a disruption in the bladder's protective lining, known as the urothelium, which can make the bladder more susceptible to irritation and inflammation. When the urothelium is healthy, it acts as a barrier, preventing irritating substances in the urine from directly contacting the underlying bladder tissue. However, the urothelium may become compromised in individuals with IC, leading to increased permeability or "leakiness." A leaky urothelium allows toxins, bacteria, and inflammatory mediators to penetrate the bladder tissue, leading to chronic bladder inflammation and irritation. (31)
Dysregulation of the immune system has been implicated in IC. It is thought that an autoimmune response or chronic low-grade inflammation in the bladder may contribute to the development and progression of the condition. Immunoglobulin and immune mediators are detected at higher levels in the urine of affected individuals. A growing body of evidence suggests a correlation between IC and histamine intolerance, as histamine released during an immune response can contribute to bladder inflammation and trigger IC symptoms in susceptible individuals. (31)
Ongoing research is exploring the connection between the urinary microbiome and IC. Traditionally, urine was believed to be sterile, but recent studies have shown that the urinary tract contains a diverse microbial community. In individuals with IC, imbalances or dysbiosis in the urinary microbiome have been observed, potentially contributing to the development or worsening of IC symptoms. It is hypothesized that these microbiome alterations may trigger chronic inflammation and immune responses in the bladder; specific microorganisms within the urinary microbiome could directly irritate the bladder or disrupt its normal function. (6)
Other factors contributing to IC include pelvic floor dysfunction, nerve abnormalities, and lifestyle factors such as diet and stress. Pelvic floor dysfunction can increase tension or weakness in the pelvic muscles, leading to bladder dysfunction and pain. Nerve abnormalities in the urinary system can disrupt the communication between the bladder and the brain, contributing to IC symptoms. Moreover, dietary triggers such as acidic foods, caffeine, artificial sweeteners, alcohol, and other food sensitivities may exacerbate IC symptoms in some individuals. Psychological stress can also worsen symptoms, as the stress response can affect the immune system and trigger inflammation. (2)
How to Diagnose Interstitial Cystitis
IC remains challenging to diagnose given the lack of a definitive diagnostic test to determine its presence; therefore, it remains a diagnosis of exclusion, meaning that other diagnoses must be excluded first before landing on IC as the cause of symptoms.
Step 1: History and Physical Examination
A comprehensive patient history should confirm the presence of pelvic pain, pressure, or discomfort related to the bladder. Pain is often associated with the persistent urge to void or urinary frequency. Symptoms should be present for at least six weeks. (23)
Doctors will also perform a comprehensive physical exam to help find other explainable causes for symptoms. This will include a pelvic and digital rectal exam to see if symptoms are related to spasms in the pelvic floor muscles, infection, or prostate problems. (17)
Step 2: Laboratory Assessment to Rule Out Other Pathology
The differential diagnosis for chronic pelvic/bladder pain should include:
- Urinary tract infection
- Bladder cancer
- Overactive bladder syndrome
- Chronic prostatitis
- Endometriosis
- Vaginitis
- Bladder or lower ureteral stone
- Urogenital prolapse
- Pelvic floor muscle-related pain
The following labs can be ordered as part of an initial evaluation to narrow the differential:
- Urinalysis w/ Reflex to Culture by Access Med Labs
- CBC by Access Med Labs
- Vaginosis Profile by Doctor's Data
- Cystoscopy with Hydrodistention: this is a test that allows doctors to examine the inside of the bladder
Step 3: Labs to Uncover the Root Causes of Interstitial Cystitis
Although there isn't a definitive test to rule in the diagnosis, specialty labs can assist in uncovering the underlying imbalances contributing to urinary inflammation and symptoms.
Microbiome Testing
While urinary microbiome testing is not readily available, research suggests that the gastrointestinal microbiota may influence the urinary tract. Reductions in certain types of bacteria have been measured in patients with IC. Additionally, gastrointestinal dysbiosis is a known trigger for immunological dysfunction, immune hyperreactivity, and systemic inflammation.
A stool test collected at home by the patient can assess the patient's complete gut microbiome and function. Examples include:
- GI Effects Comprehensive Profile with Microbiomix by Genova Diagnostics
- GI-MAP by Diagnostic Solutions
- BiomeFx by Microbiome Labs
SIBO Breath Test
In a 12-year cohort study, irritable bowel syndrome (IBS) increased the risk of developing IC. The study found that, on average, it took approximately five years from diagnosing IBS to developing IC. Additionally, these results suggest that shared common factors may contribute to the development of both conditions.
Studies suggest that up to 80% of people with IBS have small intestinal bacterial overgrowth (SIBO), contributing to their digestive symptoms. The following SIBO breath tests measure gaseous byproducts derived by intestinal microbes to diagnose and differentiate between the various SIBO subtypes.
- trio-smart SIBO Breath Test by Gemelli Biotech
- SIBO - 3 Hour by Genova Diagnostics
- SIBO/IMO Lactulose Breath Test by Commonwealth Diagnostics International, Inc.
Histamine
Histamine is a chemical compound involved in immune responses, inflammation, and allergic reactions. Studies have observed increased expression of histamine receptors in bladder tissue samples retrieved from patients with IC and that antihistamines improve IC-related pelvic pain.
Measuring histamine with one of the following labs can help assess histamine intolerance as a contributor to bladder inflammation and assist in monitoring treatment effectiveness.
- Histamine by DHA Laboratory
- Advanced Intestinal Barrier Assessment by Precision Point
Food Sensitivities
Research reveals that patients with IC have significantly more food sensitivities than those without. Some studies indicate that as many as 90% of patients with IC report food sensitivities.
A comprehensive panel that measures immune-mediated reactions to common food allergens can help identify dietary-related IC triggers and refine therapeutic dietary modification recommendations:
- P88-DIY Dietary Antigen Test by Precision Point
- FIT 176 by KBMO Diagnostics
- IgG Food MAP with Candida + Yeast by Mosaic Diagnostics
Hormone Panel
IC symptoms in women often fluctuate with hormonal changes, with some experiencing their first symptoms during perimenopause or menopause. This connection is likely linked to estrogen levels. A decrease in estrogen can activate mast cells, so many women may begin to experience IC symptoms leading up to menopause. Furthermore, inflammation, mast cell activity, and estrogen affect the bladder lining and detrusor muscle, potentially causing thinning, dryness, and increased susceptibility to inflammatory changes. Restoring hormonal balance becomes crucial in reducing the susceptibility to IC. (2)
One of the following hormone panels can help identify and correlate hormonal imbalances with IC symptoms throughout the various phases of the menstrual cycle.
- DUTCH Cycle Mapping (Dried Urine) by Precision Analytical (DUTCH)
- Rhythm by Genova Diagnostics
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Treatment Plan for Interstitial Cystitis
Once IC has been diagnosed and its root causes have been identified, an integrative treatment plan incorporating dietary modifications to reduce inflammatory triggers, stress management techniques, interventions to restore a healthy microbiome, and other targeted therapies to support bladder health and immune function can be implemented.
Step 1: Reduce Inflammation
Here's Why This Is Important:
Inflammation is recognized as a key contributor to the symptoms and progression of the disease.
How Do You Do This?
Therapeutic dietary modifications play an important role in managing the symptoms of IC. While there is no one-size-fits-all diet for IC, certain nutritional changes have shown promise in reducing bladder irritation and alleviating symptoms. (21, 34)
- Avoidance of Trigger Foods: Per patient survey, common IC trigger foods include coffee, alcohol, citrus fruits, tomatoes, carbonated drinks, and spicy foods. Food sensitivity testing can also help customize elimination diets. Avoiding trigger foods usually results in symptom improvement within 1-2 weeks. (2)
- Another dietary approach is the IC diet, which focuses on consuming bladder-friendly foods that are less likely to irritate the bladder. This typically includes low-acid foods like pears, apples, green vegetables, lean proteins, whole grains, and non-citrus juices.
The following natural supplements possess anti-inflammatory properties that convey benefits to patients with IC:
- Quercetin is a flavonoid with antioxidant and anti-inflammatory properties. It modulates the immune response and inhibits the release of histamine and other inflammatory mediators from mast cells. This small study showed that patients who took 500 mg of quercetin twice daily for just four weeks experienced improvement in IC urinary symptoms and pain scores.
- Kava (Piper methysticum) has been used historically as a urinary antispasmodic and anti-inflammatory agent. It can also be used as a natural anxiolytic agent, helpful in IC cases reported to be aggravated by stress, or to support the general emotional well-being of patients. A typical dose recommendation for kava is 70 mg of kavalactones three times daily.
Step 2: Improve Bladder Structure & Function
Why Is This Important?
The loss of the urothelial barrier is considered another key factor in IC pathogenesis. Treatments that aim to improve bladder structure and function help repair the damaged urothelium, enhance the bladder's protective barrier against inflammation, and restore its normal capacity.
How Do You Do This?
Bladder training techniques, which involve gradually increasing the time between urinations, may be recommended to improve bladder capacity and reduce urgency. (31)
Glycosaminoglycans (GAGs) are naturally occurring substances contributing to the protective urothelium. GAG supplementation aims to restore and support the integrity of the urothelium to reduce bladder irritation. Clinical studies have shown that GAG supplementation in doses as low as 100 mg three times daily can improve urinary symptoms, decrease pain, and enhance bladder capacity in some individuals with IC.
Arginine is an amino acid that plays a role in various physiological processes, including wound healing and immune function. Some individuals with IC may consider arginine supplementation due to its potential vasodilatory effects and its involvement in nitric oxide synthesis, which can impact bladder function. Although evidence is limited, several studies have reported positive benefits of L-arginine supplementation in treating IC. For example, one study reported increased urinary nitric oxide-related enzymes and metabolites, combined with reduced IC symptoms, with long-term L-arginine supplementation (dosed 1,500 mg daily for six months).
More invasive procedures may be considered for individuals with severe IC symptoms that are unresponsive to other treatments. These can include bladder distention, where the bladder is filled with fluid to stretch the bladder wall and reduce pain signals, or neuromodulation techniques, such as sacral nerve stimulation or botulinum toxin injections, which aim to regulate nerve signaling and improve bladder function. (2, 31)
Step 3: Alleviate Symptoms
Why Is This Important?
The debilitating symptoms of IC possess the capacity to negatively impact work productivity, mood, sleep, sexual function, and mobility. Many of the strategies discussed above take months to produce clinically impactful changes. Patients with severe symptoms may require faster-acting palliative interventions to improve quality of life metrics. In some cases, doctors may consider including the following interventions in their initial treatment plan to provide symptomatic relief to patients.
How Do You Do This?
Medications can play a significant role in managing IC symptoms. Oral medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, and tricyclic antidepressants (TCAs) can help alleviate pain, reduce inflammation, and improve sleep quality. Additionally, bladder-instilled medications, such as pentosan polysulfate sodium (PPS) or lidocaine, may be administered directly into the bladder to provide localized relief. (19, 31)
Sacral or pudendal nerve stimulation may reduce urinary frequency and urgency associated with IC (19). A thin wire is placed near the nerve during this procedure to send electrical impulses to the bladder (26).
Risks of Untreated Interstitial Cystitis
IC can lead to various complications that can significantly impact a person's quality of life. These complications may include chronic pain, sleep disturbances due to nocturia, emotional distress such as anxiety and depression, and decreased sexual intimacy and satisfaction. Additionally, the chronic nature of IC and the constant need to manage symptoms can lead to limitations in daily activities, work productivity, and social interactions. (26)
Interstitial Cystitis Case Study
You can read about a real case study here:
Case Study: Sarah's 5 Month Integrative Medicine Journey That Healed Her Interstitial Cystitis
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Key Takeaways:
- Interstitial cystitis can cause debilitating bladder and pelvic pain for affected individuals.
- The complexity of IC, along with the lack of definitive diagnostic testing available, makes it underdiagnosed and challenging to manage.
- Medical guidelines for treatment call for a multifaceted approach to effectively manage symptoms and improve affected patients' quality of life. Achieving a pain-free life is possible using an integrative treatment approach that targets the underlying pathophysiology contributing to bladder irritation and inflammation.
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