Interstitial cystitis: Causes, Symptoms, Treatment and complications

Interstitial Cystitis: Practice Essentials, Background, Pathophysiology

What is interstitial cystitis?

Interstitial cystitis is also known as painful bladder syndrome. It is a chronic condition which results from a chronic inflammation of the bladder muscles producing signs and symptoms such as pelvic or abdominal pain, increased frequency or urination, urgency of urination (the feeling of need to urinate, even after passing urine), and incontinence (passage of urine unknowingly).

The duration and the severity of the pain can vary from person to person. The discomfort can be just felt as a mild burning sensation to some patients while it may present as  a severe pain in the others. Interstitial cystitis is a common condition affecting more than 12 million people in the United States of America. There is a tendency for women to get this condition compared to men. However, both children and adult men can get this condition.

How is it different from a bladder infection?

A bladder infection, also known as cystitis is the inflammation of the bladder wall. It is usually caused by bacteria. Bladder infections are common in women. More than half of the women develop a bladder infection at some stage of their life. Bladder infections are very rare in males. However the risk of bladder infection in men increases as they age due to the increase in their prostate size.

The exact reason why women are more affected than men is not known but they think it is because women have a shorter urethra, the tube carrying urine out of the bladder. In women, the urethra is short about one and a half inches long. Therefore the bacteria can easily enter the bladder as it is only a short distance to travel. In addition, the urethra is found close to the woman’s vagina and anus. Therefore bacteria from those areas can easily gain access to the urethra.

Cystitis is common. It is not a serious infection if treated early and accurately. However, it is common to get number of recurrences during their lives. Rarely, the infection can ascend up to the kidneys causing kidney infections. This can result in damage to kidneys permanently. Therefore it is important that you get your bladder infection treated as early as possible and take precautions to avoid future recurrences.

A bladder infection can occur all of a sudden, known as an acute infection or it could keep recurring for a long period of time known as a chronic infection.

Interstitial Cystitis (IC) and Bladder Pain: Symptoms, Causes

What are the signs and symptoms of interstitial cystitis?

The following signs and symptoms may be experienced by patients who have interstitial cystitis:

  • Pain in the pelvic or within the vagina and anus in women which may be chronic and intermittent in nature.
  • Males may present with pain in between the scrotum and the anus.
  • Urgency to urinate – The feeling of need to urinate, even after passing urine.
  • Increased frequency of urination both during the day and night.
  • Pain within the bladder as the bladder fills and is relieved by urinating.
  • Pain during sexual intercourse

The severity of these symptoms will vary from one person to another and there can be symptom free periods in between as well. The symptoms may get worse if you develop a urinary tract infection on top of this.

What are the symptoms of bladder infection?

Signs and symptoms of bladder infection will vary from person to person. The signs and symptoms may also depend on the severity of the infection. Typically, the first few days after contracting an infection, you will only notice changes in your urinary habits but as the condition worsens, pain may develop.

The following signs and symptoms can occur:

  • Frequent urination
  • Strong foul smelling odor with urine
  • Dysuria – Burning sensation during urination.
  • Lower abdominal pain
  • Cloudy or blood stained urine
  • Urgent need to urinate
  • Urinary urge incontinence – Uncontrollable loss of urine. It is a common occurrence in elderly people.
  • Nocturia – This refers to frequent urination at night
  • Fever is rare but may occur
  • Back pain on either side – The back pain is due to the kidney pain. This indicates that the infection has spread to the kidneys.
What signs and symptoms would you expect to see with interstitial cystitis and why?
Image credit: S. Kasturia

What are the causes of interstitial cystitis?

The exact cause of interstitial cystitis is not known but several factors have been identified that may damage the mucosal lining of the bladder thus triggering interstitial cystitis. Some of these factors include:

  • Iatrogenic trauma to the bladder lining such as during a surgical procedure
  • If the pelvic floor muscles are weak or dysfunctional
  • The presence of autoimmune diseases
  • History of recurrent bacterial infections
  • Extension of the bladder for long period of time such as retention of urine

What are the causes of bladder infection?

Bladder infections are usually caused by bacterial organisms. They can travel through the urethra into the bladder causing an infection. Normally, the body removes bacteria from the urinary tract by the flushing action during urination. In men, the prostate secretions help to eliminate bacteria. However, sometimes these bacteria can cling on to the walls and multiply. The increasing bacterial population overrides the body’s ability to destroy them thus leading to bladder infections.

The commonest organism that is responsible for bladder infections is Escherichia coli (E. coli). This is a naturally occurring bacterium found in the large intestine. Bladder infections can result if the E.coli number is increased or if they are not eliminated through urination.

Other causative organisms include Chlamydia and Mycoplasma. Unlike E.coli, these organisms are transmitted through sexual intercourse and therefore can affect your reproductive system as well. Frequent sexual intercourse makes it easier for bacteria to enter the urethra. Such infections are termed as Honeymoon cystitis.

Other causes of bladder infections include:

  • Use of diaphragms and condoms also increase the chance of bladder infections.

Spermicides used in diaphragms and condoms can suppress the normal healthy bacteria in the vagina and allows the bad bacteria to cause an infection.

  • Rectovaginal fistula

Rarely, cystitis can recur due to an abnormal connection between the vagina and the anus.

  • Prostate infection

In males, the commonest cause of cystitis is the bacterial infection of the prostate. Even though antibiotics have the ability to quickly clear off bacteria in the bladder, they do not have the ability to reach the prostate. Therefore to cure a prostate infection, weeks of antibiotics has to be taken.

  • Bladder or urethral stones

Stones in the bladder or urethra will obstruct the flow of urine which will result in collection of urine in the bladder. This provides a good environment for the bacterial organism thus leading to an infection.

  • Strictures or narrowing of the urethra
  • Prostate enlargement which may cause kinking of the urethra and therefore results in bladder outflow obstruction.
  • Insertion of a catheter or any other instrument to the urinary tract.

What are the risk factors of bladder infections?

The risk of developing bladder infections in females is greater than in males. The reason for this is that women have shorter urethras, thus making it easier for the bacteria to reach the bladder. Another added point is that due to its anatomical position closer to the anus. The anus is an area which is rich in bacteria and therefore due to the short distance between the urethra and the anus, the bacteria can easily travel causing infections.

Other risk factors include:

  • Reduce fluid intake
  • Elderly people
  • Insertion of a urinary catheter
  • Immobility
  • Blockage of the bladder outflow tract
  • Urinary retention
  • Abnormalities of the urinary tract, which is caused by birth defects or injuries.
  • Enlarged prostate
  • Diabetes mellitus
  • Narrowing of the urethra
  • Fecal incontinence
  • Pregnancy

How is interstitial cystitis diagnosed?

There is no exact one test that is available to diagnose interstitial cystitis. Because of this reason, several cases of interstitial cystitis may remain undiagnosed. Therefore many of the doctors diagnose this condition after excluding all the other possible causes for your signs and symptoms. Your doctor will exclude the following conditions before diagnosing interstitial cystits:

  • Urinary tract infection
  • Chronic prostatitis and chronic pelvic pain syndrome in men
  • Endometriosis in women
  • Bladder cancer

Once these conditions have been excluded, your doctor may diagnose interstitial cystitis. This form of diagnosis is known as diagnosis by exclusion.

How is a bladder infection diagnosed?

A doctor can make a diagnosis based on the symptoms you experience. However, the diagnosis can be confirmed by performing a urine analysis. This test is done to test a sample of your urine for the presence of:

  • White blood cells
  • Red blood cells
  • Nitrites
  • Bacteria
  • Other chemicals

For this test, you have to provide a mid-stream or a clean catch sample of urine. This is to make sure that the urine sample is not contaminated with bacteria from the vagina or the tip of the penis.

The presence of nitrites in urine can be detected by dipping a testing strip into the urine. Nitrites are usually not found in urine. It is a substance released by the bacterial organisms. In addition, the sample is tested under the microscope to look for white blood cells, red blood cells and bacteria.

If during this test, it is confirmed that you have a bladder infection, then your doctor may order further tests such as a urine culture to identify the number and type of bacteria causing the infection. Together with this, they will also order an antibiotic sensitivity test (ABST) to find out what antibiotics will help clear off the bacteria soon. The results of these investigations will help your doctor to plan your management effectively.

What are the complications of interstitial cystitis?

Interstitial cystitis can lead to several complications. Some of the common complications are given below:

  • Reduced bladder capacity which occurs as a result of stiffening of the bladder wall causing the bladder to hold less amount of urine compared to before.
  • Sexual problems causing problems to your personal relationships also can occur because of the need to urinate more frequently and due to the pain.
  • Lower quality of life can be caused by the need to urinate more frequently. This will make it uncomfortable for you during social activities and other daily life activities.
  • Sleep disturbance due to the pain and the need to urinate in the middle of the night frequently.

How is interstitial cystitis treated?

There is no exact treatment available for interstitial cystitis yet. There are various treatment modalities available to relieve the signs and symptoms of interstitial cystitis.

  1. Physical therapy – This is important because as you know, one factor that may lead to this condition is weakened pelvic floor muscles therefore following exercises that may strengthen the pelvic floor muscles may help.
  2. Oral medications – There are several oral drugs that will help to relieve the signs and symptoms of interstitial cystitis.
    1. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Naproxen and Ibuprofen are helpful in relieving the pain.
    2. Tricyclic antidepressants such as amitriptyline will help to relax the bladder as well as to block the pain.
    3. Antihistamines such as Loratidine will help to reduce the urinary symptoms such as urgency and frequency.
    4. Pentosan polysulfate sodium (Elmiron) is a drug that is designed to treat specifically for interstitial cystitis. While the exact mechanism of action is not known, but it is believed to relieve the symptoms by protecting the bladder wall from toxic substances. However, it might take some 2 to 4 months to show effectiveness.
  3. Nerve stimulation – This can be done via transcutaneous electrical nerve stimulation (TENS). During this procedure mild electrical pulses are delivered through the skin to stimulate the nerves supplying the bladder. As TENS improves the blood supply to the bladder thus strengthening the pelvic floor muscles, it is able to relive the signs and symptoms of interstitial cystitis.
  4. Bladder training – These techniques will be taught by your health care provider and are usually aimed to lengthen the time period between urinating.
  5. Stop smoking – Smoking has a strong association with bladder cancer, even though there is not proven correlation between interstitial cystitis and smoking. Due to this association with the bladder cancer, stopping smoking may help to lessen or reduce the symptoms.
  6. Surgery – This option in management is considered last and is rarely considered. This method of treatment is only thought of if the symptoms are very severe and the other treatment methods have failed to show any improvement. During surgery, the surgeon or the urologist will try to increase the size of the bladder by trying to insert a patch of bladder or intestine and remove or treat any ulcers that are found to be within the bladder.
    1. If the ulcers are burnt, this procedure is known as Fulguration.
    2. If the ulcers are completely excised, it is known as resection.
    3. Bladder augmentation refers to the surgical procedure where the urologist will try to increase the size of the bladder by trying to insert a patch of bladder or intestine.

What is the treatment for bladder infections?

The aims in the treatment of bladder infections are to kill the bacteria and to relieve the pain and burning sensation. Therefore the treatment includes:

  • Antibiotic therapy

Since bacteria are the usual cause, antibiotics are used. Before prescribing antibiotics, your doctor will find out if you have an underlying condition that may worsen the cystitis such as diabetes mellitus, weakened immune system or a structural abnormality. Such conditions will need more powerful antibiotics for a longer duration. This is because the infection is likely to return again after stopping the antibiotic treatment. People with such conditions, may also have infections caused by other organisms such as fungi or atypical bacteria. They will require different medications other than antibiotics.

The usual duration of treatment is just 3 days for women with uncomplicated bladder infections. However, if the infection does not seem to go away, the treatment may be continued up to 7 to 10 days. In men, the usual underlying cause is prostatitis and thus needs antibiotic treatment for weeks.

Your symptoms may disappear within a few days after starting treatment but it is important that you continue to take your drugs as prescribed.

  • Analgesia

A common analgesic drug used in bladder infections is Phenazopyridine (Pyridium). This does not treat the infection but provides analgesia to the urinary tract. It will help you to bear the pain while you wait for antibiotic treatment to take its effect. This drug can be bought over the counter but speak with your doctor before you take them.

  • Topical estrogen for postmenopausal women with recurrent bladder infections.
  • Surgery

If you have a physical obstruction or a structural abnormality in the urinary tract that makes infections more likely, you will need to undergo surgery

How can you prevent bladder infections?

If you have experienced 3 or more bladder infections within the past year, then these preventive measures may help you:

  • Drink more water; Drink at least 6 to 8 glasses of water a day.
  • Wear cotton underwear.
  • Urinate as soon as you feel the need to.
  • Urinate soon after sexual intercourse
  • Avoid using condoms and diaphragms with spermicides in them; Change to an alternative form of contraception.
  • If you are a female, wipe from front to back after urinating.
  • Prophylactic antibiotic treatment – Your doctor may prescribe you low dose antibiotics to be taken daily or when you feel the symptoms of bladder infection. You may also be given a single dose of antibiotic drug after sexual intercourse.

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Thilini Gunawardane
About Thilini Gunawardane 28 Articles
I am a final year medical student and I'm currently doing my clinical rotations in a private hospital. A huge people-person, an open minded who spent several years in the field of Medicine. I am at my final year on Medicine and clinical rotations at a Hospital (Dr Neville Fernando Teaching Hospital (NFTH). My long term run is to be a consultant one day and serve everyone in need. This has always been in my bucket list and I myself as a go-getter, will make my promisses and prove it to my self. Every-day I wake up knowing how little I know and I work for it. I learn, I use all my sources I have. Working online, I have gained so much experience and learned many things that a person should have in a working environment, time/project management, satisfying the client, meeting deadlines on time.

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