Interstitial cystitis (IC) is considered a chronic bladder pain syndrome (CBPS) in which women experience painful bladder symptoms, irritation, tenderness, urination at night, and frequent urination and urges for weeks, months and sometimes years. In severe cases, some women will void (urinate) up to 20-30x's per day to avoid the irritation and pain of a full bladder, creating a fear-avoidance cycle propagating the urgency and anxiety(1,2). IC is predominantly a female condition (about 90% of cases), with most women being diagnosed at middle-age (3,4). Unlike acute cystitis which is an infection of the bladder that can most often be easier identified and treated, IC does not have an infectious cause. Standard urinary dip-stick testing, looking to identify bacterial infections appear negative leaving many doctors and patients elusive to the underlying condition and diagnosis. This has often lead to either unnecessary harmful treatment not proven to be of benefit or a complete lack of treatment. Thankfully, we have learned much more about IC in recent decades, shedding some light on this painful condition and providing hope and direction for patients.
What's Happening in the Bladder in IC?
There have been many proposed underlying factors contributing to the chronic bladder pain in IC.
Research best supports that IC is likely a multifactorial syndrome comprised of bladder lining dysfunction, nervous system sensitivity and irritation, and immune imbalance (3,5).
One pivotal theory is the role of urothelial abnormalities. The urothelium is the lining of the inside of the bladder that effectively helps contain urine within the bladder. This lining, in healthy individuals is well-sealed by protective cells, uroplakin, chondroitin sulfate, proteins, and a strong glycosaminoglycan (GAG) layer, preventing urine contents from penetrating through its barrier(3). In IC, however, this lining is weakened and may allow urinary irritants to penetrate the urothelium and activate and irritate the underlying nerve and muscle tissue(6,7). In about 10% of women, this can lead to the formation of "Hunner's ulcers", which are small lesions in the bladder wall that may bleed and cause inflammation(3). Once this process ensues, the urine leakage may cause further tissue damage to nerves and underlying tissue promoting increased sensitivity and pain. Additionally, activation of the immune system as a result of this tissue damage can cause inflammation further weakening and irritating the tissues(5,6). To summarize, the pain associated with IC is likely due to a number of factors including a weakened or damaged urothelium (bladder lining), irritated surrounding tissues, organs and nerves due to leakage of urine, activation of inflammatory immune cells, and heightened nervous system sensitivity (both locally and in the brain)(3,5,8).
Going Beyond the Bladder
Just studying the bladder does not give us a whole picture. The fact that many other chronic pain syndromes are associated with IC leads us to believe that there are other factors to consider beyond the bladder. For example, many patients with IC may also have irritable bowel syndrome (IBS), vulvodynia, fibromyalgia, rheumatoid arthritis, asthma, allergies, other chronic pain syndromes as well as psychosocial co-morbidities(9). After all, your bladder doesn't live alone in isolation, but rather it is intimately connected to other pelvic organs such as the uterus and vagina, colon and rectum, and pelvic floor muscles. Think of it as analogous a fruit bowl. Once one fruit turns bad, the rest of the fruit seems to turn bad faster as well. This is a simplified explanation of what may be happing within the pelvis and the organs it contains. Therefore, we must consider the health of these neighbouring tissues in order to fully understand this complex condition. This is where I believe integrative naturopathic medicine can really help. Taking a person-centered holistic view allows us to fully evaluate the overall health and vitality of the individual and surrounding organ systems to allow for an individualized treatment approach.
The Integrative IC Approach
Both conventionally and in complementary medicine, first-line treatments include proper fluid management (hydration), physical therapy, and avoidance of irritating substances(10,11). Because what we eat ultimately ends up in the blood to be filtered by the kidneys and excreted through the bladder, our diet has a large influence on urine contents. Some foods appear to be particularly irritating to the bladder including coffee, citrus fruits, spicy hot foods, MSG, soy, caffeine, tea, sodas, alcohol, tomatoes, cranberry juice, and chocolate. Keeping a symptom and diet journal may help individuals find which of these foods are true irritants. While this may help initially to reduce symptoms, healing the bladder lining, repairing damaged tissue, and decreasing nerve sensitivity will help with lasting pain relief. An individualized approach to treatment will help uncover contributing factors to your pain and allow for target treatments. Foundational integrative treatments include the use of natural central nervous system and muscle relaxants, botanical and supplemental antihistamines, bladder soothing herbs, restoring glycosaminoglycans, and food elimination and challenge diets(3). As well, stress management techniques and psychological support have been reported to improve IC symptoms(11-14). Acupuncture treatments have also been found to be helpful in the treatment of IC and is relatively non-invasive(5). Multiple treatment options exist for IC patients. Starting with the least invasive therapies and continuing to escalate therapy as needed on an individual basis will help increase the efficacy and safety in the treatment of IC.
Overview of Integrative Treatment Options for IC/CBPS (3,5,10-14):
Diet & Nutrition: Food and symptom journalling, monitoring hydration, bladder training
Physical Medicine: Pelvic floor physiotherapy, acupuncture, trigger-point therapy, exercise
Supplements & Botanicals: natural nervous system and muscle relaxants, natural analgesics and bladder soothing herbs
Nervous system and Psychosocial Support: sleep hygiene, stress management, emotional support and education
Medications: Pentosan polysulfate (PPS), and neuropathic pain medications
Surgery: bladder installations of medication, bladder muscle botox injections, and radical surgery
At first, all of this may seem overwhelming. The goal, however, is to quickly improve pain and irritative bladder symptoms, while simultaneously healing the lining and surrounding tissues. Once the tissues and nervous system have had time to heal, de-escalating therapy can help simplify the treatment plan. With time and patience, the goal is to have less reliance on dietary changes, supplements and/or medications, and to regain your natural bladder health.
- Dr. Randi Brown, ND
If you have IC, or know someone with IC please comment or share. If you want to learn more about potential natural and integrative treatment options, you can book a 15-minute complimentary meet and greet here, or view my availability and book an initial appointment online.
References
1. Konkle KS, Berry SH, Elliott MN, et al. Comparison of an interstitial cystitis/bladder pain syndrome clinical cohort with symptomatic community women from the RAND Interstitial Cystitis Epidemiology study. J Urol 2012; 187:508.
2. Clemens JQ, Joyce GF, Wise M, Payne C. Interstitial Cystitis and Painful Bladder Syndrome. In: Urologic Diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Litwin MS, Saigal CS (Eds), Washington, DC 2007. p.123.
3. Hudson, T. (2007). Women's Encyclopedia of Natural Medicine: Alternative Therapies and Integrative Medicine for Total Health and Wellness. MACMILLAN HEINEMANN.
4. Simon LJ, Landis JR, Erickson DR, Nyberg LM. The Interstitial Cystitis Data Base Study: concepts and preliminary baseline descriptive statistics. Urology 1997; 49:64.
5.Cox, A., Golda, N., Nadeau, G., Nickel, J. C., Carr, L., Corcos, J., & Teichman, J. (2016). CUA guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Canadian Urological Association Journal, 10(5-6), E136.
6. Slobodov G, Feloney M, Gran C, et al. Abnormal expression of molecular markers for bladder impermeability and differentiation in the urothelium of patients with interstitial cystitis. J Urol 2004; 171:1554.
7. Graham E, Chai TC. Dysfunction of bladder urothelium and bladder urothelial cells in interstitial cystitis. Curr Urol Rep 2006; 7:440.
8. Hurst RE, Roy JB, Min KW, et al. A deficit of chondroitin sulfate proteoglycans on the bladder uroepithelium in interstitial cystitis. Urology 1996; 48:817.
9. Clemens JQ, Meenan RT, O'Keeffe Rosetti MC, et al. Case-control study of medical comorbidities in women with interstitial cystitis. J Urol 2008; 179:2222.
10. Friedlander JI, Shorter B, Moldwin RM. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU Int 2012; 109:1584.
11. Rothrock NE, Lutgendorf SK, Kreder KJ, et al. Stress and symptoms in patients with interstitial cystitis: a life stress model. Urology 2001; 57:422.
12. Powell-Boone T, Ness TJ, Cannon R, et al. Menstrual cycle affects bladder pain sensation in subjects with interstitial cystitis. J Urol 2005; 174:1832.
13. Tsai CF, Ouyang WC, Tsai SJ, et al. Risk factors for poor sleep quality among patients with interstitial cystitis in Taiwan. Neurourol Urodyn 2010; 29:568.
14. Nickel JC, Tripp DA, Pontari M, et al. Psychosocial phenotyping in women with interstitial cystitis/painful bladder syndrome: a case control study. J Urol 2010; 183:167.