Overview%20of%20Interstitial%20Cystitis%20for%20the%20Primary%20Care%20Physician%20WVU%20WOMENS%20HEALTH%20CURRICULUM%20 - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

Overview%20of%20Interstitial%20Cystitis%20for%20the%20Primary%20Care%20Physician%20WVU%20WOMENS%20HEALTH%20CURRICULUM%20

Description:

Title: Female Urology Curriculum Lecture 3: September Author: szaslau Created Date: 8/7/2003 6:22:03 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

Number of Views:55
Avg rating:3.0/5.0
Slides: 69
Provided by: szas
Learn more at: http://www.glowm.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Overview%20of%20Interstitial%20Cystitis%20for%20the%20Primary%20Care%20Physician%20WVU%20WOMENS%20HEALTH%20CURRICULUM%20


1
Overview of Interstitial Cystitis for the Primary
Care PhysicianWVU WOMENS HEALTH CURRICULUM
Revisions 9/2008
  • Stanley Zaslau, MD, MBA, FACS
  • Program Director Associate Professor
  • Section of Urology
  • West Virginia University

2
Objectives
  • In this lecture, participants will learn
  • Incidence, epidemiology and pathogenesis of
    Interstitial Cystitis (IC)
  • Understand the role of the urothelium in the
    prevention and treatment of IC.
  • Key concepts in the physical examination of the
    IC patient
  • Understand the concept of multimodal therapy for
    the treatment of IC.

3
Objectives
  • In this lecture, participants will learn
  • Key treatments of IC
  • Antidepressants
  • Gabapentin
  • Intravesical therapy
  • Pentosan polysulfate
  • Neuromodulation
  • Sexual dysfunction in the IC patient
    pathogenesis and treatment strategies

4
Introduction
  • Challenge to diagnose
  • Traditional view recognizes patients with
    end-stage disease
  • A continuum--rather than a fixed disease
  • Confused with other GU or GYN disorders

5
Definition
  • First reported in 1915
  • NIH criteria established in 1987
  • characterize IC syndrome patient
  • describe advanced disease
  • do not define IC
  • criteria represent a small part of the IC
    population

6
Interstitial Cystitis (IC)
Definition
  • Interstitial cystitis is urgency, frequency, and
    pain in the absence of a defined etiology

C. Lowell Parsons, MD
The triad of urinary urgency, frequency, and
bladder or pelvic pain in the absence of
bacterial infection or other definable pathology
is the definition of interstitial cystitis
Grannum Sant, MD
7
Better Definitions
  • Clinical syndrome
  • Gradually progressive
  • Time line concept
  • 20s mild, intermittent urgency with UTI
  • 30s urethral syndrome (persistent -Cx)
  • 40s meets NIH criteria for IC
  • 60s severe, constant symptoms c/w IC

8
Clinical Picture of IC
  • Urgency, frequency, nocturia, chronic pelvic pain
    (CPP)
  • Pain associated with sexual intimacy
  • /- incontinence
  • Negative culture and sensitivity

1. Parsons CL.
9
Epidemiology
  • Affects 2.5 million women in US
  • Significant number of men affected
  • Studies
  • Finnish incidence 1.2 cases/100,000 people
  • prevalence of 10-11/100,000
  • Held 44,000 cases in US prevalence of 450,000
    cases
  • May only reflect end-stage disease

10
Epidemiology
  • More recent studies
  • 284 UCSD Female MS attending lectures
  • All filled out PUF questionnaire
  • 8 items
  • symptom, bother and total score
  • pelvic pain
  • urgency
  • frequency
  • 24 had scores gt 10 Parsons, et al Urol 2002

11
Increasingly a Concern in Women
  • Estimated prevalence of self-reported IC in
    womenis 1.5 million1
  • IC is often misdiagnosed or underdiagnosed
  • 38 of women scheduled for laparoscopyfor
    suspected endometriosis werecystoscopically
    confirmed to have IC2
  • IC may be a common cause of Chronic Pelvic Pain
    (CPP)
  • 80 to 85 of women with CPP of unidentified
    etiology shown to have pain of bladder origin3

1. Curhan GC et al. J Urol. 1999161549-552. 2. C
lemons JL et al. 2002100337-341. 3. Parsons CL
et al. Obstet Gynecol. 200198127-132.
12
Possible Presentations
  • Refractory Patients
  • New Patients

Consider IC
1. Parsons CL et al. Female Patient. May
2002(suppl)12-17. 2. Chung MK et al. JSLS.
20026311-314. 3. Miller JL et al. Urology.
199545587-590.
13
Diagnostic considerations for the Primary Care
Physician
  • For patients with
  • urgency
  • frequency
  • dysuria
  • painful with sexual intercourse
  • negative urine cultures and urine cytologies
  • SUSPECT INTERSITIAL CYSTITIS

14
Physical Examination
  • Females
  • anterior vaginal wall tenderness
  • suprapubic tenderness
  • pelvic floor dysfunction
  • Males
  • suprapubic tenderness
  • sphincter spasm
  • tender rectal examination

15
IC Evaluation Tools for the Primary Care Physician
  • Routine testing for the PCP
  • urine analysis
  • urine culture
  • urine cytology
  • voiding diary
  • Additional testing to be undertaken by the
    urologist
  • cystourethroscopy and urodynamics
  • KCL testing

16
Voids per day
  • Statistics (mean)
  • Normal population 6.5times/day
  • IC population 16.5 times/day

17
Anesthetic Bladder Capacity
  • Normal people 1100 cc
  • IC patients 575 cc

18
Clinical Approach to IC A Primer for the
Primary Care Physician
  • Female
  • History
  • ICSI
  • PUF
  • Physical exam
  • Urinalysis and/or culture
  • Elective tests
  • Potassium sensitivity test
  • Cystoscopy andhydrodistention
  • Cystometrogram
  • Urine for cytology
  • Male
  • History
  • ICSI
  • CPSI
  • PUF
  • Physical exam
  • Urinalysis and/or culture
  • Elective tests
  • PPMT
  • Potassium sensitivity test
  • Cystoscopy andhydrodistention
  • Cystometrogram
  • Urine for cytology

1.
ICSI Interstitial Cystitis Symptom Index. PUF
Pelvic Pain and Post-Prostate Massage Test.
19
Pathogenesis
  • Vascular insufficiency
  • Epithelial leak
  • Role of Urinary Potassium
  • Neural Up-regulation
  • Mast Cells

20
Epithelial Leak
  • Leak --gt impaired migration of solutes across
    epithelium
  • Leak assay studies (75 in IC)
  • Potassium sensitivity test in 90
  • suggest leaky epithelium
  • may suggest neurological inflammatory component

21
Role of Urinary Potassium
  • Principle toxic substance in urine is potassium
  • Toxic to human cells
  • Urine concentration 75 mEq/L
  • Levels gt 15 mEq/L depolarize sensory nerves and
    muscle

22
Role of Urinary Potassium
  • Effects of excessive K back diffusion
  • vascular destruction
  • lymphatic destruction
  • sensory nerve muscle depolarization
  • up-regulation of mast cells
  • induction of substance P and up-regulation of
    pain fibers
  • disease progression

23
Potassium SensitivityMay Be a Good Predictor of
IC
  • Detects abnormal bladder epithelial permeability
  • Positive in 70 to 90 of IC patients
  • 81 of gynecologic patients with pelvic pain had
    increased potassium sensitivity

1. Parsons CL et al. J 1054-1057.
24
Role of Urinary Potassium
  • Sodium chloride instillation does not cause
    symptoms
  • Conclusion
  • individual potassium sensitivity
  • useful diagnostic tool for IC
  • useful even in patients with mild symptoms
  • useful when one is unsure of the diagnosis

25
Neural Up-regulation
  • Up-regulation of sensory nerves in the bladder
  • Seen in severe forms of IC
  • Difficult to treat
  • Can persist after treatment of epithelial defect

26
Mast Cells
  • Role not fully understood
  • Present in IC and non-IC bladders
  • Causative or secondary role in IC?
  • Cause degranulate produce symptoms
  • Secondary response to epithelial leak
  • Interact with sensory nerves release
    neurotransmitters that activate pain

27
Glycosaminoglycan (GAG) Layer in IC
  • GAG, a mucoprotein, is a component of bladder
    epithelium
  • GAG may be essential for bladder protection
  • Irritants and toxins in urine
  • Bacterial adherence
  • GAG deficiency may result in pathologicchanges
    associated with IC
  • Permeability of urothelium
  • Inflammatory/allergic response

Lilly JD, Parsons CL.171493-496.
28
Vicious Cycle of IC
Bladder Insult
Epithelial Layer Dysfunction
More Injury
29
Principles of Treatment--Multimodal
  • Dietary guidelines
  • Stabilize the urothelium
  • pentosan polysulfate
  • Modulate neural activity
  • Tricyclic antidepressants like amitriptyline,
    gabapentin
  • Stabilize mast cells
  • Antihistamines, ex. Hydroxyzine
  • Stabilize the pelvic floor
  • sacral neuromodulation

30
Pentosan Polysulfate
  • Mechanism re-establish GAG layer function and
    decrease K leak
  • The only FDA-approved oral therapy proven
    effective for IC pain or discomfort
  • Reduces painful symptoms long-term
  • Dose 100 mg TID (200 mg BID)
  • Full effect takes up to 6 months
  • Side effects headache, GI upset, hair loss

31
Antihistamines
  • Role blockade of mast cell release of histamine
  • Dose 25 mg to 75 mg qHS
  • Useful
  • allergy sufferers (spring/fall)
  • Adverse sedative properties

32
Antidepressants
  • Role decrease neural pain, decrease urgency and
    frequency (Ach effect)
  • Dose 25 mg to 100 mg qHS amitriptyline
  • Some patients respond to lower doses (10 mg)
  • SSRI can also be considered (watch for
    drug-induced FSD

33
Gabapentin
  • Role inhibit neural up-regulation and
    neurogenic spinal cord inflammation
  • Use chronic unrelenting pain
  • Dose 300 mg to 2400 mg/day
  • Side effects sedation
  • Advise careful dose titration to balance
    sedative properties

34
Intravesical Agents
  • Dimethyl Sulfoxide (DMSO)
  • Principle FDA approved intravesical agent
  • Instilled once weekly for at least 6 weeks
  • Cocktails DMSO, sodium bicarbonate, heparin,
    triamcinolone, bupivicaine
  • 50 objective response rate

35
Sacral Neuromodulation
  • Rationale
  • Disrupt afferent inputs to the bladder and pelvic
    floor that cause pathologic voiding
  • Specifically help regulate
  • capsaicin-sensitive C-afferent neurons
  • originate from sacral parasympathetic plexus
  • may relieve pelvic pain/muscle spasm
  • neural input through the pelvic nerve
  • may aid in detrusor contraction

36
Sacral Neuromodulation
  • Goals of sacral neuromodulation Therapy
  • Improve pelvic pain
  • Improve urinary frequency
  • Improve voided volumes
  • Improve overall symptom scores
  • IC Symptom Index
  • Chronic Prostatitis Symptom Index

37
Sacral Neuromodulation
  • Potential uses of sacral neuromodulation
  • Refractory urinary urge incontinence
  • Non-obstructive urinary retention
  • Refractory urinary urgency and frequency
  • Interstitial Cystitis

38
Sacral Neuromodulation Current Literature
  • Refractory Urgency/Frequency (IC) Comiter C.
  • 25 patients, prospective study
  • Mean age 47 years
  • Trial of sacral nerve stimulation
  • 50 improvement in frequency
  • 50 improvement in nocturia
  • 50 improvement in voided volume
  • 50 improvement in pain
  • 17/25 qualified for permanent implant

39
Sacral Neuromodulation Current Literature
  • Prospective study for refractory IC
  • Mean follow up 14 months
  • Parameters
  • Daytime frequency 17 ---gt 8.7 voids (plt0.01)
  • Nocturia 4.5 ---gt 1.1 voids (plt0.01)
  • Mean Voided Volume 111 cc ---gt 264 cc (plt0.01)
  • Pain (1-10 scale) 5.8/10 to 1.6/10 (plt0.01)
  • IC Symptom Index 16.5 ---gt 6.8 (plt0.01)

40
Sacral Neuromodulation Current Literature
  • Prospective study for refractory IC
  • 16/17 (94) had improvement in all parameters at
    last follow up
  • Conclusions
  • Sacral neuromodulation is safe and effective
    treatment of dysfunctional voiding/pelvic pain
  • Useful treatment for refractory IC symptoms
  • Comiter CV. J Urol 2003 Apr169(4)1369-73.

41
Sacral Neuromodulation Current Literature
  • West Virginia University Hospital Experience
  • Collaborative model (Pain Treatment Center and
    Urology)
  • All patients evaluated with cystoscopy and
    urodynamics prior to test stimulation
  • 2 stage approach (test stimulation -gt permanent
    implant

42
Sacral Neuromodulation Current Literature
  • West Virginia University Hospital Experience
  • To date
  • 210 test stimulations
  • 195 permanent implants
  • 80 implants have refractory urgency/frequency
    (IC)
  • Mean age 51 years
  • Mean follow up is 2 year (longest out is 3 years)
  • All with improvement in symptoms and voided
    volume as well as decline in pelvic pain/bladder
    spasm
  • Zaslau S, et al. West Virginia Medical Journal,
    August, 2003

43
Sexual Problems Affecting the IC Patient
  • Pain associated with intercourse
  • Entry dyspareunia
  • Deep dyspareunia

44
Entry Dyspareunia
  • Pain at the opening
  • Atrophic vaginitis
  • post menopausal women
  • estrogen loss
  • Tx topical or oral estrogen replacement
  • Vaginitis
  • infectious (fungal)
  • Tx oral or topical antifungal agents

45
Entry Dyspareunia
  • Herpes vulvitis
  • must rule out other causes first!
  • Vulvodynia
  • vulvar pain of unknown cause
  • feels like dragging sandpaper thru open wound
  • Infectious vulvitis
  • glandular enlargement tx antibiotics

46
Deep Dyspareunia
  • Most common type of dyspareunia in IC
  • Sources of pain
  • Vaginal infections
  • Vaginal dryness
  • estrogen loss
  • psychological stress

47
Deep Dyspareunia
  • Bladder pain
  • pain in front portion of vagina
  • caused by penile pressure on bladder trigone
  • Pain from other pelvic abnormalities
  • endometriosis
  • ovarian diseases
  • pelvic infections
  • diverticulosis

48
Deep Dyspareunia
  • Pain from pelvic floor muscles
  • most common source of pain for IC patient
  • pelvic floor spasm occurs in 70 of IC patients
  • can prevent penile insertion

49
Vicious cycle of muscle spasm
  • 1. SPASM OF PELVIC MUSCLES
  • 2. FEAR OF PAIN WITH PENETRATION
  • PENILE PENETRATION
  • 3. MORE MUSCLE TIGHTENING
  • 4. PENIS PENETRATES INTO SPASTIC, TENDER MUSCLES
  • 5. FURTHER TIGHTENING OF MUSCLES

50
IC and Female Sexual Dysfunction (FSD)
  • 100 patients with IC
  • FSFI administered
  • Assess 6 domains of sexual function
  • Desire
  • Arousal
  • Orgasm
  • Lubrication
  • Satisfaction
  • Pain

51
IC and FSD
  • Results
  • Mean age 39 years
  • Impairment in all domains 50-75 of the time
  • Conclusions
  • FSD in IC involves more than pelvic pain
  • Zaslau, S et al FSFF, Vancouver, BC 2002

52
FSD in IC 1st 400 Patients
  • 400 IC patients
  • FSFI administered on line at IC-Network
  • Compared to two groups
  • Controls (131)
  • Female sexual arousal disorder (129)

53
FSD in IC 1st 400 Patients
  • Results
  • Statistically significant decrease in all domains
    when compared to controls
  • Stastically significant decrease in all domains
    when compared to Arousal Disorder Group
  • Lowest scores pain
  • Zaslau, et al AUA 2003, Chicago, IL.

54
Conclusions IC and FSD
  • Global sexual dysfunction affecting all domains
  • May be age related and progressive
  • Pain domain has lowest scores
  • Treatment is multimodal and may involve
    counseling, sex therapy and physical therapy

55
General Treatment Principles
  • Talk to your partner
  • create game plan to deal with partner needs
  • role for physician, social worker, sex therapist
  • Dont focus only on penetration
  • Shift major focus to foreplay, full body massage,
    deep kissing, fondling, oral-genital contact

56
General Treatment Principles
  • Watch out for medication effects on orgasm
  • medications can cause fatigue and/or loss of
    sexual desire
  • antidepressants impair orgasm
  • Go slow
  • forget the terrible memories
  • Relax to prevent pelvic muscle spasm
  • Go slow with insertion and thrusting

57
General Treatment Principles
  • Lots of lubrication
  • aids in penetration
  • especially helpful in vulvodynia
  • Be in control
  • goes along with going slow
  • let the patient call the shots
  • communicate!

58
General Treatment Principles
  • Find the right position
  • There is no perfect position
  • Goal minimize vaginal tenderness, adjust
    vault-penis angle and partner weight
  • Missionary most discomfort for female partner
    (penile--gtbladder base pressure)
  • Female superior more control for IC female

59
General Treatment Principles
  • Go one step at a time
  • Step-wise approach for vaginal penetration
  • First goal NOT penis in vagina orgasm!
  • Dont focus on vaginal entry initially
  • Instead superficial penetration and maximize
    foreplay

60
General Treatment Principles
  • Avoid intercourse during flares
  • Flare can be related to menses
  • Increased urinary frequency and pelvic pain
    flare
  • Focus away from intercourse and onto foreplay!
  • Take advantage of remissions
  • take things slow roll with the punches

61
General Treatment Principles
  • Take a warm bath after sex
  • can relax pelvic floor muscles
  • can be therapeutic after sex
  • however, warmth can be irritating!
  • Avoid urinary tract infections
  • void before and after sexual relations
  • Avoid use of diaphragm
  • can increase UTI and pelvic pain/irritation

62
General Treatment Principles
  • Use vaginal dilators/biofeedback
  • can relax vaginal vault
  • patient in total control of insertion
  • step-wise treatment strategy
  • minimizes anxiety

63
General Treatment Principles
  • Read and learn more about IC
  • Interstitial Cystitis Association
    (www.ichelp.org)
  • Interstitial Cystitis Network
    (www.ic-network.com)

64
Summary
  • Interrelationships between conditions
  • Overactive Bladder
  • No bacteriuria
  • No bladder pain
  • Urinary Tract Infection
  • Bacteriuria and bladder pain
  • Interstitial Cystitis
  • Bladder pain and no bacteriuria

65
Summary (continued)
  • The prevalence of IC is much higher than
    previously estimated
  • IC should be considered in patients who have
    failed standard therapy for endometriosis (prior
    to hysterectomy), OAB, or have symptoms of
    recurrent/chronic UTI and do not improve on
    antibiotics
  • Increase awareness of IC as part of CPPS
    differential diagnosis
  • Symptoms of CP/CPPS appear to be similar to IC
  • Treatment of IC is multimodal (pentosan
    polysulfate, antidepressants, antihistamines,
    role for sacral neuromodulation in treatment
    failures)

NBP non-bacterial
66
References 1
  • Peters KM, Killinger KA, Carrico DJ, Ibrahim IA,
    Diokno AC, and Graziottin A Sexual Function and
    Sexual Distress in Women with Interstitial
    Cystitis A Case Control Study. Urology. 2007
    70(3) 543-547.
  • Zaslau S, Triggs J, Morgan L, Osborne J, Subit M,
    Riggs D Characterization of Female Sexual
    Dysfunction in Patients with Interstitial
    Cystitis. Presented at the American Urological
    Society Meeting, Chicago, IL, April 27, 2003.

67
References - 2
  • Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson
    B, Kandzari S Sexual Dysfunction in Patients
    with Interstitial Cystitis. Presented at the
    American Urogynecology Meeting, Hollywood, FL,
    September 12, 2003.
  • Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson
    B, Kandzari S. Sexual Dysfunction in Patients
    with Interstitial Cystitis Initial Analysis of
    Under 40 Cohort. Presented at the Mid-Atlantic
    Section of the American Urological Society
    Meeting, Boca Raton, FL, October 26-29, 2003.

68
References - 3
  • Zaslau S Blueprints in Urology, 1st ed. Boston,
    MA Blackwell Science, Inc., 2004.
  • Zaslau S SOAP Notes in Urology, 1st ed.
    Baltimore, MD Lippincott Williams and Wilkins,
    Inc., 2006.
  • Messing EM. Interstitial cystitis and related
    syndromes. In Campbells Urology, 6th Edition.
    Walsh PC, Retik AB, Stamey TA, Vaughan ED Jr
    (eds). Philadelphia WB Saunders Co., Volume 1,
    Chapter 24, pp. 982-1005, 1992.
About PowerShow.com