Screening, Treatment, and Management of Interstitial Cystitis by kmo20868

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									Screening, Treatment, and
Management of Interstitial
Cystitis/Painful Bladder Syndrome
Association of Reproductive Health Professionals
www.arhp.org
Interstitial Cystitis Association
www.ichelp.org
Expert Medical Advisory Committee
• David Burks, MD
• Michael Chancellor, MD
• Robert Evans, MD
• Philip Hanno, MD (co-chair)
• Fred Howard, MD
• Mary W.L. Lee, PharmD, BCPS, FCCP
• Robert Moldwin, MD (co-chair)
                                more…
Expert Medical Advisory Committee
(continued)

• Diane K. Newman, RN-C, MSN, CRNP,
  FAAN
• Kenneth Peters, MD
• Vicki Ratner, MD
• Lee P. Shulman, MD
• Diane Smith, MSN, CRNP
• Kristene Whitmore, MD
Learning Objectives
• Define interstitial cystitis/painful bladder
  syndrome (IC/PBS)
• Identify the characteristic symptoms of
  IC/PBS
• List six tools frequently used in the basic
  assessment of IC/PBS


                                        more…
Learning Objectives (continued)
• Identify the three basic components of
  IC/PBS management
• Identify four elements of counseling for
  individuals with IC/PBS
Case Study: Jennifer Jones
• 38-year-old mother of 3
• Urinary urgency
• Urinary frequency
• Occasional urinary
  incontinence
• Negative urinalysis and
  urine culture
Case Study: Sandra Smith
• 38-year-old mother of 2
• Urinary urgency
• Urinary frequency
• Nocturia
• Bladder discomfort/pain,
  reduced with voiding
• Negative urinalysis and
  urine culture
Interstitial Cystitis/Painful Bladder
Syndrome (IC/PBS)


      “It feels like shards of glass being
           ground into your bladder.”


                                          Patient with IC/PBS


ICA. The Many Faces of IC. 2006; Hanno PM. In: Campbell-Walsh Urology, 9th ed. 2007.
Challenges of IC/PBS
• Invisible
• Lag time to diagnosis: 5 to 7 years
• Many providers and patients unaware
• Little known




ICA. The Many Faces of IC. 2006; Curhan GC. J Urol. 1999;
Clemens JQ. J Urol. 2005.
Nomenclature Related to IC/PBS

                         “Interstitial Cystitis”
                   “Interstitial Cystitis/Painful
                       Bladder Syndrome”
                        “Urethral Syndrome”
                                 “Trigonitis”


Washington, DC Consensus Meeting on IC/PBS, February 10, 2007; ICA Web site.
Definition of IC/PBS
• Pelvic pain, pressure, or discomfort
• Typically with persistent urge to void or
  urinary frequency
• Absence of infection or other pathology




Washington, DC Consensus Meeting on IC/PBS, February 10, 2007.
Prevalence of IC/PBS
              Gender specific prevalence of interstitial cystitis in a
                         managed care population
                         197     ICD-9Dx
      No. Per 100,000




                                                               Cystoscopy
                                                        99


                                   41
                                                                     19


                        Female    Male                Female        Male
Clemens JQ. J Urol. 2005; Curhan GC. J Urol. 1999;
Clemens JQ. In: Urologic Diseases in America. 2007.
IC/PBS Risk Factors
    Prevalence of IC symptoms and “confirmed” IC
  among first-degree relatives of 2,058 Fishbein/ICA
   survey respondents with complete family reports
                                 First-Degree Relatives (n)
                                                                     Prevalence of
                Individuals       Only IC          “Confirmed”        “Confirmed”
    Sex             (n)          Symptoms              IC            (per 100,000)

Female             5,802             678                83                1,431

Male               5,663             227                 9                    159
Female             3,138             360                46                1,466
(31–73 yr)

Warren JW. Urology. 2004; Curhan GC. J Urol. 1999; Clemens JQ. In: Urologic
Diseases in America. 2007; Moldwin RM. Clin Obstet Gynecol. 2002.
Impact of IC/PBS on Quality of Life
(QoL)
             Pain, urinary urgency, and urinary frequency




  Limitations               Curtailed                Sleep                   Reduced
  on sexual                 activities             deprivation               ability to
   intimacy                                                                   work




                                     Reduced QoL
ICA. The Many Faces of IC. 2006; Held PJ. In: Interstitial Cystitis. 1990; Ratner V.
Urol Clin N Am. 1994; Ottem DP. Urology. 2007; Rabin C. Women & Health. 2000.
Economic Costs of IC/PBS




 Physician or clinic outpatient                 Total medical expenditures:
  visits: 4,137,000 in 2000                        $65.9 million in 2000
Litwin MS. In: Urologic Diseases in America. 2007; Clemens JQ. In: Urologic
Diseases in America. 2007; Hanno PM. In: Campbell-Walsh Urology, 9th ed. 2007.
Signs and Symptoms of IC/PBS
• Range of severity
• Bladder pain or discomfort that increases
  with filling and may diminish with voiding
• Urinary frequency: 10 to 50 times per 24 hr;
  sometimes more than once per hour
• Urgency caused by increasing pain
• Nocturia


Clemens JQ. In: Urologic Diseases in America. 2007; Hanno PM. In: Penn Clinical
Manual of Urology. 2007; Rosenberg MT. Cleveland Clinic Journal of Medicine. 2007.
    Distinction from Overactive Bladder
    (OAB)

                                                            OAB: urgency forces
                   IC/PBS                                   voiding because of
                                                            possibility of leakage/
Sensation




                                                Sensation
                                                            incontinence




                   Time                                               Time
       (Increasing Bladder Volume)

  Hanno PM. In: Penn Clinical Manual of Urology. 2007.
What Does IC/PBS Feel Like?

     “A hot poker being placed up into
              your bladder.”


                                   Patient with IC/PBS

                                                more…
ICA. The Many Faces of IC. 2006.
What Does IC/PBS Feel Like?
(continued)



       “Having to urinate so frequently
          you can’t go anywhere.”


                                   Patient with IC/PBS

                                                more…
ICA. The Many Faces of IC. 2006.
What Does IC/PBS Feel Like?
(continued)



             “A deep aching pain in the
                   pelvic region.”


                                   Patient with IC/PBS


ICA. The Many Faces of IC. 2006.
Possible Etiology of IC/PBS
          Bacterial Cystitis?                   Primary Neurogenic
                                                   Inflammation?
 Autoimmune Disorder?
                                                           Bladder Trauma?
  Pelvic Floor
  Dysfunction?                    Bladder                         Bladder
                                   Insult                      Overdistention?
        Spinal Cord
         Trauma?                                     Pelvic Surgery?


             Damage to Bladder Epithelium
                                                                        more…
Adapted from Hanno PM. In: Penn Clinical Manual of Urology. 2007.
 Possible Etiology of IC/PBS (continued)
 Antiproliferative                                              Bladder Fails to
 Factor Secreted                                                Repair Damage
by Epithelial Cells            Leak of Urine
                          Constituents (potassium)
                              into Interstitum
    C-fiber
   Activation:                                                  Immunogenic
                            Mast Cell Activation &                & Allergic
  Substance P
                             Histamine Release                   Responses
    Release


                             Progressive                          Possibility of
                            Bladder Injury Spinal Cord              Chronic
                                                  Changes       Neuropathic Pain
Hanno PM. In: Penn Clinical Manual of Urology. 2007; Keay SK.
Proc Natl Acad Sci USA. 2004.
Associated Diseases and Conditions
• Allergies
• Sensitive skin
• Irritable bowel syndrome (IBS)
• Vulvodynia
• Chronic fatigue syndrome/fibromyalgia



                                                                         more…
Alagiri M. Urology. 1997; Hanno PM. In: Campbell-Walsh Urology, 9th ed. 2007.
Associated Diseases and Conditions
(continued)

• Inflammatory bowel disease
• Systemic lupus erythematosus (SLE)
• Endometriosis
• Pelvic floor dysfunction
• Not associated with bladder cancer




Alagiri M. Urology. 1997; Hanno PM. In: Campbell-Walsh Urology, 9th ed. 2007.
Associated Diseases
40.6          Percentage of individuals with condition
                                                                Diagnosed with IC/PBS
                                                                General population
               25.4
       22.5                 22.6


                                                 15
                                                       12.8
                                   10.6   10.9
                                                                     7.3
                      2.9                                     3.2
                                                                                  1.7
                                                                           0.07         0.05

Allergies        IBS        Sensitive     Vulvodynia    Fibro-      Colitis/      SLE
                              skin                      myalgia     Crohn’s
                                                                    Disease
Alagiri M. Urology. 1997; Hanno PM. In: Campbell-Walsh Urology, 9th ed. 2007.
IC/PBS and Pelvic Floor
Dysfunction (PFD)




Moldwin RM. NIDDK International Symposium.2006.
Issues Related to Diagnosis of
IC/PBS


                                  Restrictive
              No                                            Painful,
                                  research-
           biological                                      invasive
                                    based
            markers                                      techniques
                                    criteria




Clemens JQ. In: Urologic Diseases in America. 2007; Hanno PM. In:
Penn Clinical Manual of Urology. 2007.
NIDDK Diagnostic Inclusion Criteria
for IC/PBS
• Bladder pain or urinary urgency
• Glomerulations or Hunner’s ulcer on
  cystoscopy
• Specific findings after hydrodistention




Gillenwater JY. J Urol. 1988; Hanno PM. J Urol. 1999.
IC/PBS Diagnosis
• Empirical
• Absence of other conditions
• Tests sometimes used:
   ▪   Hydrodistention under anesthesia
   ▪   Lidocaine instillation
   ▪   Potassium chloride challenge




Moldwin RM. Clin Obstet Gynecol. 2002; Sant GR. Urology. 2001; Sant GR.
Rev Urol. 2002; Clemens JQ. In: Urologic Diseases in America. 2007; Hanno
PM. In: Penn Clinical Manual of Urology. 2007; Gregoire M. J Urol. 2002.
Basic Assessment of IC/PBS

                                                       Cytoscopy with
 History                    Urinalysis                 hydrodistension




             Physical                           Urine               Urine cytology
              exam                             culture              when indicated




Clemens JQ. In: Urologic Diseases in America. 2007; Hanno PM. In:
Penn Clinical Manual of Urology. 2007.
When to Consider IC/PBS




Clemons JL. Obstet Gynecol. 2002; Forrest JB. Urology. 2007.
Physical Exam in IC/PBS




Rosenberg MT. Cleveland Clinic Journal of Medicine. 2007.
Differential Diagnosis
• Urinary tract infection (UTI)
• Overactive bladder
• Endometriosis
• Chronic pelvic pain syndrome
• Bladder carcinoma
• Drug effects: cyclophosphamide,
  aspirin, NSAIDs, allopurinol

Hanno PM. In: Penn Clinical Manual of Urology. 2007.
Criteria for Working Diagnosis of
IC/PBS
• Pelvic pain or discomfort
• Urinary frequency
• Urinary urgency
• Negative urinalysis
• Absence of urinary tract infection
• Duration >3 months



Hanno PM. In: Penn Clinical Manual of Urology. 2007.
Case Study Follow-up:
Jennifer Jones
• Urgency caused by concern
  about impending
  incontinence
• Probable diagnosis:
  overactive bladder
  syndrome (OAB)



Hanno PM. In: Penn Clinical Manual of Urology. 2007.
Case Study Follow-up:
Sandra Smith
• Urgency caused by
  progressive bladder pain
• Probable diagnosis:
  interstitial cystitis/
  painful bladder
  syndrome (IC/PBS)



Hanno PM. In: Penn Clinical Manual of Urology. 2007.
Management of IC/PBS
Management of IC/PBS: Diet




Shorter B. J Urol. 2007; Moldwin RM. Clin Obstet Gynecol. 2002.
Management of IC/PBS:
Behavior Modification
• Gentle exercise
• Stress reduction
• Pain relief strategies
• Non-restrictive clothing




                                                                      more…
Moldwin RM. Clin Obstet Gynecol. 2002; ICA 2006; Moldwin RM. Clin Obstet
Gynecol. 2002; Oyama IA. Urology. 2004.
Management of IC/PBS:
Behavior Modification (continued)
• Alternative therapies
• Physical therapy
• Bladder retraining
• Controlled fluid intake




Moldwin RM. Clin Obstet Gynecol. 2002; ICA 2006; Moldwin RM. Clin Obstet
Gynecol. 2002; Oyama IA. Urology. 2004.
Management of IC/PBS:
Oral Therapy
• Pentosan polysulfate
  sodium (PPS; Elmiron®)
• Amitriptyline
• Hydroxyzine (Atarax®,
  Vistaril®)




Hanno PM. In: Penn Clinical Manual of Urology. 2007.
Pentosan Polysulfate Sodium
(Elmiron®)
• Only FDA-approved oral therapy
• Heparin analogue
• May counteract increased bladder
  permeability
• Efficacy up to 60%
• Dyspepsia
• Alopecia


Parsons CL. J Urol. 1993; Mulholland SG. Urology. 1990; Hanno PM. Urology. 1997; Hanno
PM. In: Penn Clinical Manual of Urology. 2007; Moldwin RM. Clin Obstet Gynecol. 2002.
Amitriptyline
• Tricyclic antidepressant
• May help stabilize mast cells
• May increase bladder capacity
• Significantly reduced symptom scores
• Sedation
• Anticholinergic effects



van Ophoven A. J Urol. 2004; Hanno PM. In: Penn Clinical Manual
of Urology. 2007; Moldwin RM. Clin Obstet Gynecol. 2002.
Hydroxyzine (Atarax®, Vistaril®)
• H1 histamine antagonist
• Inhibits mast cell degranulation
• May promote sleep and act as muscle
  relaxant
• No large controlled clinical trials to
  confirm efficacy
• Sedation
• Anticholinergic effects

Theoharides TC. Urology. 1997; Sant GR. J Urol. 2003; Hanno PM. In: Penn
Clinical Manual of Urology. 2007; Moldwin RM. Clin Obstet Gynecol. 2002.
Other Oral Agents
• Other tricyclics
• Other antihistamines
• Anticonvulsants
• Muscle relaxants
• Opioids



                                                                       more…
Hanno PM. In: Penn Clinical Manual of Urology. 2007; Chancellor M. Urology. 2004; Moldwin
RM. Clin Obstet Gynecol. 2002; Moldwin RM. Urology. 2007; Nichol JC. Rev Urol. 2006.
Other Oral Agents (continued)
• SSRIs
• H2 antagonists
• Leukotriene inhibitors
• Urinary anesthetics
• Alpha blockers




Hanno PM. In: Penn Clinical Manual of Urology. 2007; Chancellor M. Urology. 2004; Moldwin
RM. Clin Obstet Gynecol. 2002; Moldwin RM. Urology. 2007; Nichol JC. Rev Urol. 2006.
Management of IC/PBS: Intravesical
Dimethylsulfoxide (DMSO)




Hanno PM. In: Penn Clinical Manual of Urology. 2007; Moldwin RM. Clin Obstet Gynecol.
2002; Moldwin RM. Urology. 2007; Perez-Merrero R. J Urol. 1988; Peeker R. J Urol. 2000.
Management of IC/PBS:
Other Intravesical Agents
• Lidocaine
• Heparin alone or in combination
• Rarely used:
   ▪   Oxychlorosene (Clorpactin®)
   ▪   Silver nitrate




Moldwin RM. Clin Obstet Gynecol. 2002; Hanno PM. In: Penn Clinical Manual of Urology.
2007.
Management of IC/PBS:
Hydrodistention




Moldwin RM. Clin Obstet Gynecol. 2002; Hanno PM. In: Campbell-Walsh Urology. 2007.
Management of IC/PBS: Surgery




Moldwin RM. Clin Obstet Gynecol. 2002; Hanno PM. In: Penn Clinical Manual of Urology.
2007; Clemens JQ. In: Urologic Diseases in America. 2007; Peters KM. Rev Urol. 2002;
Comiter CV. J Urol. 2003.
Management of IC/PBS:
When to Refer
Current Areas of Research
•   Antiproliferative factor
•   Liposomes
•   Suplatast tosilate
•   Intravesical resiniferatoxin
•   Gene therapy delivery of
    preproenkephalin

                                                                      more…
Zhang CO. BMC Urology. 2005; Keay SK. Proc Natl Acad Sci USA. 2004.
Current Areas of Research (continued)
•   Sacral nerve stimulation
•   Mycophenolate mofetil (CellCept®)
•   Intravesical botulinum toxin type A
•   MN-001 (an oral mast cell stabilizer)
•   Physical therapy




http://www.clinicaltrials.gov.; MediciNova press release 2007.
Research Needs
• Etiology
• Efficacious treatments
• Markers
• Standard definition
• Epidemiology, including prevalence and
  natural history
• Identification of risk factors
• Costs
Clemens JQ. In: Urologic Diseases in America. 2007.
Counseling for Individuals with
IC/PBS
Understanding Challenges for
Patients




ICA The Many Faces of IC. 2006; Slade D. Urology. 1997.
Exploring Diagnosis
Exploring Treatment Options
Supporting Self-Care




Moldwin RM. The Interstitial Cystitis Survival Guide. 2000.
Patient Support and Education:
Interstitial Cystitis Association
• Founded by physician with IC/PBS
• Goals: raise awareness, support patients,
  promote and fund research
• Books, newsletters, videos, fact sheets,
  brochures
• Registry of health care professionals
• www.ichelp.org
• 1-800-HELP ICA
Sources of Patient Support and
Education: Associated Diseases
• International Foundation for Functional
  Gastrointestinal Disorders
• Crohn’s and Colitis Foundation of America
• The Chronic Fatigue and Immune
  Dysfunction Syndrome (CFIDS)
  Association of America
Sources of Patient Support and
Education (Continued)
• National Vulvodynia Association
• National Fibromyalgia Association
• National Fibromyalgia Partnership
Expert Medical Advisory Committee
     David Burks, MD
     Division Head for Urology
     Fairlane Ambulatory Center
     Henry Ford Health System
     Ann Arbor, MI
     Michael Chancellor, MD
     Professor
     Department of Ob/Gyn
     University of Pittsburgh School of Medicine
     Pittsburgh, PA

     Robert Evans, MD
     Chief of Surgery
     The Urology Center
     Greensboro, NC
Expert Medical Advisory Committee
     Philip Hanno, MD (co-chair)
     Professor
     Division of Urology
     University of Pennsylvania
     Philadelphia, PA

     Fred Howard, MD
     Director, Division of GYN Specialties
     Professor, Associate Chair of Ob/Gyn
     University of Rochester School of Medicine
     Rochester, NY

     Mary W.L. Lee, PharmD, BCPS, FCCP
     Professor of Pharmacy Practice
     Chicago College of Pharmacy
     Vice President and Chief Academic Officer, Pharmacy and Health
     Sciences Education
     Midwestern University, Downers Grove, IL
Expert Medical Advisory Committee
     Robert Moldwin, MD (co-chair)
     Associate Professor of Clinical Urology
     Director, Pelvic Pain Center
     The Smith Institute for Urology
     Long Island Jewish Medical Center
     New Hyde Park, NY
     Diane K. Newman, RN-C, MSN, CRNP, FAAN
     Co-Director, Penn Center for Continence and Pelvic Health
     Division of Urology
     University of Pennsylvania Health Center
     Philadelphia, PA


     Kenneth Peters, MD
     Chair, Department of Urology
     William Beaumont Hospital
     Birmingham, MI
Expert Medical Advisory Committee
     Vicki Ratner, MD
     Founder and President Emeritus
     Interstitial Cystitis Association
     Rockville, MD


     Lee P. Shulman, MD
     Professor, Department of Ob/Gyn
     Feinberg School of Medicine
     Northwestern University
     Chicago, IL


     Diane Smith, MSN, CRNP
     President, UroHealthcare, LLC
     Newtown Square, PA
Expert Medical Advisory Committee
     Kristene E. Whitmore, MD
     Professor and Chair
     Urology and Female Pelvic Medicine/Reconstructive Surgery
     Drexel University College of Medicine
     Philadelphia, PA

								
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