Unit Eight: Treatment
Treatment of a newly diagnosed case of IC/BPS begins with education of the patient and her/his immediate attendants. This is to describe to them that this is an unusual disease but not rare. Many of these patients are suffering like them all over the globe. Encourage them to read about this disease on Internet. Positive thinking is what needs to be infused. Let them know that even though this is a discomfort which can be reduced by medication, it can not be life threatening and cant be passed on to their nears and dear ones. If the expectations are realistic, then acceptance of treatment outcome becomes better. Treatment is started in the following sequence.
1) Oral non-specific medications. These include
a) Hydroxyzine (Atarax, 10, 25 mg) is an antihistamine, used extensively by dermatologists for allergic reactions. It causes sedation and therefore should be started at a lower dose and can be titrated upwards upto 25 mg twice a day if the patient tolerates it well
b) Amitryptiline (Tryptomer, 25 mg) is anti depressant with central and peripheral action. It modifies pain sensation and exerts a mild ant inflammatory effect by virtue of its anti histaminic action.it also reduces the psychic response to pain. Sedation is a desirable side effect in some patients. Generally should be given as a single bedtime dose
c) Anti muscarinic agents like Tolterodine (Roliten, 1,2,4 mg) or Soliifenacin ( Soliten ,5,10 mg) may be given to reduce the frequency of urination. These act by relaxing the bladder muscles and increasing the bladder capacity. They can cause dry mouth and constipation, which could be a problem
d) Alkalisers work by reducing the acidity of urine, thereby reducing the burning sensation, which may result from contact of acidic urine on the bladder and urethral mucosa.
e) Skeletal muscle relaxants, Clonazepam (0.25mg);Chlorbenzaprine (Mobrine/Flexabenz, 5mg)are useful in cases where pelvic floor spasm is suspected on clinical examination. They cause sedation and may cause dependance
f) Pain killers: Usually NSDAIDs are not effective in treating this condition. Tramadol with central action along with paracetamol can be tried in acute phase.
g) Immune modulators like Montleucast act by blocking the inflammatory effects of leucotrines as they are released after mast cell degranulation. They are usually prescribed for bronchial asthma and seasonal allergies. Adverse effects include hypersensitivity reactions, headache, drowsiness, and neuropsychiatric disturbances and increased bleeding tendencies.
h) Anti mitotic agents Azathioprine, Supalast Tosylate, Mycophenolate and Methotrexate have been used in research settings but haven’t found recommendation for use in clinical guidelines.
i) Corticosteroids have some role, both as intravesical agents and as systemic in a group of patients with severe inflammatory kind of IC/ BPS
2) Oral specific medicine: Pentosan Poly sulphate (PPS) is a synthetic sulphated polysaccharide that has heparin like properties. When ingested orally, 4-6{9802d47d6d88dfb86fe34586c63757e96508e528afd0c0bb3af5da2789c058d3} of the dose is excreted unchanged in the urine. It is expected to replenish the GAG layer, the protective aminoglycan layer of the urothelium of urinary bladder. PPS (Comfora , 100 mg) is to be administered orally one hour before or at least two hours after meals , three times a day. The therapy should be evaluated at least after three months before labeling it as a failure.it is generally a well-tolerated drug, with only 4{9802d47d6d88dfb86fe34586c63757e96508e528afd0c0bb3af5da2789c058d3} patients reporting any adverse effect. The common adverse effects are alopecia, diarrhea, nausea, rash and rarely bleeding tendencies.
3) Intra vesical treatments: Various intra vesical agents have been used for treatment of IC/BPS. Dimethyl sulphoxyl (DMSO) is an industrial solvent has been used as a popular intravesical agent. However its efficacy has not been proved in randomized trials. Patients treated with DMSO develop garlic like odour. PPS, Chondroitin sulphate and heparin have been used as intra vesical treatments. All these have been postulated to replenish the GAG layer of urothelium . Various cocktails have been tabulated for quick reference. Usually these are instilled into the urinary bladder once a week for 6-8 weeks.
Intravesical injections of Botox have been tried with little evidence of relief in symptoms. Intravesical BCG is mentioned not to be used for IC /BPS.
4) Cystoscopy, hydrodistension with or without ablation of Hunner’s lesions. This has already been described at length
5) Role of diet cant be over emphasized. Dietary elements are metabolized in the body and many of them are excreted in urine in a form that can either initiate an urothelial injury to the urothelial barrier and /or perpetuate the insult to damaged urothelium since there are wide variations in the dietary practices across the globe , it is better to identify the region specific dietary constituents which have an adverse effect on the bladder pain. The best way is to teach the patient to identify the offending agent by writing down in diary whatever they ingested in the last four hours of an acute episode of exacerbation of symptoms.
THE MOST BOTHERSOME FOODS
Coffee – Regular and Decaf
Tea – Caffeinated
Carbonated Drinks – Cola, Non- Colas, Diet and Caffeine Free
Alcohols – Beer, Red Wine, White Wine, Champagne
Fruits – Grapefruit, Lemon, Orange, Pineapple
Fruit Juices – Cranberry, Grapefruit, Orange, Pineapple
Vegetables – Tomato and Tomato Products
Flavor Enhancers – Hot Peppers, Spicy Foods, Chilli, Horseradish, Vinegar, Monosodium Glutamate (Msg)
Artificial Sweeteners – Nutrasweet, Sweet N Low, Equal (Sweetener), Saccharin
Ethnic Foods – Mexicam, Indian, Thai
THE LEAST BOTHERSOME FOODS
Water/Milk – Low Fat and Whole
Fruits – Bananas, Blueberries, Honeydew Melon, Pears, Raisins, Watermelon
Vegetables – Broccoli, Brussels Sprouts, Cabbage, Carrots, Cauliflower, Celery, Cucumbers, Mushrooms, Peas, Radishes, Squash, Zucchini, White Potatoes, Sweet Potatoes and Yams
Poultry – Chicken, Eggs, Turkey
Meat – Beef, Pork, Lamb
Seafood – Shrimp, Tuna Fish, Salmon
Grains – Oat, Rice
Snacks – Pretzels, Popcorn
Now let’s solve the questions