Interstitial Cystitis Naturopathic Perspective

Interstitial cystitis (IC), also known as bladder pain syndrome, causes a reduced bladder capacity accompanied by symptoms of frequent, painful urination, and may or may not include blood in the urine (either seen by the naked eye or identified by urinalysis). The theory behind IC primarily emphasizes bladderwall inflammation as the root cause of symptoms. On physical examination, individuals with IC often have no physical findings, but a vague suprapubic (an area of the abdomen, just above the top of the pubic bone) tenderness may be present. The urinalysis (urine test) is often negative but may identify small/trace amounts of blood within the urine.[1]

Interstitial cystitis is defined by the American Urological Association (AUA) as follows: “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable causes.”[2] Interstitial cystitis affects both males and females, but most individuals with IC are women. Interestingly enough, IC symptoms tend to worsen a few days prior to the start of the menses, which contrasts with endometriosis, which is typically worse during menses.[2]

Characteristics of IC

Interstitial cystitis typically includes a combination of pain, frequency, nocturia (excessive urination at night), and urgency. Pelvic pain is a hallmark symptom of IC.[2] In early or milder cases of IC, the pelvic pain may not be identified as blunt pain, but rather described as pressure or burning, sharp or vaguely, or as a general discomfort that revolves around the need to urinate. These sensations are typically felt in the suprapubic area and may refer or radiate to the lower pelvic area, including the urethra, vagina, labia, inguinal area, perineum, lower abdomen, or back. Patients with IC often require frequent urination in order to control pain. Urination may even temporarily relieve the pain.[2]

In patients with IC, symptom scores are helpful measures to monitor any improvements or regression with therapeutic interventions. The O’Leary Sant Symptom and Problem Index focuses on symptoms within the last month, focusing on urgency, frequency, nocturia, and pain. The most common symptoms found in IC patients include bladder pain, a persistent urge to urinate, and high frequency of urination.[2]

Cystoscopy may be recommended in individuals with suspected IC. Cystoscopy can potentially identify Hunner’s lesions, which are seen in some individuals with IC. Cystoscopy is not diagnostic and is not required in all individuals with suspected IC. Only approximately 16% of IC patients have identifiable Hunner’s lesions.[2]

How it Differs from Chronic Urinary Tract Infections (UTIs) or Overactive Bladder (OAB) Urinary Tract Infections (UTIs)

Urinary frequency, urgency, pain during urination, and suprapubic pain may occur in both urinary tract infections (UTIs) and IC. UTIs may also have fever and flank pain (pain in the upper abdomen, upper back, or on the sides of the abdomen), which is not commonly seen in IC. Pyuria indicates the presence of white blood cells (WBCs) in the urine and is generally indicative of an infection in the urinary tract, which is often not seen with IC. When a urinalysis is performed for a suspected UTI, obvious blood or microscopic blood may be observed, and bacteria are frequently cultured from the urine.

Even though individuals with IC do not have a UTI at the time of diagnosis, a significant number of individuals with IC do have a previous history of urinary tract infection(s).[2]

Overactive Bladder (OAB)

Patients with an overactive bladder tend to urinate frequently in order to relieve the urge to urine and decrease the possibility of leakage (incontinence). These same individuals may have nocturia, but the symptoms often do not present with painful urination or pain. It has been shown that IC can overlap with an overactive bladder—making this an important consideration in IC cases.

Naturopathic Approaches

First and foremost, it is important to understand both diet and lifestyle modifications that can help reduce the frequency and severity of IC. To reduce the frequency of urination and reduce pelvic discomfort, individuals with IC may actually limit fluid intake. However, adequate water intake will help dilute irritants and toxins in the urine and help flush the bladder, potentially preventing urinary tract infections.[2] It is important to encourage appropriate hydration with neutral, nonirritating liquids. Adequate hydration can also help reduce constipation, which can further exacerbate symptoms of IC. If constipation is a concern in someone dealing with IC, there are useful dietary approaches, such as fibre, to soften and form proper stools.Diet is also important for managing IC. There are a number of bladder-irritating foods, and limitation or complete avoidance of these foods can be helpful in reducing frequency and severity of these urinary episodes. Some of these irritating foods include:[2]

• Caffeinated beverages: coffee, tea (green, black, white), energy drinks, preworkout drinks
• Carbonated beverages
• Alcoholic beverages
• Citrus fruits or citrus products (e.g. juice)
• Tomatoes
• Bananas
• Artificial sweeteners
• Spicy foods

If an individual is struggling to identify trigger foods, a naturopathic doctor can guide them through an elimination diet in order to determine potential triggers. Sexual dysfunction is also common in patients with IC, and several self-care strategies are beneficial, in addition to pelvic-floor physiotherapy. Pelvic-floor physiotherapy can teach individuals with IC how to relax the pelvic-floor muscles. Interestingly enough, Kegel exercises (which strengthen the pelvic-floor muscles) are often aggravating for IC patients.[3] In patients with IC, higher levels of stress have also been found to correlate to greater urinary urgency and pain. Stress and sleep management is important for managing symptoms of IC and can take shape in the form of yoga, meditation, acupuncture, botanical medicine, and other lifestyle modifications. In fact, there is a guided imagery script for patients with IC—a prospective, randomized controlled pilot study used guided imagery to focus on healing the bladder, relaxing the pelvic-floor muscles, and quieting the nerves that are involved in IC.[4]

The University of Michigan Department of Urology has produced a Frequency and Volume Chart, which allows individuals to record and monitor fluid intake and urine output. This chart is helpful for both patients and their health-care providers (especially if the patient is working with a urologist). This chart also monitors any leaking, sensations, pain/discomfort, and type of fluid intake.[5] There are also bladder-training protocols, which can be helpful in the management of IC. This takes significant commitment and motivation on behalf of the individual, and it should be regularly assessed by the primary health-care provider. These protocols include various bladder-control techniques, including pelvic-floor relaxation and urge suppression, perineal pressure, and mental distraction. A voiding diary may also be helpful and insightful for both the health-care provider and the individual dealing with IC. In IC, the average voided volume is 86–174 ml per day, compared to 289 ml in individuals without IC. IC patients often void 17–25 times per day, in comparison to six (6) times per day in individuals without IC.[2]

Cranberry

Many patients with IC may be using cranberry (Vaccinium macrocarpon) juice or concentrated cranberry supplements, which can contribute to the frequency and severity of the urinary episodes of IC. As individuals may be afraid of the potential consequences of discontinuing cranberry products, it’s helpful to understand that cranberry can trigger these urinary flare-ups. Under the guidance of a naturopathic doctor, several natural health products and botanical medicines may also be considered in the management of IC.

Chondroitin Sulfate

Theoretically, components of chondroitin sulfate may be useful in improving the glycosaminoglycan (GAG) mucopolysaccharide integrity of the mucosal surface of the bladder, reducing bladder-wall inflammation.[6]

Quercetin

Theoretically, quercetin may help with mast-cell stabilization, therefore protecting the bladder mucosa, by decreasing inflammation.[7]

Acupuncture

According to a systematic review of 23 randomized controlled trials, acupuncture may also be a useful, noninvasive, adjunct therapy alongside other therapeutic approaches.[8]

When it comes to interstitial cystitis/bladder pain syndrome, there are many nonpharmacologic and conservative therapies to consider before deliberating more invasive treatment options. Treatment of IC is multifactorial, and individuals with IC should be educated and equipped to address behavioural adaptations, diet, and stress. In addition to supporting those lifestyle changes, naturopathic doctors are well equipped to provide additional support by utilizing natural health products, botanical medicine, and acupuncture.