Interstitial cystitis (IC) is one of the diseases that seriously affects the quality of life of patients
Interstitial cystitis is still a major unconquered problem for urologists, obstetricians and gynecologists.
I. Definition.
Interstitial cystitis (IC) is a chronic inflammatory disease of bladder dysfunction, a chronic disease with frequency, urgency, painful urination, difficulty in intercourse, nocturia, and chronic pelvic pain as the main clinical manifestations.
II. History of IC
In 1808, Dr. Phillip, Syng and Physick proposed in their clinical teaching that inflammatory bladder disease “ulcer” could also cause severe lower urinary tract symptoms.
In 1836, his student Parrish included it in his textbook.
In 1887, Skene first officially named it interstitial cystitis.
In 1915 Hunner was the first to report a bleeding area on the bladder wall later called Hunner’s ulcer.
III. Classification of IC
Ulcerative (typical IC): abnormal epithelium and characteristic inflammatory cell infiltration, high levels of nitric oxide (NO) in the bladder; expression of proteoglycans that bind growth factors, such as CD44, is significantly higher in ulcerative IC than in non-ulcerative IC
Non-ulcer type (atypical IC): mild inflammatory response.
Recent studies suggest that chronic sterile prostatitis, prostatodynia and chronic pelvic pain syndrome may be different forms of IC .
Epidemiology
Worldwide, the prevalence ranges from 8/100,000 to 10/100,000.
In Finland, it is 18.6/100,000, and in the Netherlands, it is 16/100,000,
In Japan, it is 4.5/100,000, and in the United States, it is 60/100,000.
No relevant statistics have been reported in China.
Prevalence in women (male to female ratio about 9:1)
The average age of onset is 42-48 years old. 25% are younger than 30 years old.
In recent years, the incidence in children is also on the rise
Caucasians are significantly more affected than other races, and black people are rare.
The incidence of IC in family members of patients is 17 times higher than that of normal people
There is no significant difference in symptoms between men and women
Self-reported depression, pain and education are positively correlated with the severity of IC
Often associated with allergic diseases, autoimmune diseases, rheumatoid, irritable bowel syndrome
The duration of symptoms varies from 1 to 10 years.
The onset of symptoms is subacute, and then the plateau of chronic symptoms is maintained.
V. Etiology and pathophysiology
1. Defects in the mucopolysaccharide layer of the bladder wall lead to endothelial dysfunction, resulting in diffuse transmural inflammation caused by exposure of the migrating epithelium to toxins in the urine.
2. Autoimmune and inflammatory reactions Various causes promote autoimmune and inflammatory reactions, causing mast cells and eosinophils to accumulate, thus releasing various inflammatory mediators that make the bladder more susceptible to damage and stimulating an immune response that causes the characteristic IC ulcers.
3. Infection Some patients have a history of recurrent urinary tract infections.
4. Endocrine influences The manifestations of IC are aggravated during menstruation in women, and estrogen may play an important role in the development of IC by causing neurogenic inflammatory responses.
5. Urinary toxic components Some small cations or difficult to culture pathogenic bacteria in urine damage the urinary tract epithelium and smooth muscle cells.
6, Neurogenic abnormalities It is believed that IC may be a chronic visceral pain syndrome. Studies have confirmed an increased density of bladder nerve fibers in IC. Extracellular adenosine triphosphate (ATP) acts as a sensory neuromediator to transmit pain sensation, and high concentrations of substance P are present around the bladder nerves in patients with IC.
7. Other hypoxia, mental stress, etc.
VI. Clinical manifestations
The earliest manifestations are often frequent, urgent, painful urination and increased nocturia.
Perineal or pelvic pain
The clinical manifestations are very similar to those of endometriosis or pelvic inflammatory disease.
Symptoms are relieved after urination
Depressed mood
Misdiagnosis as urinary tract infection, non-bacterial prostatitis, pelvic inflammatory disease, etc.
VII. Diagnosis
The diagnosis is exclusionary:
①clinical symptoms are the main ones
② exclude urinary tract infection: urine routine no white blood cells; urine bacterial culture and drug sensitivity negative
③Urodynamics: bladder volume is reduced, flow rate is slowed, and residual urine is increased. It is controversial as one of the diagnostic criteria mainly advantageous for the diagnosis of transitional active bladder.
④B ultrasound, CT, urine exfoliative cytology: exclude pelvic and urinary tract tumors
⑤ exclude gynecological diseases
⑥Cystoscopy, hydrodilation of the bladder under anesthesia: gold standard, but less sensitive
Ulcerated (Hunner’s ulcer): one or more small ulcers in the bladder base or lateral wall, found in about 10% of cases.
Non-ulcerated type: redness of the bladder mucosa in multiple patches, strawberry bleeding or spotting, seen in 90% of patients. (7) Bladder biopsy to rule out carcinoma in situ, mast cells are considered to be one of the diagnostic markers
The potassium sensitivity test was introduced in 1994 by Parsons et al. to detect bladder epithelial permeability. Potassium ions pass through an incomplete mucosal barrier to depolarize submucosal sensory nerve endings and produce painful symptoms. Patients with TC are particularly sensitive to the potassium excitation test, producing unbearable pain.
The positive rate is up to 75%. The disadvantage is that 25% of IC patients are not diagnosed.
False positives: instability of the detrusor muscle (25%), radiation cystitis (100%), and
Bacterial cystitis (100%) patients.
VIII. Treatment
The aim of treatment: mainly to improve symptoms and quality of life.
Can relieve symptoms but prone to recurrence, can not be cured,
1, general treatment
Psychotherapy
Change of dietary habits: Avoid acidic foods, avoid foods rich in potassium (such as tomatoes, chocolate, etc.), take vitamins and minerals (Vital A, B6, E, C and b2 carotene, calcium and magnesium), etc. can improve the symptoms of IC patients. Alkalinization of the urine,
2, bladder dilatation: It is the most widely used treatment for IC, mainly to increase bladder capacity and reduce the time between voiding. The mechanism may be the replacement of non-functional epithelial cells by new epithelial cells, or denervation to reduce the pain caused by nerve damage. The relief rate is 20-60%. It is more effective for patients with bladder volume >150ml
3. Drug treatment
3. 1. bladder perfusion drugs
① Dimethyl sulfoxide: the only approved drug for intravesical use approved by FDA in 1978, the standard treatment for IC.
Anti-inflammatory and pain relief, muscle relaxation, collagen dissolution, mast cell inhibition, antibacterial and diastolic vascular pharmacological effects such as symptom relief rate of 65%, recurrence rate decreased by 52%,
Heparin: anti-inflammatory and inhibit bladder contracture.
③ BCG: inhibits the action of T-lymphocytes. Intravesical administration has been shown to be effective in 6010% of patients, with 8910% of patients experiencing relief at two years.
Hyaluronic acid: Promotes recovery of the glucosaminoglycan layer, relieves pain and urinary frequency.
⑤ Iodophor bladder perfusion: protective effect on the mucosal glucosaminoglycan (GAG) layer of the bladder
(6) Second-line regimen: botulinum toxin type A in the detrusor muscle, de-afferent drug infusion (capsaicin)
3. 2. Oral drugs
① Sodium pentosan: Glucosaminoglycan, can promote the growth and recovery of epithelial cells, reduce pain, improve the symptoms of urinary frequency. It is used as the first-line drug for IC treatment and is the only orally effective drug approved by FDA.
②Antihistamines: Kaminergic, Antalox, Cimetidine, etc., which usually take 3 weeks to be effective.
(3) Antibiotics: Long-term prophylactic medication is useful for some IC patients. Repeated trials are required to determine
④Tricyclic antidepressants and anxiolytics: irritability and anxiety are obvious causes of IC, and antidepressants and anxiolytics have a certain effect on the relief of IC, which is one of the most widely used methods for treating IC.
4. Neuromodulation therapy
Pelvic floor manual physiotherapy: reduce neurogenic stimulation and sensitivity.
Transcutaneous electrical nerve stimulation treatment.
5.Surgical treatment.
Only a small percentage (less than 10%) of patients with IC choose surgical treatment,
Refractory symptoms or conservative treatment is ineffective.
The success rate is quite limited.
Methods: These include transurethral resection or laser excision of the ulcer,
Cystectomy for urinary diversion is the ultimate treatment option for interstitial cystitis, but the quality of life is poor.
The potential mortality of the procedure should be fully explained to the patient before surgery and should be chosen with caution.