Fibromyalgia and Interstitial Cystitis

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Interstitial Cystitis (IC) is a disease that results in frequent discomfort or pain in the bladder and the surrounding areas of the pelvis. Symptoms vary from person to person and may include mild discomfort, pressure, tenderness, or intense persistent pain in the bladder and pelvis. The pain may increase or decrease in intensity as the bladder fills with urine or after it is emptied. Individuals may also feel the urgent or frequent need to urinate. For women, symptoms often worsen during menstruation and they may sometimes experience symptoms during vaginal intercourse.

 Due to the fact that IC varies so greatly with regard to symptoms and their severity, a majority of researchers and doctors feel that IC is actually a combination of several diseases. Recently, the terms “bladder pain syndrome” (BPS) and “painful bladder syndrome” (PBS) have emerged to describe those cases in which individuals have painful urinary symptoms but do not meet the strict criteria for a diagnosis of IC. As such, the term IC/PBS refers to all cases of urinary pain that are not attributable to other causes (like infection or kidney stones), whereas IC refers to only those cases that meet all of the IC criteria established by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

 In IC/PBS, there may be bleeding present on the bladder wall, as well as patches of broken tissue. Some individuals with IC/PBS are unable to hold much urine in their bladders and may urinate as many as 60 times per day, including during the nighttime. IC/PBS affects more women than men, including an estimated 3.3 million women in the U.S over the age of 18 and 1.6 million men.

Causes and Diagnosis of IC/PBS

Although many symptoms of IC/PBS suggest that a bacterial infection may be the cause, medical tests reveal no bacteria in the urine of individuals with IC/PBS. In addition, these patients do not show improvement in symptoms following antibiotic therapy. Little is known about the causes of IC/PBS but researchers are working to better understand the disease.

Many women who are affected with IC/PBS also suffer from other conditions such as Irritable Bowel Syndrome and Fibromyalgia. As such, some researchers think that IC/PBS may be a response of the bladder to a more generalized condition elsewhere in the body that causes overall inflammation.

There is no test to diagnose IC/PBS. Since the symptoms of IC/PBS are so similar to other bladder conditions, doctors must first rule out other treatable bladder conditions before they diagnose IC/PBS. Urinary tract infections and bladder cancer must be ruled out for both sexes. For women, doctors must also rule out endometriosis (a condition in which cells that line the uterus grow out into other areas of the body), while for men they must exclude chronic prostate inflammation or chronic pelvic pain syndrome.

Treatments for IC/PBS

IC/PBS is difficult to treat, as symptoms may come and go, disappear for weeks, months or even years, and then suddenly return. There is currently no cure. Since the causes of IC/PBS are not known, treatment focuses on relieving the symptoms associated with the condition.

Bladder distension is a procedure used to stretch the bladder to its capacity by filling it with liquid or gas. While it is initially painful for individuals it IC/PBS, the pain subsides within a matter of days and two to four weeks following the procedure, pain may actually be improved. Researchers do not know why this procedure can relieve symptoms for some individuals with IC/PBS, but think it has a way of interfering with the way the bladder signals pain to the brain.

A bladder instillation procedure acts much like a bath for the bladder. Using a catheter (a tube inserted into the bladder through the urethra), the bladder is filled with a solution that is held for around 10 to 15 minutes before being emptied. Currently, the only drug that is approved by the U.S. Food and Drug Administration (FDA) for the purposes of bladder instillation is a drug called DMSO. Bladder instillations are typically given every week or two weeks for a total of six to eight weeks and then repeated as needed. Individuals who respond to DMSO treatments notice their symptoms improving about three to four weeks following the first six or eight week cycle.  This procedure can be self-administered at home if the patient wishes to do so.

A drug known as Elmiron may also be prescribed for some patients. It is generally taken three times a day by mouth. In clinical trials, Elmiron was shown to improve symptoms in up to 30% of patients with IC. Certain anti-depressant medications known as tricyclic antidepressants – in particular a drug called Elavil – may also be beneficial to some patients to help reduce pain, increase bladder capacity, and decrease the frequency of urination at night. Severe pain is often treated with prescription narcotic pain medications such as Tylenol with codeine and others. Aspirin and ibuprofen may also be recommended to treat the pain associated with IC/PBS.

Mild electrical impulses can also be used to stimulate the nerves of the bladder. This can be done through the skin or via a small implanted device. The trans-skin method is referred to as transcutaneous electrical nerve stimulation, or TENS.

Dietary modifications may be beneficial as well. Many IC/PBS patients report that alcohol, tomatoes, spices, chocolate, caffeine, citrus, artificial sweeteners, and high-acid foods contribute to their bladder irritation. Natural therapies that have been investigated in IC include L-arginine and superoxide dismutase. Some evidence exists to suggest their possible effectiveness (Ehrin et al., 1998; Wheeler et al., 1997; Korting et al., 1999; Kadrnka et al., 1981).

Fibromyalgia and Interstitial Cystitis

Individuals with Fibromyalgia also frequently suffer from Interstitial Cystitis. IC in and of itself can be severely debilitating, therefore when it coexists with Fibromyalgia it can have a profound impact on a patient’s quality of life. The reason for the co-occurrence of both conditions is not well understood, but many researchers believe the pain in both conditions is the result of malfunctioning nerve signals, and some believe that the chronic pain that is associated with IC may lead to the general pain sensitization associated with Fibromyalgia. Furthermore, both conditions are much more common in women than in men, suggesting certain genetic or hormonal factors may be at play.

If you have both IC and Fibromyalgia, it is important to tell your doctors all of the medications you are taking to treat each condition, as certain drugs used to treat IC may interact adversely with drugs used to treat Fibromyalgia and many of its symptoms.

The co-occurrence of IC/PBS and Fibromyalgia is well-documented in the medical literature. A 2011 study by Peters et al. contacted patients with and without a diagnosis of IC/PBS via a mailed survey to assess the incidence of 21 different conditions, including Fibromyalgia. The researchers found an increased rate of Fibromyalgia among women with IC/PBS. 

Research published in 2010 by Nickel and colleagues studied 322 subjects, including 205 patients with IC/PBS and 117 age-matched controls. They found that the patients with IC/PBS were more likely to report also having a diagnosis of Fibromyalgia (17.7% vs. 2.6%). The authors also found that the more conditions an individual reported having, the more severe their pain, stress, depression, and sleep disturbances were (as measured by questionnaires).

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 References

1.        Ehren I, Lundberg JO, Adolfsson J, Wiklund NP. Effects of L-arginine treatment on symptoms and bladder nitric oxide levels in patients with Interstitial Cystitis. Urology. 1998;52:1026-1029.

2.        Wheeler MA, Smith SD, Saito N, et al. Effect of long-term oral L-arginine on the nitric oxide synthase pathway in the urine from patients with Interstitial Cystitis. J Urol. 1997;158:2045-2450.

3.        Korting GE, Smith SD, Wheeler MA, et al. A randomized double-blind trial of oral L-arginine for treatment of Interstitial Cystitis. J Urol. 1999;161:558-565.

4.        Kadrnka F. [Results of a multicenter orgotein study in radiation induced and Interstitial Cystitis]. Eur J Rheumatol Inflamm. 1981;4:237-243.

5.        Peters KM, Killinger KA, Mounayer MH, Boura JA. Are ulcerative and nonulcerative Interstitial Cystitis/painful bladder syndrome 2 distance diseases? A study of coexisting conditions. Urology. 2011;78(2):301-308.

Nickel JC, Tripp DA, Pontari M, Moldwin R, Mayer R, Carr LK, Doggweiler R, Yang CC, Mishra N, Nordling J. Interstitial Cystitis/painful bladder syndrome and associated medical conditions with an emphasis on irritable bowel syndrome, Fibromyalgia and chronic fatigue syndrome. J Urol. 2010;184(4):1358-1363.

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