More Painful Bladder Syndrome Non-invasive Treatments

I have painful bladder victims that do not want instillations – multiple allergies that would make infections impossible to treat is one issue. There are some other options mentioned in a recent review that are not common.

Int Urogynecol J. 2015 Aug 14. [Epub ahead of print]
Treatment of bladder pain syndrome and interstitial cystitis: a systematic review.
Pazin C(1), de Souza Mitidieri AM, Silva AP, Gurian MB, Poli-Neto OB, Rosa-E-Silva JC.
http://www.ncbi.nlm.nih.gov/pubmed/26272202

1) Hyperbaric oxygen:

Van Ophoven A, Rossbach G, Pajonk F, Hertle L (2006) Safety and efficacy of hyperbaric oxygen therapy for the treatment of interstitial cystitis: a randomized, sham-controlled, double-blind trial. J Urol 175:1442–1446. doi:10.1016/j.juro.2006.06.065
http://hbotnova.com/resources/urologic/IC_HBOT%202006.pdf

  • 21 cases
  • 90 minutes treatment in a hyperbaric chamber pressurized with 100% O 2 to 2.4 atmosphere absolute for 30 treatments sessions 6 six times a week for 5 weeks
  • 3/14 got 24% decrease of urgency intensity and a decrease of 28% in pain intensity at 3 months.
  • will be available in Moosejaw’s new hospital.
  • This could be an option for someone who could not tolerate anything else…

2)Piroxicam (Feldene)40 mg/day (anti-inflammatory rather hard on stomach) and doxepin 25 – working up to 75 mg/day.

Wammack R, Remzi M, Seitz C, Djavan B, Marberger M
Efficacy of oral doxepin and piroxicam treatment for Interstitial cystitis.
Eur Urol 41:596–600 (2002).
doi:10.1016/S0302-2838(0200174-4
http://www.ncbi.nlm.nih.gov/pubmed/12074775
“Medication was not tolerated by five patients [out of 37]. Twenty-six of 32 patients have experienced virtual total remission of symptoms (81%) and six patients had significant relief (19%). DOXCAM treatment resulted in a significant percent decrease in pain (65% versus 21%). Daytime frequency decreased from 17.6+/-5.7 to 11.3+/-3.6 voids while nocturia did not improve significantly. Twenty-three of the 26 patients who became symptom free and four of the six patients who showed significant improvement had a return of symptoms after cessation of therapy.”

3) Desipramine – old antidepressant – would have less drowsiness than amitriptyline (but I have no access to such an old article so can’t say much more)

Renshaw DC.
Desipramine for interstitial cystitis.
JAMA. 1988;260(3):341.
http://jama.jamanetwork.com/article.aspx?articleid=372916

4) Cyclosporine – an immune suppressant

In “Oral Therapy for Bladder Pain Syndrome Directed at the Bladder”
Bladder Pain Syndromes Springer 2013

re
Sairanen, Jukka, Tapio Forsell, and Mirja Ruutu.
Long-term outcome of patients with interstitial cystitis treated with low dose cyclosporine A.
The Journal of urology 171.6 (2004): 2138-2141.
http://www.jurology.com/article/S0022-5347%2805%2962117-9/fulltext?refuid=S1570-9124%2804%2900045-5&refissn=1570-9124&mobileUi=0

“Eleven patients received cyclosporine for 3–6 months at an initial dose of 2.5–5 mg/kg daily and a maintenance dose of 1.5–3 mg/kg daily. Micturition frequency decreased, and mean and maximum voided volumes increased significantly. Bladder pain decreased or disappeared in ten patients. After cessation of treatment, symptoms recurred in the majority of patients.In a longer term follow-up study, 20 of 23 refractory IC patients on cyclosporine therapy followed for a mean of 60.8 months became free of bladder pain. Bladder capacity more than doubled. Eleven patients subsequently stopped therapy, and in 9,symptoms recurred within months, but responded to reinitiating cyclosporine [47]. Sairanen et al. further found that cyclosporine A was far superior to sodium PPS in all clinical outcome parameters measured at 6 months [48] . Global response assessment showed a 75% response to the immune modulator.”

5) Quercetin

Katske F, Shoskes DA, Sender M, Poliakin R, Gagliano K, Rajfer J.
Treatment of interstitial cystitis with a quercetin supplement.
Tech Urol. 2001;7(1):44–6.
http://www.ncbi.nlm.nih.gov/pubmed/11272677

“Twenty-two patients (5 men and 17 women; average age 53.1 years) with classically documented IC received one capsule of Cysta-Q complex (equivalent to 500 mg of quercetin) twice a day for 4 weeks. Symptoms were assessed before and after therapy by the IC problem and symptom indices as well as by global assessment of pain (range 0-10).

RESULTS: Two patients did not complete the study. In the remaining 20 patients, improvement was seen in all three parameters tested. After 4 weeks of treatment, the mean (+/- SEM) problem index improved from 11.3 +/- 0.6 to 5.1 +/- 0.7 (p = .000001), the mean symptom index improved from 11.9 +/- 0.9 to 4.5 +/- 0.5 (p = .000001), and the mean global assessment score improved from 8.2 +/- 0.4 to 3.5 +/- 0.4 (p = .000001). None of the patients experienced any negative side effects, and all but one patient had at least some improvement in every outcome measure.”

Theoharides, T. C., and G. R. Sant.
A pilot open label study of Cystoprotek® in interstitial cystitis.
International journal of immunopathology and pharmacology 18.1 (2005): 183-188.
http://algonot.com/articles/wp-content/uploads/2010/12/Cystoprotek-IJIP.pdf

6)Nifedipine

Fleischmann, Jonathan. “Calcium channel antagonists in the treatment of interstitial cystitis.” The Urologic clinics of North America 21.1 (1994): 107-111.

article is no longer available online but in
Oral Therapy for Bladder Pain Syndrome Directed at the Bladder
Bladder Pain Syndromes Springer 2013

“The calcium channel antagonist nifedipine inhibits smooth muscle contraction and cell-mediated immunity. In a pilot study [63] , 30 mg of an extended-release preparation was administered to ten female patients and titrated to 60 mg daily in four of the patients who did not get symptom relief. Within 4 months five patients had at least a 50% decrease in symptom scores, and three of the five were asymptomatic. No further studies have been reported.” – I could find none either

7)Misoprostol (cytotec)

Kelly, J. D., et al.
Clinical response to an oral prostaglandin analogue in patients with interstitial cystitis.
European urology 34.1 (1998): 53-56.
http://www.ncbi.nlm.nih.gov/pubmed/9676414

METHODS:

Twenty-five patients were commenced on misoprostol 600 micrograms daily for 3 months. Patients who responded to therapy were offered treatment for a further 6 months. Assessment of the response was by a voiding log and an interstitial cystitis symptom score.

RESULTS:

At 3 months, 14 patients (56%) had significantly improved, and after a further 6 months, 12 patients (48%) had a sustained response. The incidence of adverse drug effects was 64%. Most side effects were minimal, and the response rate in patients who were able to tolerate the drug was 87% at 3 months and 75% at 9 months.

CONCLUSIONS:

The oral prostaglandin analogue misoprostol is effective in treating the symptoms of interstitial cystitis. It is possible that prostaglandins have a cytoprotective action in the urinary bladder.

8) Methotrexate

A Moran, Paul, et al.
Oral methotrexate in the management of refractory interstitial cystitis.
Australian and New Zealand journal of obstetrics and gynaecology 39.4 (1999): 468-471.

http://www.ncbi.nlm.nih.gov/pubmed/10687766

  • decided to study it because patient on methotrexate for psoriasis got much better re IC
  • no placebo group
  • Started at 7.5 mg once weekly and after 3 months went to 12.5 mg if no response. Folic acid 1 mg/day.
  • helped 4/9 re pain  (VAS 8 to 7) but no effects on frequency
  • doesn’t seem like much – cyclosporine would be much more likely a drug to use

Comments: –

  • My favorite oral agent to try is monteluctast (singulair) – an asthma drug with minimal side effects (heck they give it to young children) but I have discussed that before.Amitriptyline (Elavil), cimetidine (Tagamet), and Hydroxyzine (atarax) are safe drugs but most have already tried them
  • Cysta-Q (Quercetin) seems like a safe place to start but one would have to see how the irritable bowel part liked the pills; not sure re cost. 
  • Nifedipine is an idea if someone has hypertension but could make subjects dizzy if BP dropped too much.
  • Misoprostol will worsen dyspepsia and is an abortion agent so rarely used.
  • Piroxicam and doxepin – Doxepin is an antidepressant that has anti-histaminic properties but will cause drowsiness. Piroxicam has pain killing properties but can cause ulcers.
  • Hyperbaric oxygen sounds useless
  • Cyclosporine results are mouth watering but this is a big league drug – immunosuppression is linked to serious opportunistic infections and rarely cancers. Opioids immune suppress and I have had pain patients develop life threatening pneumonia for no apparent reason. So one should have a pneumonvac pneumonia vaccination and a shingles vaccination before its use.. One needs to find someone who uses this drug. It is used in kidney transplants so a nephrologist might be an option.
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