International Urogynecology Journal

, Volume 19, Issue 10, pp 1379–1384 | Cite as

Treatment of interstitial cystitis with hydrodistention and bladder training

  • Ching-Hung Hsieh
  • Shao-Tung Chang
  • Chia-Jung Hsieh
  • Chun-Sen Hsu
  • Tsung-Cheng Kuo
  • Hui-Chin Chang
  • Yi-Hui Lin
Original Article

Abstract

This study aimed to evaluate the efficacy of hydrodistention (HD) and bladder training for interstitial cystitis (IC). From 1997 to 2006, 361 consecutive IC patients were treated by HD, followed by bladder training. Each patient was followed up using a diary for 8 weeks after HD weekly and monthly thereafter. The efficacy of the treatment was evaluated using the average of the voided volumes and the voiding frequency. The mean ± standard deviation of the pre-HD daytime voided volumes and voiding frequency were 110.0 ± 47.0 ml and 14.7 ± 11.0, respectively. Furthermore, the nocturnal values were 173.1 ± 91.8 ml and 2.8 ± 1.7, respectively. After 72 weeks post-HD, the 185 patients who completed the follow-up had volumes/frequency of daytime, 306.5 ± 80 ml and 6.9 ± 2.1, respectively, and nocturnal, 325.8 ± 122.4 ml and 1.3 ± 0.6, respectively. The implementation of HD and bladder training is crucially important for long-term remission among IC patients.

Keywords

Frequency Hydrodistention Interstitial cystitis Nocturia Painful bladder syndrome Urgency 

Introduction

Interstitial cystitis (IC) has been described as a chronic debilitating sterile inflammatory multifactorial bladder disease or a chronic syndrome of the bladder of unknown etiology; it is characterized by supra-pubic pain, urinary frequency, urgency, and nocturia. Consequently, IC has usually been underdiagnosed [1] and the consensus on best available treatment for this condition is lacking [2]. Until recently, IC was still an enigma and an uncommon disease without an existing positive diagnostic test. In 1987, the National Institute of Arthritis, Diabetes, Digestive, and Kidney Diseases (NIDDK) developed standardized inclusion and exclusion criteria to aid in the clinical study of IC [3]. They concluded that, to be diagnosed with IC, patients must have either glomerulations or a classic Hunner’s ulcer on cystoscopic examination and they must have either pain associated with the bladder or urinary urgency. An examination for glomerulations should be undertaken after distention of the bladder under anesthesia to a pressure of 80–100 cmH2O for up to 1–2 min. The bladder may be distended up to two times before examination. In addition, the glomerulations must present in at least three quadrants of the bladder and there must be at least ten glomerulations on each quadrant of the bladder. In order to eliminate artifact from contact instrumentation, the glomerulations must not be along the path of the cystoscope. The criteria which exclude the diagnosis of IC are bladder capacity >350 ml on awake cystometry, absence of an intense desire to void at 150 ml with a medium filling rate (30–100 ml/min), demonstration of phasic involuntary bladder contractions on cystometry, symptomatology of less than 9 months duration, absence of nocturia, symptoms relieved by antimicrobials, urinary antiseptics, anticholinergics, or antispasmodics, urinary diurnal frequency less than nine times, a diagnosis of bacterial cystitis within 3 months, bladder calculi, active genital herpes, gynecological malignancy, urethral diverticulum, chemical cystitis, tuberculosis, radiation cystitis, bladder tumors, vaginitis, and age <18 years. A diagnosis of IC is made mainly based on clinical symptoms and cystoscopic findings after hydrodistention (HD) when other disorders are excluded [4, 5, 6, 7, 8].

Treatment of IC up to the present has mainly been based on empiricism. Multiple forms of therapy are available including self-care, dietary restrictions, bladder training, medical treatment, intravesical instillations, neuromodulation, multimodality treatment, bladder HD, and surgical intervention. The efficacy of HD of the bladder in the treatment of IC had been known since 1930 [9], yet the proportion of patients who, after bladder HD, show improvement and the duration of any such improvement remain uncertain. The report by Bumpus (1930) revealed that bladder HD improved the symptoms of IC and, as a result, this procedure has become a mainstay of IC patient therapy. However, there is little evidence of the treatment’s efficacy in spite of the fact that bladder HD is considered therapeutic and is often recommended as a treatment for IC [10]. Ottem and Teichman [11] reported that cystoscopy with HD provided little useful information above and beyond what was available from the patient’s history and physical examination findings. Furthermore, it was stated that, after therapy, 56% of the patients reported improvement, but the duration of such improvement was short lived. In addition, reports on the use of prolonged bladder HD for the treatment of patients with IC remain controversial [12].

IC patients afflicted with the chronic form of this disease will usually have a reduced-capacity bladder, which is caused in part by sensory urgency and also is, in part, based on their frequent low volume voiding. These two factors result in the bladder entering a state of disuse and atrophy [1]. The famous words “use or disuse” by La March, a French biologist (1744–1829), may help to explain the reduced bladder capacity of IC patients. This study evaluates whether gradual bladder training of IC patients after HD is able to reverse the problems with their small bladders and thus helps them to obtain functional bladder recovery.

Materials and methods

Between August 1997 and August 2006, 361 consecutive female patients with a mean age of 46.2 ± 12.4 years (range 21 years to 84 years) being treated for IC were prospectively studied (Table 1). The majority, 76.7%, of the IC patients in this study was aged between 30 and 59 years. The study had been started before the Institutional Review Board was available. In addition, both hydrodistention and bladder training were well-recognized treatment modules. Thus, this study did not include a statement regarding institutional ethics committee approval. All patients provided oral and written informed consent before enrollment. Those who did not have informed consent were excluded from the study.
Table 1

Age distribution of the IC patients (N = 361)

Age

20–29

30–39

40–49

50–59

60–69

70–79

80–89

 

Number (%)

27 (7.5)

93 (25.8)

112 (31.0)

72 (19.9)

37 (10.2)

18 (5.0)

2 (0.6)

46.2 ± 12.4a

SD Standard deviation

aMean ± SD

The diagnosis of IC was made based on the clinical symptoms, history, physical examination, unremarkable urinalysis and urine culture results, 1-week bladder diary findings, a urodynamic study, urine cytology, the results of a bladder biopsy, and the findings after HD cystoscopy under intravenous general anesthesia. During the cystoscopic evaluations, the patient’s bladder was filled with normal saline to maximal capacity at a pressure of 80 cmH2O. In every patient, the urethra was compressed around the cystoscope to avoid water leak during the procedure. The full bladder was not maintained and was emptied immediately. At this point, the bladder was inspected for the presence of glomerulations and petechial hemorrhages. HD was not repeated after the bladder was drained. The whole procedures took about 15 min for each patient and were performed and completed in the Out-Patients Department (OPD). All patients then returned to their homes. Patients meeting the NIDDK criteria were diagnosed as having IC.

All patients were asked to create bladder diaries during weekly follow-up during the 8 weeks following HD. Thereafter, they returned to the OPD for follow-up once every month and this process also included a bladder diary. Hyoscine butylbromide (Buscopan, by Boehringer Ingelheim GmbH, Germany), 10 mg, was prescribed four times a day for all patients except those who had a history of glaucoma. Pain when the bladder was full was controlled using acetaminophen (Panadol, by GlaxoSmithKline, Malaysia), 500 mg, until it subsided.

At the OPD, both before and after HD, all IC patients and their accompanying family members were educated by a physician about the characteristics of IC and the details of how to carry out bladder training. After HD, bladder training involved asking the patient to drink water gradually at a speed of 150–200 ml/h except during three meals and at night. They then underwent training whereby a program of progressively holding in their urine in order to increase their bladder capacity was instituted. At the first OPD follow-up after HD, the average time interval between voids for the patients was recommended to be 2 h and this interval was gradually increased by 15 min weekly. If the patients were usually voided at intervals of more than 2 h at the end of the first week of bladder training, it was recommended that she attempted to void every 2 h and 15 min; and at the end of one later week, this was increased to 2 h and 30 min. The aim was for the patients to have progressed to voiding every 3 h at 2 months post-HD. The number of patients followed-up at 1, 2, 4, 8, 12, 24, 48, and 72 weeks after HD were 361, 360, 347, 320, 306, 251, 222, and 185, respectively (Table 1). The exclusion criterion of this study was the nonadherent participant. Those who could not come back for OPD follow-up or could not provide the urinary diaries were excluded from this study. A total of 176 patients were dropped out of the study.

The International Continence Society (ICS) in 2002 [13] defined daytime frequency, increased daytime frequency, nocturia, and urgency, respectively. It also defined bladder, urethral, vaginal, and perineal pain. This study, when evaluating the lower urinary tract symptoms mentioned above, adopts the ICS definitions.

Among the patients, 83.1% had visited one or more doctors before IC was correctly diagnosed (Table 2). A lot of different disorders, including chronic urinary tract infection, pelvic inflammatory disease, and an overactive bladder, had been diagnosed by different doctors. About one third (35.1%) of the patients had suffered from IC for more than 2 years before a diagnosis was made. Most of the patients had symptoms of urinary frequency, urgency, nocturia, and pain, and these had deteriorated year by year.
Table 2

Number of doctors visited and time in years over which the IC symptoms had occurred before IC was diagnosed (N = 361)

Doctors visited

0

1

2

3–5

>5

Number of patients (%)

61 (16.9)

112 (31.0)

75 (20.8)

61 (16.9)

52 (14.4)

Length of time the patient has suffered from IC symptoms (months, m; years, y)

<9 m

9 m–1 y

1–2 y

2–5 y

>5 y

Number of patients (%)

41 (11.4)

87 (24.1)

106 (29.4)

65 (18.0)

62 (17.1)

The clinical symptoms, relapse, and remission conditions, voiding frequency, and voided volume of all patients were used to evaluate the efficacy of the HD and bladder training as a treatment for IC. The mean voiding values at different times were recorded from the information collected in the bladder diaries. The descriptive data are reported as mean ± standard deviation and 95% confidence interval (CI) as analyzed by Student’s t test. To compare differences between groups, χ2 tests were used for nominal or ordinal data and the Fisher’s exact test was used for categoric relationships if the sample was small. Probability values of <0.05 or no overlapping of the 95% CI of the means was used as a measure of statistical significance. Statistical analysis was performed using the Statistical Package Minitab Release 14 for Windows.

Results

Table 3 shows that pains when the bladder was full, including bladder, urethra, vagina, perineum, and back pain, were very common among the IC patients and about half of them (158/314) suffered from bladder, supra-pubic, or retro-pubic pain. At 8 weeks after HD, there had been good remission of pain and only 14.4% of the patients still need to use analgesic intermittently to relieve their pain. Similarly, HD and bladder training were successful at alleviating the sensory urgency caused by IC. Even among the 13.4% of the patients who still felt urgency occasionally at 8 weeks after HD, this bothersome symptom was subsiding gradually.
Table 3

Urgency and pain among IC patients before and after HD treatment

Symptom

Number (%)

χ2

df

p

Before HD (n = 361)

8 weeks after HD (n = 320)

Urgency

253 (70.1)

43 (13.4)

221.5

1

<0.001

Pain when bladder is full

314 (87.0)

46 (14.4)

358.9

1

<0.001

  Bladder

158 (43.8)

23 (7.2)

116.3

1

<0.001

  Urethra

103 (28.5)

20 (6.3)

56.9

1

<0.001

  Vagina

36 (10.0)

2 (0.6)

28.1

1

<0.001

  Perineum

2 (0.6)

0 (0.0)

  

0.501a

  Back

15 (4.1)

1 (0.3)

  

0.001a

HD Hydrodistention, df degrees of freedom

aFisher’s exact test is used due to small sample size.

Menstruation and sexual intercourse were the two main flare factors associated with IC among the patients at baseline (Table 4). Overall, 40.2% and 36.3% of the patients indicated that their IC symptoms deteriorated right before and after menstruation, respectively. Nevertheless, 37.7% (136/361) of the patients stated they had remission of the IC symptoms during the menstrual period. At 2 months after HD, more than 80% of the IC patients who had suffered from these flare factors reported a significant reduction in the effect of menstruation and coitus on the induction of IC symptoms.
Table 4

Factors associated with symptom flare in IC patients

Flare factors

Flare of symptom (%)

χ2

df

P

Before HD (n = 361)

8 weeks after HD (n = 320)

Menstruation

 Before

145/361 (40.2)

24/320 (7.5)

97.0

1

<0.001

 During

5/361 (1.4)

0/320 (0.0)

  

0.064a

 After

131/361 (36.3)

13/320 (4.1)

105.7

1

<0.001

Post-coitus

106/361 (29.4)

11/320 (3.4)

80.1

1

<0.001

HD Hydrodistention, df degrees of freedom

aFisher’s exact test was used due to small sample size.

Table 5 compares the voided volumes and voiding frequency for eight consecutive follow-ups to those of the baseline. There are significant differences present between the daytime voided volumes, the nocturnal voided volumes, the daytime frequency, and the nocturnal frequency at p < 0.001. With the help of IC education and patient bladder training, among 51.2% (185/361) of the patients with continuous follow-up of 72 weeks after HD, there was a durable remission of symptoms. In addition, around 30% of the IC patients after treatment were no longer bothered by nocturia.
Table 5

Voiding profiles of patients with IC

 

Before hydrodistention (n = 361)

Week or weeks after hydrodistention

pa

1 (n = 361)

2 (n = 360)

4 (n = 347)

8 (n = 320)

12 (n = 306)

24 (n = 251)

48 (n = 222)

72 (n = 185)

Voided volumes (ml)

  Daytime

         

<0.001

    Range

(12–267)

(14–511)

(29–570)

(26–593)

(44–582)

(64–762)

(50–565)

(114–494)

(90–553)

 

    Mean

110.0

189.0

233.1

256.4

273.9

299.7

293.0

310.4

306.5

 

    SD

47.0

76.8

89.0

92.9

93.9

97.2

92.9

83.9

79.9

 

    95% CI

(105.1–114.8)

(181.1–196.9)

(223.9–242.3)

(246.6–266.2)

(263.6–284.2)

(288.8–310.6)

(281.5–304.5)

(299.4–321.5)

(294.9–318.0)

 

  Nocturnal

         

<0.001

    Range

(25–550)

(20.–730)

(43–680)

(50–720)

(59–1000)

(50–980)

(75–720)

(50–800)

(83–700)

 

    Mean

173.1

236.6

267.8

311.1

327.4

331.3

353.4

328.7

325.8

 

    SD

91.8

110.0

114.2

117.5

134.6

144.7

134.4

141.1

122.4

 

    95% CI

(163.7–182.6)

(225.2–248.0)

(255.8–279.7)

(297.3–324.9)

(310.5–344.3)

(312.0–350.5)

(333.1–373.4)

(306.3–351.2)

(304.6–347.0)

 

Number of voidings

  Daytime frequency

          

    Range

(5–155)

(1–35)

(3–48)

(4–18)

(4–12)

(4–12)

(3–13)

(4–15)

(4–10)

 

    Mean

14.7

9.8

8.0

6.9

6.2

6.1

6.3

6.5

6.9

 

    SD

11.0

3.9

3.3

1.8

1.4

1.3

1.8

2.3

2.1

 

    95% CI

(13.6–15.8)

(9.4–10.2)

(7.7–8.4)

(6.7–7.1)

(6.1–6.4)

(6.0–6.3)

(6.1–6.5)

(6.2–6.8)

(6.6–7.2)

 

  Nocturia

    Range

(1–12)

(0–9)

(0–10)

(0–7)

(0–6)

(0–4)

(0–4)

(0–4)

(0–3)

<0.001

    Number (%)with no nocturia

0 (0)

2 (0.6)

10 (2.8)

68 (18.2)

77 (24.1)

89 (29.1)

80 (31.9)

70 (34.7)

57 (30.8)

 

    Mean

2.8

2.1

1.8

1.5

1.4

1.4

1.5

1.6

1.3

 

    SD

1.7

1.2

1.1

0.9

0.7

0.8

0.7

0.6

0.6

 

    95% CI of mean

(2.6–3.0)

(2.0–2.3)

(1.7–1.9)

(1.4–1.7)

(1.3–1.5)

(1.3–1.5)

(1.4–1.6)

(1.5–1.7)

(1.2–1.4)

 

SD Standard deviation, CI confidence interval

aComparison of each category between before hydrodistention and 72 weeks after hydrodistention

Just after HD, the urgency/frequency symptoms of a few patients might be exacerbated but the effect is transient and this problem resolved spontaneously in 1 to 2 days. No case of bladder rupture occurred during or after HD in this study.

Discussion

Cystoscopy with HD is the most commonly performed diagnostic test and one of the most common procedures used for the treatment of patients with IC. When this is combined with patient education in order to obtain a good understanding by the patient and her family of the characteristics of IC and good compliance with bladder training, HD of the bladder gives long-term symptomatic remission among IC patients. The therapy gives not only good remission of pain and urgency but also obvious improvement in the daytime and nocturnal voided volumes and frequency of daytime and nocturnal voidings over a 72-week period. After HD, getting into a habit of persistently and gradually drinking water, together with family members’ support/involvement in the therapeutic regime, is exceedingly helpful. As a result, the IC patients are able to cope with a small-capacity bladder that was based on sensory urgency and frequent low volume voiding. Adequate HD combined with subjective bladder training would seem to be able to reverse the bladder from a state of disuse/atrophy into a functional state. Thus, the results of this study on the bladder are consistent with the “use or disuse” hypothesis.

For those who were unresponsive to HD and patient bladder training, there were several kinds of treatments offered to them. They were still treated, but not included in this study, technically.

The HD methods used to treat IC and their efficacy seem to vary significantly. Yamada et al. [14] reported that adjuvant HD under epidural anesthesia was effective for about 70% of IC patients and lasted more than 3 months. This is similar to the reports of Ottem and Teichman [11] and Parsons and Toozs-Hobson [4] who also showed that IC symptoms are improved following cystoscopy and HD in many patients, but they suggest that the benefits are short lived. When prolonged bladder HD for symptomatic treatment of IC is considered, McCahy and Styles [12] and Glemain et al. [7] reported that either its place in the management of patients with IC remained controversial or it showed good but transient efficacy when used to treat the least developed or least severe forms of IC. In contrast to our study, the above studies did not ask their patients to perform bladder training. This study shows that HD followed by bladder training, when there was good patient compliance, was able to produce both a good efficacy and long-term benefits.

HD of the bladder should be recommended as the first treatment choice for patients with IC because it provides significant remission, is a conservative therapy, and avoids the need for extirpative surgery. However, the fact that HD might only be effective as a treatment for a short time requires that a second-line therapy option remains available if needed for better long-term management and benefits. Education of IC patients and the attendance of their family members when combined with good compliance with bladder training as described in this study suggest that these approaches, when used together, provide a treatment route of choice.

Essentially, IC is still an enigma and a diagnosis of exclusion. A lack of understanding of the disease’s pathophysiology remains the biggest hurdle to reliable diagnosis and treatment of this puzzling and troublesome disorder. A type of disuse/atrophy effect seems to happen with the bladders of IC patients and this reveals itself as small bladder capacity and generalized glomerulation, which can be detected during cystoscopy and HD. Together, these suggest that “use or disuse” is likely to be one of the mechanisms of IC pathophysiology. The stably bigger voided volumes produced at 72 weeks after HD and bladder training over the same 72 weeks, as described in this study, support this hypothesis.

The limitations of this study are twofold. Firstly, not all patients within the baseline group were followed up regularly at the OPD. Secondly, the bladder biopsies of the patients sometimes also revealed inflammation of the bladder wall. Based on the latter result, there is a need for ultrastructure reports combined with much more detailed information on the bladder symptomology when making a diagnosis of IC. Together, these approaches might help us to find the mechanism behind IC pathophysiology. Nevertheless, as per the results of this study, we have shown that it is helpful to combine bladder training with HD when treating IC patients and that there is significant remission of the patients’ symptoms after such treatment. These results are clear even without knowing the true cause of the IC in these patients.

Notes

Conflicts of interest

None.

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Copyright information

© International Urogynecology Journal 2008

Authors and Affiliations

  • Ching-Hung Hsieh
    • 1
    • 2
  • Shao-Tung Chang
    • 3
  • Chia-Jung Hsieh
    • 4
  • Chun-Sen Hsu
    • 1
  • Tsung-Cheng Kuo
    • 2
  • Hui-Chin Chang
    • 5
  • Yi-Hui Lin
    • 1
  1. 1.Department of Obstetrics and GynecologyTaipei Medical University-Wan Fang HospitalTaipeiTaiwan
  2. 2.Department of Obstetrics and GynecologyKuo General HospitalTainanTaiwan
  3. 3.Department of MathematicsNational Taiwan Normal UniversityTaipeiTaiwan
  4. 4.School of MedicineFu Jen Catholic UniversityTaipeiTaiwan
  5. 5.EBM CenterChung Shan Medical University HospitalTaichungTaiwan

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