Is It Really Another Uti? Interstitial Cystitis And The Pharmacist's Role In Identifying The Patient At Risk
Candace S. Brown, PharmD*
Urinary frequency, urgency, and pelvic pain are symptoms that are common to a number of disorders and diseases. For example, some or all of these symptoms are present in various gynecologic and urologic conditions, including malignancies; in multiple sclerosis and Parkinson's disease; in urinary tract and vaginal infections; and in interstitial cystitis (IC). Yet, despite manifesting the same urinary symptoms and pelvic pain, these conditions have distinctly different etiologies that require different treatment regimens to address the underlying pathology. While antibiotics are appropriate if the symptoms are caused by an infection, they are not appropriate if the origin of the symptoms is noninfectious.
Therein lies the rationale for this issue of Advanced Studies in Pharmacy (ASiP), which focuses on various aspects of IC, a chronic inflammatory condition of the bladder that affects 1 million1,2 and perhaps as many as 9 million to 14 million people in the United States. There is no doubt that IC is frequently misdiagnosed and underdiagnosed, and therefore inappropriately treated until a correct diagnosis is established.1,3 Indeed, many patients ultimately diagnosed with IC see an average of 8 healthcare professionals over an average of 5 to 7 years before an accurate diagnosis is made.4 Clearly, earlier diagnosis is needed so that IC can be treated sooner with effective therapy.
At present, there are 2 pharmacologic agents approved for the treatment of IC: intravesical dimethyl sulfoxide (DMSO) and oral pentosan polysulfate sodium (PPS). However, because the etiology of IC is most likely multifactorial, neither agent uniformly relieves symptoms in all patients. Treatment must therefore be individualized, with various other pharmacologic agents and nonpharmacologic modalities added to the regimen to enhance the therapeutic effects of DMSO and PPS. The choice of ancillary therapy depends on the etiologic factors involved in a given patient with IC and the nature and severity of the patient's symptoms.
As with all chronic conditions, particularly those involving pain and bothersome symptoms, IC has a significant impact on quality of life. Depression is common in IC, as are varying degrees of social isolation and a reduction in the ability to work full-time.
To increase awareness of IC in the pharmacy community, this issue of ASiP takes a closer look at this chronic, bothersome, and often enigmatic condition by presenting 3 articles by healthcare professionals with expertise in IC.
Dr Robert J. Evans, a urologist and recognized authority in IC, reviews the epidemiology, etiology, pathogenesis, and diagnosis of IC. He notes that because the presenting symptoms of IC are also seen in patients with urinary tract infection and various gynecologic, urologic, and neurologic conditions, the diagnosis of IC is largely one of ruling out these other conditions. Pointing out that the diagnostic criteria used since 1988 were based on severe and advanced disease, he presents an updated diagnostic paradigm that is based on the patient's history, physical examination, laboratory findings, and the results of symptom surveys that are more likely to detect earlier disease. Under this new paradigm, previously used diagnostic procedures such as cystoscopy with hydrodistention under anesthesia and urodynamic testing are now optional.
Dr Jeffrey R. Dell, a urogynecologist and an expert in IC, reviews the various pharmacologic and nonpharmacologic treatment options for IC. He describes the standard regimens for intravesical DMSO and oral PPS, off-label use of other intravesical compounds and solutions, and numerous oral agents used to provide additional relief from pain and urinary symptoms. He also addresses the multimodal approach to IC therapy in which oral PPS is used as the foundation, intravesical therapy is used adjunctively to speed the response to primary therapy, and oral agents are used, on an individualized basis, to enhance the therapeutic benefits of PPS.
Dr Mary Lee, Dean of Midwestern University Chicago School of Pharmacy, addresses the psychosocial ramifications of IC and the role of the pharmacist in identifying patients who might have IC despite a presumptive diagnosis of some other disorder that manifests the same symptoms, and then encouraging these patients to seek a diagnostic evaluation or reevaluation. She also describes the pharmacist's role in patient education and counseling, particularly with regard to dosing and side effects of prescribed therapy and the use of self-help measures, as well as in monitoring the response to prescribed therapy in patients with suspected or correctly diagnosed IC.
Together, these articles increase awareness of IC among pharmacists, assist them in identifying, educating, counseling, and monitoring patients with the condition, and help them improve their quality of life.
1. Hanno PM. Epidemiology, diagnostic criteria, and markers of IC. Rev Urol. 2002;4(suppl 1):S3-S8.
2. Jones CA, Nyberg L. Epidemiology of interstitial cystitis. Urology. 1997;49(5A, suppl):2-9.
3. Kusek JW, Nyberg LM. The epidemiology of interstitial cystitis: is it time to expand our definition? Urology. 2001;57(6, suppl 1):95-99.
4. Moldwin R, Dell J. Diagnosis of interstitial cystitis. Available at: http://www.npwh.org/ic/diagnosis.htm. Accessed January 22, 2005.
*Professor of Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee.
Address correspondence to: Candace Brown, PharmD, University of Tennessee College of Pharmacy, 847 Monroe Ave, Room 205N, Memphis, TN 38163.