From the Guidelines
The patient's worsening interstitial cystitis symptoms should be managed with a multifaceted approach, including optimization of her current amitriptyline dose, behavioral modifications, and consideration of additional therapies such as pentosan polysulfate sodium, as suggested by the most recent guidelines 1. Given her recent sexual activity and symptoms of worsening urinary urgency and pain with voiding, despite the negative urine culture, it is essential to consider the possibility of a urinary tract infection and the impact of sexual activity on her symptoms, as noted in the clinical principles outlined in 1 and 1. The patient's treatment plan should include:
- Optimization of her amitriptyline dose, potentially increasing to 50-75 mg at bedtime if she's on a lower dose, to help manage her symptoms.
- Behavioral modifications, such as:
- Avoiding bladder irritants (caffeine, alcohol, spicy foods, acidic juices) as suggested in 1 and 1.
- Practicing timed voiding.
- Using stress reduction techniques, such as meditation or imagery, to help manage IC/BPS flare-ups.
- Considering an elimination diet to determine which foods or fluids may contribute to her symptoms.
- Consideration of additional therapies, such as pentosan polysulfate sodium (Elmiron) 100 mg three times daily with meals, to help coat and protect the bladder lining, reducing inflammation and pain.
- Pelvic floor physical therapy to address muscle tension contributing to her pain, as suggested in 1 and 1. The patient should follow up in 2-3 weeks to assess treatment response, with instructions to return sooner if symptoms worsen or she develops fever, ensuring timely adjustment of her treatment plan as needed, based on the guidelines outlined in 1 and the clinical principles discussed in 1 and 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Presentation
The patient is a 29-year-old woman with a history of interstitial cystitis, presenting with worsening urinary urgency and pain with voiding. She has been experiencing chronic urinary frequency and suprapubic pain relieved with voiding for six months, and was initially prescribed amitriptyline, which improved her symptoms.
Diagnostic Considerations
- The patient's symptoms and urinalysis results, including positive leukocyte esterase and 40 white blood cells per high power field, suggest a possible urinary tract infection or other inflammatory condition 2.
- However, the negative nitrites and absence of bacteria on urinalysis, as well as the negative urine culture, make a urinary tract infection less likely.
- The patient's symptoms and physical examination findings, including diffuse lower abdominal discomfort to deep palpation, are consistent with interstitial cystitis.
Treatment Options
- The patient is currently taking amitriptyline, which is a commonly used treatment for interstitial cystitis, but has shown limited efficacy in this case 3.
- Other treatment options for interstitial cystitis include pentosan polysulfate sodium, which has been shown to be effective in repairing the glycosaminoglycane layer on the urothelium of the urinary bladder 4.
- Intravesical instillation of hyaluronic acid has also been shown to be effective in improving symptoms of interstitial cystitis, as seen in a case study of a pregnant patient with interstitial cystitis 5.
- Multimodal therapy, including oral and intravesical treatments, as well as behavioral techniques and dietary modifications, may be necessary to effectively manage the patient's symptoms 6.
Further Evaluation
- Urodynamic studies, including filling cystometrogram and pressure-flow-EMG studies, may be helpful in excluding other causes of the patient's symptoms and confirming the diagnosis of interstitial cystitis 2.
- A thorough physical examination, including evaluation for local urethral tenderness, may also be helpful in identifying other potential causes of the patient's symptoms 2.