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THE
URINARY
SYSTEM
Kidney Stones
Renal stones:
Chemical analysis can indicate why they have
formed
Oxalate  usually hyperoxaluria, low magnesium
and vitamin B6 levels
Uric acid  usually hyperoxaluria
Calcium phosphate  possibly primary
hyperparathyroidism or renal tubular acidosis
Magnesium, ammonia or phosphate  may indicate
urinary tract infections
Cystine  rare inherited metabolic disorder
cystinuria
Calcium Oxalate
Uric acid
Calcium phosphate
Cystine
URINARY TRACT
INFECTIONS
URINARY TRACT INFECTIONS
Definitions
• Urinary tract infection (UTI) means the finding of
bacteria (or other microorganisms, such as
yeasts), in bladder urine with or without clinical
symptoms and with or without renal disease. It is
especially common in the bladder and urethra and
more common in women than men.
• Uncomplicated UTI is encountered most frequently
in healthy, young, non pregnant women.
Definitions
• Complicated UTI refers to the presence of
predisposing anatomic or functional
conditions that interfere with the free flow of
urine e.g.
o Congenital disorders
o Neuromuscular disease
o Spinal cord injury
o Kidney stones
o Or metabolic abnormalities.
This is more difficult to treat and usually
requires more aggressive treatment and
follow up.
• Lower UTI’s refer to infection at or below the level of the
bladder e.g.
o Cystitis
o Prostatitis
o Urethritis
• Upper UTI refer to infection of the urinary tract above
the level of the bladder, that is
o Ureters
o Kidneys
The term is mainly used in reference to pyelonephritis
(inflammation of the kidney and renal pelvis)
• Pyuria indicates the presence of pus (white blood cells;
leukocytes) in the urine which may or may not be
caused by urinary tract infection.
Clinical Presentation
•
•
•
•
•
•
Suprapubic pain
Increased frequency and urgency of urination
Dysuria-pain or burning with urination
Nocturia
Hematuria- blood in urine
Cloudy urine with / without a foul or strong
urine odour
• Upper: fever, chills, malaise, N/V, weight loss,
• flank or back pain
Aetiology, Epidemiology and
Risk Factors
• Refer to page 515 and summarise in
point form the aetiology, epidemiology
and risk factors of Urinary Tract
Infections (UTI’s).
• Many risk factors traditionally linked to
candiduria may be associated with urinary
tract infections in general. Factors which
predicted occurrence of candiduria, as
opposed to bacteriuria, included prior use of
antimicrobial agents and elevated plasma
glucose. (Paul,N., Mathai,E et al. 2007, Factors associated
with candiduria and related mortality’, Journal of Infection,
no.55, pp.450-55)
Further Risk Factors
Urinary obstruction and reflex:
• Interference with the free flow of urine with any
abnormality of the urinary tract such as kidney
stones, creating an environment open to infection
• Urinary tract obstructions can result in urine being
pooled in the bladder instead of being voided, thus
creating an ideal medium for micro-organisms to
flourish
• Reflux, which causes urine from the urethra to the
bladder or from the bladder to the ureter is a risk
factor in that bacterially contaminated urine from
the urethral orifice can cause infection
Menopausal women
• Due to a decrease in oestrogen production,
menopausal women do not produce sufficient
mucin to protect the bladder epithelium from
pathogens. (Mucin is the protective layer that lines the bladder
and postmenopausal women produce less mucin.)
Women who are sexually active
(especially if using a diaphragm or spermicide for
contraception)
• Women in the 15-24 year old age group are going
through hormonal and physiological changes
which can upset the flora balance in the system.
Men with prostate conditions
• The prostate surrounds the urethra and with
prostate enlargement and urinary stasis, it
places pressure on the urethra, making
urination difficult or blocking it altogether.
Incomplete bladder emptying tends to favour
the growth of organisms as bacteria is not
flushed out of the bladder for opportunistic
infection.
• Researchers (www.niddk.nih.gov/health) have found that
women whose partners use a condom with spermicidal
foam tend to have growth of E.coli bacteria in the
vagina. This occurs because:
 it kills off friendly flora therefore providing the
ideal environment for contamination.
 It induces colonization of the vagina by E. coli and
alters the overall vaginal flora.
• Friction during intercourse can then force the bacteria
to travel up the urethra.
• UTI’s may be due to sexually transmitted diseases
which are transmitted during sexual intercourse.
Women are more susceptible to these because they
have a shorter urethra that is close to the external
environment and can therefore be more open to
contamination by micro-organisms from outside
influences.
Urinary catheterisation
• Catheters are made of latex and plastic, and
bacteria can build up as an infective film over the
surface. This film can become resistant to
antibiotics. These bacteria that exist on the catheter
can travel up the urethra and infect the bladder.
• In hospitals the primary risk factor is
instrumentation of the urinary tract mainly by
catheterisation. (Jensen,CS & Walter,S. 2007, ‘Urinary Tract
Infections… occurrence, causes and prevention, Ugeskr Laeger,
169(49):4265-8)
• Catheterization of urinary bladder resulted in
urinary tract infection or colonization. Each day of
urinary bladder catheterization increased the risk of
development of urinary tract infection by 21.7%.
(Adukauskienne,D., Kinderyte,A et al. 2006, ‘Aetiology, risk factors
and outcomes of urinary tract infection’, Medicina 42(10):805-9 )
Pregnancy
• Can predispose to urinary tract infections
due to the normal changes in the functioning
of the urinary tract such as dilation and
relaxation due to:
 the obstruction from the enlarged uterus
 urethral relaxation caused by higher
progesterone levels
• The risk of preeclampsia was increased in
pregnant women with urinary tract infection.
(Conde-Agudela,A et al. 2008, ‘Maternal infections and risk of
preeclampsia: systemic review and metaanalysis’, American
Journal of Obstetrics and Gynaecology, 198(1): 7-22)
Diabetes
(Geerlings,SE. 2008, ‘Urinary tract infections in patients with diabetes
mellitus: epidemiology, pathogenesis and treatment’, International
Journal of Antimicrobial Agents, 31S : S54 S57)
• Patients with diabetes mellitus (DM) have a higher
prevalence of asymptomatic bacteriuria (ASB) and
incidence of urinary tract infections (UTIs)
compared with patients without DM. They also more
often have bacteraemia, with the urinary tract as the
most common focus for these infections.
• Bacterial growth in vitro is increased after the
addition of glucose, however glucosuria is not a risk
factor for ASB or for the development of UTIs in
vivo.
• Women with both ASB and DM had lower urinary
cytokine and leukocyte concentrations than women
with ASB without DM. As well, it was found that E.
coli expressing type 1 fimbriae adhere better to
uroepithelial cells of women with DM compared with
those isolated from women without DM.
Treatment Protocol
Antimicrobial and urinary antiseptics:
Arctostaphylos uva-ursi:
• Used traditionally for urinary tract infections and
diarrhoea.
• Has antimicrobial action against several
organisms, including Bacillus subtilis, E.coli,
Mycobacterium smegmatis, Staphylococcus
aureus and some Shigella. It has antiseptic and
astringent properties and is mildly diuretic and
antilithic. Uva Ursi requires an alkaline urine to
exert its antiseptic properties, so highly acidic
foods should be avoided during treatment.
(Heinrich et al 2004)
• Maximum urinary antiseptic activity of uva ursi
occurs 3–4 hours after its oral ingestion. A high
intake of fruits and vegetables will sufficiently
alkalinize the urine for efficacy of uva ursi in
some people. (Kathy Abascal & Eric Yarnell, 2008,
‘Botanical Treatments for Cystitis, Journal of Alternative and
Complementary Therapies, April, pp. 70-77)
• The alkalinity required to produce the
antimicrobial hydroquinone from uva ursi has
raised concern that it should not be combined
with cranberry, since the latter can supposedly
acidify the urine to an extent that renders this
hydroquinone ineffective. However, it is now
known that a volume of cranberry of more than
1500 mL/day is probably needed for such urinary
acidification, indicating that most people can
safely use uva ursi together with cranberry.
(Abascal & Yarnell 2008)
• The hydroquinone generated from uva ursi
has a number of potentially dangerous
effects including suppression of B
lymphocyte maturation and nephrotoxicity.
Hydroquinone is also a known mutagen, and
is one of the many toxins in cigarette smoke
that contribute to cancer. This suggests that
uva ursi should not be used over the long
term, though the absolute levels of free
hydroquinone that it generates in the urine
are exceedingly small (or entirely absent
according to one pharmacokinetic study in
humans). (Abascal & Yarnell 2008)
Antibacterial
• Refer to page 518
Enhancement of diuresis
• Refer to page 519
Improve bladder function
To ensure that bacteria is flushed from
the bladder
Crataeva nurvala
• Is the best bladder tonic.
• Kerry Bone (2003) lists it for:
o Chronic and acute urinary tract
infections.
o Hypotonic, atonic or neurogenic
bladder.
o Incontinence.
o Prevention and treatment of kidney,
ureter and bladder stones.
• Crataeva nurvala has anti-inflammatory and tonic effect
on the smooth muscles of the bladder and the other
urinary organs. This helps in the evacuation of the
bladder and the control of infections. (Arora, RP., Rajiba, NL., Vineet, M.,
Moanty, NK., Kala, SK. 2003, ‘Role of herbal drugs in the management of benign prostatic hyperplasia: Clinical
trial to evaluate the efficacy and safety of Himplasis”, Medice Update, vol.11, no.2, pp.55-58)
• Crataeva nurvala is useful in the treatment of urinary
disorders caused by enlarged prostate. It has antiinflammatory, diuretic, lithotriptic, demulcent and tonic
properties useful in disorders of urinary organs, urinary
tract infections, pain and burning micturition. (Shukla, GN &
Mahender, N. 2002, ‘Use of PR-2000, a Herbal Formulation in the Medical Management of Benign Prostatic
Hyperplasia’, Indian Journal of Clinical Practice, vol.13, no.2, pp.53-56)
Improve the chronic inflammation of the bladder wall
(see table 27.1)
Use demulcents and anti-inflammatories
It is thought that demulcent agents work via a reflex
action: As they pass through the digestive tract they
are believed to provoke neurologic reflexes that in
turn stimulate production of mucus in the respiratory
and urinary tracts. This has not been confirmed in the
urinary tract, though it has been shown to occur in the
respiratory tract in animals.
This increased mucus production is thought to relieve
inflammation and soothe pain. (Abascal & Yarnell 2008)
Improve and support immunity (Table 27.1)
• Echinacea spp.
• Andrographis paniculata
• Astragalus membranaceous
• Picrorrhiza kurroa
Antispasmodics
• It is generally found that when the urine is
alkalised and the bacterial load reduced, the
pain eases off and antispasmodics are not
required.
• Juniper offers a very appealing herbal
“package” for patients with UTIs. Besides its
potent diuretic activity, it is strongly
antimicrobial and anti-inflammatory. It is
surprising that all of these properties have not
led to a published clinical trial of juniper for
UTI. The reputation of juniper as dangerous to
the kidneys is of dubious accuracy, and one
text that attempted to trace the origin of this
belief could find only that it was due to
confusion of the essential oil of Juniperus
sabina (savin) with that of juniper. (Abascal &
Yarnell 2008)
Prevention: Page 519 plus
(Baillie, N. 2003, ‘Recurrent Cystitis & Interstitial Cystitis’)
Diet
• Avoid acidic foods
• Avoid foods high in sugar - chocolates, lollies, cordials
• Drink plenty of fluids daily
• In a study of 139 women university students, those
with diagnoses of acute UTI were compared with 185
age-matched women with no UTIs in the last 5 years.
o The researchers found that frequent consumption of
fresh juices, especially berry juices, and fermented
milk products containing probiotics was associated
with a decreased risk of recurring UTIs.
o Consuming fermented milk products 3 or more
times per week was more effective than less than
one time per week. (Hudson, T. 2006, ‘Treatment and prevention of bladder
infections’, Journal of Alternative and Complementary Medicine, December, pp. 297-302)
• Increasing garlic and onions in the diet—
both of which produce antimicrobial activity
against many organisms—may also be
helpful. These two foods have been shown to
inhibit the growth of E. coli, Proteus spp.,
Klebsiella pneumoniae, Staphylococcus
spp., and Streptococcus spp (Hudson 2006)
Contraception / menstruation / hygiene
• Menopause
o Menopausal women are more prone to
UTI’s due to the ‘drying off’ of the urinary
tract.
o Diet high in phytoestrogens  linseed,
sprouts, tofu/miso, grains and such.
o Trial a herbal vaginal cream applied daily
or after a shower.
• Probiotics
o Particularly when the client has taken
multiple course of antibiotics
o Lactobacilli species predominate in the
vaginal and urinary tracts of healthy
premenopausal women. This would
suggest that women who have recurring
UTIs have an imbalance of their flora, and
if the flora were restored, this could go a
long way to prevent the infection-causing
organisms from dominating. (Hudson 2006)
• Back treatment
o Have the back treated especially if there is
any history of injury, pain and discomfort.
o Practice back exercise, yoga or equivalent
o Avoid wearing high heals
o Impact exercise can be a trigger for
susceptible women
INTERSTITIAL
CYSTITIS
• Interstitial
Cystitis
(IC)
is
a
chronic
inflammatory condition of the bladder wall
clinically characterized by irritable voiding
symptoms of urgency and frequency in the
absence of objective evidence of another
disease that could cause the symptoms
• It was found in patients diagnosed with IC that
60% had only one symptom at onset, that of
recurrent urinary tract infections. The study
concluded that in its early stage IC manifests
often as only a single state of cystitis. (Porru,D.,
Politano., Gerardini,M., Giliberto,GL., Stancati,S., Pasini,L., Tinelli,C., Rovereto,B.,
2004, ‘Different clinical presentation of interstitial cystitis syndrome’ Int
Urogynecol J Pelvic Floor Dysfunction, vol.15, no.3, pp.198-202)
• Urinary frequency generally averages 16 times
a day, but may go as high as 40.
• In the majority of patients, IC is not a
progressive disease. The symptoms do not
tend to worsen with time, but tend to be
intermittent. Some people have remissions
for extended periods of time.
• In a small percentage of patients IC can
progress rapidly, causing the bladder to
reduce in size and become scarred.
Pathogenesis of IC:
Defective Urothelial Barrier
Irritating
Solutes
Urothelium
Irritated
Nerve
GAG
Layer
Inflammation
37
IC is Characterized by a Vicious Cycle With
Increased Symptomology With Increasing Age
Bladder Insult
More Inflammation
Mast Cell Activation and
Histamine Release
Epithelial Layer
Dysfunction
Potassium Leak Into
Interstitium
Activation of C-fibers and
Release of Substance P
Adapted from Evans RJ. Rev Urol. 2002;4(suppl 1):S16-S20.
38
Epidemiology
• The non-ulcer type of IC occurs in about 90% of
patients. The more severe type of the disease (in about
10% of patients) involves Hunner’s ulcers, which are
lesions that appear on all layers of the bladder wall and
appear as brownish-red patches on the bladder
mucosa.
• The ratio of females: males is 9:1. Children can also get
IC
• The onset is usually between 30 and 70 years and a
medium of 43.
• May have autoimmune cause since associated with
systemic lupus erythematosis
AETIOLOGY
Bladder lining deficiency
• According to Baillie (2003) the most popular theory is
that the symptoms are caused by some insult to
the lining of the bladder, damaging the protective
barrier, making it more permeable and allowing the
acid urine to damage and irritate the underlying
tissues.
• It is this deficiency in the GAG
(glycosaminoglycan-rich bladder epithelium) layer
of the bladder that is suggested as the reason
there is an increased incidence of related
diseases. The GAG epithelium may be disrupted in
patients with IC, allowing toxic substances in the
urine to damage the bladder wall. This has
prompted a likening of IC to intestinal
hyperpermeability.
Mast cell activity
• There are an increased number of mast cells
and/or, increased degranulation of mast cells by
excessive nerve activity that results in the
release of inflammatory substances which cause
pain.
• 30–50% of people with IC have an excessive
number of mast cells in the bladder wall (Baillie, N. 2003).
• Antigenic exposure of mast cells causes a
release of pharmacologically active mediators
such as histamine, prostaglandins and
Leukotrienes and have a significant effect on
smooth muscle, vascular epithelium and
inflammation.
Autoimmunity
• It has been postulated that autoimmune or allergic
characteristics are present in IC.
• The prevalence of allergies in IC is reported to be
between 40 and 80% of patients. (Van de Merwe,JP., Yamada,T.,
Sakamoto,Y., 2003, ‘Systemic aspects of interstitial cystitis, immunology and linkage with
autoimmune disorders’ International Journal of Urology, vol.10, pp. Suppl:S35-8)
• Several T cells (CD4 and CD8) were significantly more
abundant within the bladder biopsies from patients with
IC than controls (Christmas, TJ. 1994, ‘Lymphocyte sub-populations in the bladder
wall in normal bladder, bacterial cystitis and interstitial cystitis’, British Journal of Urology,
vol.73, no.5, pp.508-515).
• Patients often have a history of allergies to medications
and environmental stimuli, asthma, or conditions such
as SLE or other immunopathologic abnormalities with a
presumed
autoimmune
component
such
as
inflammatory bowel disease or fibromyalgia.
GAG Bladder lining deficiency
• Another theory is that IC is a defect in the
glycosaminoglycans component of the mucin
layer that covers and protects the urothelium.
This could allow irritants to penetrate and
activate bladder mast cells.
• The potassium leak test was proposed as a
mechanism to evaluate the status of the
glycosaminoglycans layer of the bladder. This
layer is theoretically lost in some cases of
interstitial cystitis. When this occurs, the
bladder lining becomes very irritable when
exposed to high concentrations of urinary
potassium. This is thought to be one mechanism
by which interstitial cystitis causes pain.
• The chronic pain, frequency, urgency and
sleep deprivation associated with IC may
contribute to psychological stress and
secondary depression. Suicidal tendency is 3
– 4 times more common in patients with IC
than in the general population. More than ½
of symptomatic patients with IC have
depression. These patients, in turn, report
that the stress becomes an exacerbating
factor.
Neuropathic causes: (Baillie. N. 2003)
• This theory proposes that IC is not primarily
a disease of the bladder, but of the nervous
system.
• It has also been suggested that nerve root
compression or irritation at the lumber level
of the spine can cause IC. Lower back
problems need to be taken seriously in
people with IC.
Anti-proliferative factor (APF): (Bone, K. 2004)
• A break through in IC research has found a peptide –
APF – in the urine of IC patients.
• It is hypothesised that APF in urine inhibits
appropriate bladder epithelial cell regeneration
resulting in thinning or denudation of the bladder
epithelium.
o More studies are ongoing.
• Many patients currently being treated for prostatitis
who fail to respond to therapy actually may have
undiagnosed interstitial cystitis.
Symptoms
• Suprapubic pain or pelvic pain
o Relieved with small volume voids
o Pain recurs with bladder filling
• Nocturia
• Excessive urinary urgency
o Uncomfortable constant urge to void
o Not relieved with voiding
• Urinary Frequency
o More than 8 voids per day
o Average: 16 voids per day
o Reported as high as 40 voids per day
• Symptoms persist over 9 months
o Symptoms not due to recent urinary tract
infections
o Symptoms worse during week before
menses
• Dyspareunia (difficult or painful intercourse
in women)
• Gross haematuria (20%)
• Incontinence suggests other diagnosis
• In the study by Koziol et al of 565 interstitial
cystitis patients, urgency and frequency were
reported in nearly everyone. With reduced
bladder capacity and decreased bladder
contractions, subjects urinate as often as every
1-2 hours throughout the day and night, with
increasing frequency as the duration of the
disease increases. As many as 40% of patients
may have one or more episodes of hematuria.
• Half of the subjects reported being awakened in
the middle of the night because of pain. Two
thirds of the subjects reported pelvic pain or
pressure, with more than one half reporting pain
on intercourse and one third reporting pain for
days after intercourse.
• More than one half of the subjects reported
excessive fatigue, difficulties concentrating,
and inability to enjoy their usual activities.
Almost all subjects found travel to be difficult
to impossible, and two thirds of the subjects
found employment or working at the job for
which they were qualified difficult or
impossible.
RELATED DISEASES
IRRITABLE BOWEL SYNDROME
• A strong evidential link exists between IC and IBS
• A review of the Medline database from 1996 to 2001
found that there was an increased incidence of IBS
overlapping with IC. (Aaron,LA & Buchwald,D. 2001, ‘A review of the evidence for overlap
among unexplained clinical conditions’ Annals of International Medicine, Vol.134, no.9 pt 2, pp.868-81)
• In a study of 2405 people, IBS and allergies were the
most common conditions in those who also had IC.
(Alagiri,M., Chottiner,S., ratner,V., Slade,D., Hanno,PM., 1997, ‘Interstitial cystitis: unexplained associations with other chronic
disease and pain syndromes’ Urology, vol.49, no.5A Suppl, pp.52-7)
• Bone (2001) suggests that this mast cell degranulation is
involved in the gut hypersensitivity and substance P
inflammatory release in both IBS and IC.
• A report on a bladder and colon biopsy in a
female patient with both conditions found
that the mast cell count in the bladder was
40+/- 10 mast cells/mm2 where the normal
was less than 10, and in the colon was
148+/- 11 mast cells/mm2 where the normal
was less than 50, and in both there was a
connection to many substance P positive
nerves. (Pang,X., Boucher,W., Triadafilopoulos,G., Sant,GR., Theoharides,TC., 1996, ‘Mast cell
and substance P-positive nerve involvement in a patient with both irritable bowel syndrome and
interstitial cystitis’ Urology, vol,47, no.3, pp.436-8)
ENDOMETRIOSIS
It has been suggested that many cases
of endometriosis are actually
misdiagnosed IC.
Chronic Period Pain Due to IC & Gynecologic
Causes Are Nearly Identical in Clinical Presentation
Symptom
IC
Gyn
Generalized Pelvic Pain (e.g., lower abdomen,
urethra, perineum, medial thighs)


Pain With Intercourse (dyspareunia)


Pain on Bladder Filling


Voiding Symptoms
(frequency, urgency, nocturia)


Premenstrual Exacerbations


Exacerbations After Sexual Intercourse


55
IC is Frequently Present
Concurrently With Endometriosis
Diagnosis of Patients With Chronic Period Pain by
Cystoscopy and Hydrodistention & Laparoscopy
10%
IC Alone
70%
IC and
Endometriosis
20%
Endometriosis
Alone
Clinicians should consider the bladder to be the
source of CPP, even when endometriosis is present
56
• A prospective analysis was conducted
women with CPP who presented with
base/anterior
vaginal
wall
and/or
tenderness, with or without irritative
symptoms.
in 178
bladder
uterine
voiding
• Laparoscopic findings among the 178 patients with
chronic pelvic pain supported a diagnosis of
endometriosis in 134 (75%) patients, and
cystoscopy confirmed a diagnosis of interstitial
cystitis in 159 (89%) patients. Both interstitial cystitis
and endometriosis were diagnosed in 115 patients
(65%).
• Results of this prospective study show that interstitial
cystitis and endometriosis may frequently coexist in
patients with chronic pelvic pain.
(Chung,MK., Chung,RP., Gordon,D. 2005, `Interstitial cystitis and endometriosis in patients with chronic pelvic
pain: The "Evil Twins" syndrome’, Journal of the Society of Laparoendoscopic Surgeons, vol.9, no.1, pp.25-9)
IC is typically diagnosed late in disease continuum
Average Time Between Initial Development of
Symptoms and Diagnosis is 5 Years
See at least Significant suffering
5 physicians
and reduced QOL
before diagnosis
Initial
Development of
IC Symptoms
Diagnosis of IC
2-7 years
May have
unnecessary
hysterectomy
58
• OBJECTIVES: Hysterectomies may be performed
unnecessarily in women with chronic pelvic pain if
the diagnosis of interstitial cystitis is not considered.
The objectives of this study were to investigate the
prevalence of interstitial cystitis in patients with
post-hysterectomy chronic pelvic pain and to
evaluate the efficacy of various therapies for
interstitial cystitis.
• METHODS: A study was performed of 111 patients
with chronic pelvic pain whose pain persisted after
hysterectomy.
• RESULTS: Of the 111 patients enrolled, 79% (n=88)
were diagnosed with bladder dysfunction consistent
with interstitial cystitis.
• CONCLUSION: Without determining the origin of
bladder pain, gynaecologists should not proceed to
hysterectomy in patients with chronic pelvic pain.
(Chung,MK.
2004, `Interstitial cystitis in persistent post hysterectomy chronic pelvic pain’, Journal of the Society of
Laparoendoscopic Surgeons, vol.8, no.4, pp.329-33)
Vaginal infections / vulvodynia
• This study aimed to estimate the prevalence of
bladder-origin pain, intraperitoneal pathology, and
vulvar pain in patients undergoing laparoscopy for
chronic pelvic pain (CPP) in 64 patients followed over
a 12 month period.
• Forty-four patients (69%) were found to have a positive
results indicating pain of bladder origin due to bladder
epithelial dysfunction. Cystoscopic findings diagnosed
only seven cases of classic interstitial cystitis (11%).
Laparoscopic
findings
revealed
biopsy-proven
endometriosis in 28% and adhesions in 64%. Vulvar
pain was diagnosed on examination in 20%.
Assessment of intraperitoneal pathology and bladderorigin pain accurately diagnosed 95% of patients.
• Patients with increased symptoms had a higher
likelihood of having pain from bladder epithelial
damage and intraperitoneal pathology.
• CONCLUSIONS: The aetiology of CPP may arise
from multiple sites in the pelvis including the
bladder, pelvic peritoneum, and vulva. This
study demonstrated that in a group of women
undergoing a comprehensive work-up for CPP,
the bladder was the predominant pain
generator. A work-up for CPP should include an
assessment of bladder epithelial function and
an assessment for intraperitoneal pathology.
(Stanford,EJ., Koziol,J., Feng,A. 2005, `The prevalence of interstitial cystitis, endometriosis, adhesions, and
vulvar pain in women with chronic pelvic pain’, The Journal of minimally invasive gynaecology, vol.12, no.1, pp.43-9)
Sexually transmitted diseases
• In a recent study of subjects with herpes
virus infection confirmed by HSV-2 antibody
testing, subjects exhibited a wide range of
symptoms, varying from transient complaints
of dysuria that rarely occur to frequent
prolonged attacks of dysuria, frequency,
and pain.
• Infection with Chlamydia organisms may or
may not produce symptoms but may have
an associated mucopurulent cervical or
urethral discharge.
Bogart,LM., Berry,SH., Clemens,JQ. 2007, `Symptoms of interstitial cystitis, painful bladder syndrome and
similar diseases in women: a systemic review’, The Journal of Urology, vol.177, no.2, pp.450-6
• In women, symptoms of interstitial cystitis are
difficult to distinguish from those of painful
bladder syndrome and they appear to overlap
with those of urinary tract infection, chronic
urethral
syndrome,
overactive
bladder,
vulvodynia and endometriosis.
• A systematic literature review was conducted to
determine how best to distinguish interstitial
cystitis from related conditions.
• Comprehensive
literature
searches
were
conducted using the terms diagnosis, and each
of interstitial cystitis, painful bladder syndrome,
urinary tract infection, overactive bladder,
chronic urethral syndrome, vulvodynia and
endometriosis.
• Of 2,680 screened titles 604 articles were read in full.
o The most commonly reported interstitial cystitis
symptoms were bladder/pelvic pain, urgency,
frequency and nocturia.
o Interstitial cystitis and painful bladder syndrome share
the same cluster of symptoms.
o Self-reports regarding symptoms and effective
antibiotic use can distinguish recurrent urinary tract
infections from interstitial cystitis in some but not all
women.
o Pain distinguishes interstitial cystitis from overactive
bladder and vulvar pain may distinguish vulvodynia
from interstitial cystitis.
o Dysmenorrhoea distinguishes endometriosis
interstitial cystitis, although many women
endometriosis plus interstitial cystitis.
from
have
DIET AND INTERSTITIAL CYSTITIS (Baillie, N. 2003)
• Generally foods to be avoided include
o Acidic foods as these can intensify the burning
feeling in the bladder
o Foods high in tyrosine, tryptophan and aspartate
as it appears that the metabolites of these amino
acids excreted in the urine in people with IC can
irritate an inflammed bladder lining.
o Caffeine  coffee (with or without caffeine)
stimulates gastric acid secretion
o Alcohol  can aggravate the ulceration
o High protein foods should be kept to minimum
since protein stimulates gastric acid
o Chocolate
o Artificial sweeteners
The following table provides a summary of foods to
avoid and those that are usually okay
FOOD GROUPS
FOODS TO AVOID
FOODS TO TRY
Milk / dairy products
Aged cheeses
Sour cream
Yoghurt
Chocolate
White chocolate
Carob
Cottage cheese
Ricotta cheese
Frozen yoghurt
milk
Vegetables
Fava beans
Lima beans
Onions
Tofu
Soya beans
Tomatoes
Other vegetables
Home-grown tomatoes
Carbohydrates and
grains
Rye
Sourdough bread
Other breads
Pasta
Potatoes
Rice
Meats and fish
Aged, canned, cured,
processed or smoked
meats, and fish,
anchovies, caviar,
chicken livers, corned
beef, meats containing
nitrates or nitrites
Other poultry, fish or
meat
Nuts
Most nuts
Almonds
Cashews
Pine nuts
Beverages
Alcohol
Carbonated drinks
Coffee and tea
Fruit juices, especially
citrus and cranberry
Water
Decaffeinated acid
free coffee and tea
Herbal teas
Fruits
Apples, apricots,
avocadoes,
bananas, citrus
fruits, cranberries,
grapes, nectarines,
peaches,
pineapples, plums,
rhubarb,
strawberries, juices
made from these
fruits
Melons
Blueberries
Pears
Seasonings
Mayonnaise, tomato Other seasonings
sauce, mustard,
Garlic
salsa, spicy foods,
say sauce, miso,
salad dressing and
vinegar
Preservatives and
additives
Benzol alcohol
Citric acid
MSG
Artificial sweeteners
Foods containing
preservatives and
artificial ingredients
and colours
Miscellaneous
Tobacco
Caffeine
Diet pills
Junk food
Recreational drugs
Cold and allergy
medications
containing
ephedrine and
pseudoephedrine
HINTS
• A pinch of salt can be added to carbonated
beverages to make them flat.
• Avoid Tyrosine containing foods  beef,
cheese, chicken, egg, soy beans, wild game
• Avoid Tryptophan containing foods  beef,
fish, lentils, peanuts, pumpkin seeds,
sesame seeds, soybeans, uncooked rice
• Avoid Aspartate containing foods 
asparagus, luncheon meats, nutrisweeet, oat
flakes, sausage meat, sprouting seeds, wild
game
HERBAL MEDICINE PROTOCOL
Deal with the acute cystitis infections that they often
present with:
• Arctostaphylos uva ursi
o Has antibacterial and anti-inflammatory effects
in the gastrointestinal tract as well as being an
antiseptic and anti-inflammatory in the urinary
system. (Mills & Bone. 2000) This therefore makes it
effective for the recurrent cystitis, E. coli
infection,
and
allergic
reaction-induced
inflammation.
o Has antibacterial activity against E. coli as well
as antiseptic and astringent properties (Heinrich et al
2004)
• Buchu
• Corn silk
• Couch grass
o Clinical trials have shown a positive effect
against E. coli (Mills & Bone 2000)
• Golden Seal
Anti-allergic
To stabilise the mast cell membrane, have an
antihistamine response that deals with the
possible allergic nature of the condition and
also deal with the mast cell activation that
follows an autoimmune reaction.
• Albizia lebbeck
• Scutellaria baicalensis
o Anti-allergic activity has been
demonstrated in vivo. (Chang, HM & But PP., 1987,
‘Pharmacology and Applications of Chinese Materia Medica. Vol. 2’ World
Scientific, Singapore)
• Picrorrhiza kurroa
• Allium cepa
Anti-inflammatory
With many of the herbs working via the arachidonic
pathway. By dealing with the inflammatory response
within both the bladder and the colon (if required)
effective function can be restored.
• Curcuma longa
• Tanacetum parthenium
• Salix alba
• Glycyrrhiza glabra. As well, Licorice exerts other
effects that might benefit patients with IC: (Abascal & Yarnell 2008)
o It has been shown to reduce complement levels, a
known pathogenetic factor in IC.
o Although the glycyrrhetinic acid in licorice
appears to interfere with the inflammatory
cascade by acting primarily on the early
complement components.
o Licorice is also a demulcent
• Bupleurum falcatum
• Rehmannia glutinosa
o Exhibited anti-allergic effects as well as
the promotion and modulation of immune
function (Bone, K. 2003)
o Reduced plasma histamine levels and
inhibited the release of histamine from rat
peritoneal mast cells. (Kim,H., Lee,E., Lee,S., Shin,T.,
Kim,Y., Kim,J., 1998, ‘Effect of Rehmannia glutinosa on immediate type
allergic reaction’ International Journal of Immunopharmacology, vol.20,
no.4-5, pp.231-40)
• Viburnum opulus
GAG layer restorative
Polysaccharides have a beneficial effect on the
GAG layer, it is possible that herbal medicine
with high polysaccharides may also exhibit
this action
• Ulmus rubra
• Althea officinalis
• Plantago psyllium
• Aloe vera  be wary as it is usually
preserved with citric acid which can flare up
the symptoms of IC
Smooth mucous membranes and restore effective
function to both
• Crataeva nurvala
• Hydrastis canadensis Has an effect on the mucous
membranes of both GIT and genitourinary tract (Mills &
Bone 2000)
• Althea officinalis
• Agropyron repens
• Zea mays
Analgesic
Some herbs are more effective for nerve pain and
others for organ pain. IC is a combination of both
• Hypericum perforatum
• Corydalis ambigua
• Eschscholtzia californica
• Piper methysticum
• Salix alba
Deal with the link between the stress response
and the regulation of IC
• Chamomilla reticutita
• Hypericum perforatum
• Scutellaria lateriflora
• Withania somnifera
Deal with the possible adhesion of microbes to the
bladder wall
• Vaccinium macrocarpon
o Has been shown to markedly inhibit adhesion
of E. coli to uroepithelial cells therefore acting
to prevent the development of UTI’s (Heinrich et al 2004)
o Cranberry juice has been shown to decrease
the number of symptomatic UTI’s over a 12
month period (Jepson,RG., Mihaljevic,L., Craig,J. 2004, ‘Cranberries
for preventing urinary tract infections’, Cochrane Database Sts Rev,
2:CD001321)
o Strong scientific basis has been found for the
use of Cranberries to reduce the risk of E. coli
adhesion to bladder cells and the onset of UTI.
(Reid,G. 2002, ‘The role of cranberry and probiotics in intestinal and
urogenital tract health’ Critical Review Food Science and Nutrition, vol.42,
no.3 Suppl, pp.293-300)
• Hydrastis canadensis
• Quercetin, the ubiquitous, inflammationmodulating plant flavonoid, was shown in an
open trial, to alleviate symptoms of IC. The
dose used was a relatively low 500 mg taken
twice daily. Quercetin has also proven
efficacious in a double-blind trial in patients
with chronic prostatitis, a condition closely
related to IC and sometimes confused with it.
Quercetin-rich foods include green tea,
apples, and onions. (Abascal & YArnell 2008)