间质性膀胱炎的诊疗策略
间质性膀胱炎治疗
间质性膀胱炎治疗间质性膀胱炎/膀胱疼痛综合征（IC / BPS）是一种慢性疼痛综合征，其病因尚不清楚。
因此，没有治愈性治疗，管理的目标是提供症状缓解以达到适当的生活质量。
IC / BPS有许多治疗方法，并且没有一种被证明对所有IC / BPS患者有帮助。
我们采用逐步方法处理IC / BPS。
另一种方法是根据患者的主要症状量身定制的个性化治疗计划。
对于一些患者，连续或同时治疗的组合可能是合适的，但是每个治疗应该单独启动以能够监测症状反应并且停止无效治疗。
如果在一线和二线治疗的几次试验后没有改善，则应重新考虑IC / BPS的诊断。
个体患者特征可能会影响治疗方案的选择，包括：症状特征（严重程度，位置，进展）。
以前有效或无效的治疗方法。
合并症，对于患有慢性病（例如纤维肌痛，肠易激综合征，抑郁症，焦虑症）的IC / BPS患者，需要采用多学科方法进行最佳管理。
患者偏好。
根据症状的严重程度和进展以及患者偏好，在某些患者中，快速进行更积极的治疗可能是合理的。
例如，在症状迅速恶化的患者中，如果对口服药物没有快速反应，可以选择进行膀胱镜检查并进行水分注射和膀胱内治疗。
使用镇痛药，镇痛药可以在IC / BPS患者的任何治疗点使用，目的是尽量减少疼痛和最大化功能。
一般来说，止痛药用于短期缓解膀胱疼痛的发作，而不是作为主要治疗。
它们的使用应以不利影响和依赖性的风险为指导。
在一些IC / BPS 患者中，与其他慢性疼痛病症一样，考虑到副作用和禁忌症，可能需要长期使用口服或透皮镇痛药。
尿液镇痛药，尿液镇痛药可以缓解泌尿系统症状。
可用的尿液镇痛药在可接受的使用时间上差别很大; 非那吡啶是用于短期使用，而乌洛托品可以长期使用。
一线治疗一线疗法目前最小的风险，并应提供给所有患者。
对于轻度间质性膀胱炎/膀胱疼痛综合征（IC / BPS）症状的患者，一线治疗可能单独有效。
自我护理和行为改变，应与所有患者讨论自我护理实践和行为改变，并在可行的情况下实施。
间质性膀胱炎的诊治原则
间质性膀胱炎的诊治原则写在课前的话间质性膀胱炎是一种慢性的、严重的膀胱壁炎症，常发生于中年妇女，其特点主要是膀胱壁的纤维化，并伴有膀胱容量的减少，以尿频、尿急、膀胱区胀痛为其主要症状。
对中年妇女出现严重尿频，尿急及夜尿增多伴耻骨上方膀胱区胀痛而尿检查正常者应想到间质性膀胱炎。
一、下尿路感染的定义下尿路感染是指细菌致病菌通过逆行的淋巴或血液进入尿液后引起下尿路的感染。
下尿路一般只是指膀胱炎和尿道炎，膀胱炎指感染主要位于膀胱，尿道炎指感染主要位于尿道。
下尿路感染分成单纯下尿路感染和复杂下尿路感染。
单纯性下尿路感染多指无解剖异常的下尿路一般细菌感染。
复杂性下尿路感染多指伴发上尿路感染或存在感染扩散高危因素。
二、细菌性膀胱炎（一）细菌性膀胱炎的病因下尿路感染最常见的是细菌性膀胱炎，它是人类最常见的一类细菌性感染，要远远高于上呼吸道感染。
多见于女性，女性和男性的比例为30：1，每年全世界约有10%的女性会罹患细菌性膀胱炎，约50%的女性会一生中至少有一次下尿路感染。
细菌性膀胱炎最常见是大肠埃希氏菌，大肠埃希氏菌有很多类型。
为什么女性容易发生细菌性膀胱炎？在门诊时很多女性都会问如何避免细菌性膀胱炎？这涉及到细菌性膀胱炎的诱因。
（二）细菌性膀胱炎的诱因1.引起尿流率下降的因素引起尿流率下降的因素常见的有：（1）膀胱出口梗阻、前列腺增生、前列腺癌、尿道狭窄、膀胱内异物（如膀胱结石）；（2）神经源性膀胱；（3）水摄入不足：尿量降低和速率下降会引起膀胱内的细菌排出不足，容易引发细菌性膀胱炎。
2.促进细菌种植的因素促进细菌种植是细菌能在膀胱黏膜大量繁殖的基础，膀胱黏膜有IgG抗体可以抑制细菌黏附在膀胱上，但是有些情况会导致细菌种植的增加。
比如女性性活动、应用杀精药、绝经期女性雌激素水平降低，或长期滥用抗生素导致正常菌群减少。
3.细菌逆行感染增加（1）老年女性的最多见的是粪失禁和尿失禁；（2）排尿困难和功能障碍的病人，留置尿管也会引起细菌黏附在膀胱上；（3）膀胱壁缺血的因素，如膀胱老化，膀胱壁的神经和血管减少，容易纤维化，这时血控降低、黏膜菲薄，细菌更容易黏附在膀胱黏膜上，导致细菌性膀胱炎的发生。
AUA间质性膀胱炎诊治指南(2011版)
Purpose: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syn-drome (IC/BPS).Methods: A systematic review of the literature using the MEDLINE ® data-base (search dates 1/1/83-7/22/09) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of IC/BPS. Insufficient evidence was retrieved regarding diagnosis; this portion of the guideline, therefore, is based on Clinical Principles and Expert Opinion. The review yielded an evidence base of 86 treatment articles after appli-cation of inclusion/exclusion criteria. These publications were used to cre-ate the majority of the treatment portion of the guideline. When sufficient evidence existed, the body of evidence for a particular treatment was as-signed a strength rating of A (high), B (moderate), or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. See text and algorithm for definitions and detailed diagnostic, management, and treatment frameworks.Guideline StatementsDiagnosis:1. The basic assessment should include a careful history, physical exami-nation, and laboratory examination to rule in symptoms that characterize IC/BPS and rule out other confusable disorders (see text for details). Clinical Principle2. Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects. Clinical Principle3. Cystoscopy and/or urodynamics should be considered as an aid to di-agnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations. Expert OpinionTreatment:Overall Management:4. Treatment strategies should proceed using more conservative therapies first, with less conservative therapies employed if symptom control is in-adequate for acceptable quality of life; because of their irreversibility, sur-gical treatments (other than fulguration of Hunner‘s lesions) are appropri-ate only after other treatment alternatives have been exhausted, or at any time in the rare instance when an end-stage small, fibrotic bladder has been confirmed and the patient‘s quality of life suggests a positive risk-benefit ratio for major surgery. Clinical PrincipleApproved by the AUA Board of Directors January 2011 Authors’ disclosure of potential conflicts of interest and author/staff contributions appear at the end of the article. © 2011 by the American Urological AssociationAmerican Urological Association (AUA) GuidelineDIAGNOSIS AND TREATMENT OFINTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROMEPhilip M. Hanno, David Allen Burks, J. Quentin Clemens, Roger R. Dmochowski, Deborah Erickson, Mary Pat FitzGerald, John B. Forrest, Barbara Gordon, Mikel Gray, Robert Dale Mayer, Diane Newman, Leroy Nyberg Jr., Christopher K. Payne, Ursula Wesselmann, Martha M. FaradayAmerican Urological Association Interstitial Cystitis 2 5. Initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences; appropriate entry points into the treatment portion of the algorithm depend on these fac-tors. Clinical Principle6. Multiple, simultaneous treatments may be considered if it is in the best interests of the patient; base-line symptom assessment and regular symptom level re-assessment are essential to document efficacy of single and combined treatments. Clinical Principle7. Ineffective treatments should be stopped once a clinically meaningful interval has elapsed. Clinical Principle8.Pain management should be continually assessed for effectiveness because of its importance to quality of life. If pain management is inadequate, then consideration should be given to a multidisciplinary ap-proach and the patient referred appropriately. Clinical Principle9. The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment ap-proaches. Clinical PrincipleTreatments that may be offered: Treatments that may be offered are divided into first-, second-, third-, fourth-, fifth-, and sixth-line groups based on the balance between potential benefits to the pa-tient, potential severity of adverse events and the reversibility of the treatment. See body of guideline for protocols, study details, and rationales.First-Line Treatments: First-line treatments should be performed on all patients.10. Patients should be educated about normal bladder function, what is known and not known about IC/ BPS, the benefits vs. risks/burdens of the available treatment alternatives, the fact that no single treat-ment has been found effective for the majority of patients, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved. Clinical Principle11. Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible. Clinical Principle12. Patients should be encouraged to implement stress management practices to improve coping tech-niques and manage stress-induced symptom exacerbations. Clinical PrincipleSecond-line treatments:13. Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominaland/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Clinical Principle14. Multimodal pain management approaches (e.g., pharmacological, stress management, manual ther-apy if available) should be initiated. Expert Opinion15. Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as second-line oral medications (listed in alphabetical order; no hierarchy is implied). Options (Evidence Strength- Grades B, B, C, and B)16. DMSO, heparin, or lidocaine may be administered as second-line intravesical treatments (listed in alphabetical order; no hierarchy is implied). Option (Evidence Strength- Grades C, C, and B)American Urological Association Interstitial Cystitis 3Third-line treatments:17. Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken if first- and second-line treatments have not provided acceptable symptom control and quality of life or if the patient‘s presenting symptoms suggest a more-invasive approach is appropriate. Option (EvidenceStrength- Grade C)18. If Hunner‘s lesions are present, then fulguration (with laser or electrocautery) and/or injection of tri-amcinolone should be performed. Recommendation (Evidence Strength- Grade C)Fourth-line treatment:19. A trial of neurostimulation may be performed and, if successful, implantation of permanent neu-rostimulation devices may be undertaken if other treatments have not provided adequate symptom con-trol and quality of life or if the clinician and patient agree that symptoms require this approach. Option (Evidence Strength- C)Fifth-line treatments:20. Cyclosporine A may be administered as an oral medication if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. Option (Evidence Strength- C)21. Intradetrusor botulinum toxin A (BTX-A) may be administered if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. Patients must be willing to accept the possibility that post-treatment intermittent self-catheterization may be necessary. Option (Evidence Strength- C)Sixth-line treatment:22. Major surgery (e.g., substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients for whom all other therapies have failed to provide adequate symptom control and quality of life (see caveat above in guideline statement #4). Option (Evidence Strength- C)Treatments that should not be offered: The treatments below appear to lack efficacy and/or appear to be accompanied by unacceptable adverse event profiles. See body of guideline for study details and rationales.23. Long-term oral antibiotic administration should not be offered. Standard (Evidence Strength- B)24. Intravesical instillation of bacillus Calmette-Guerin (BCG) should not be offered outside of investiga-tional study settings. Standard (Evidence Strength- B)25. Intravesical instillation of resiniferatoxin should not be offered. Standard (Evidence Strength- A)26. High-pressure, long-duration hydrodistension should not be offered. Recommendation (Evidence Strength- C)27. Systemic (oral) long-term glucocorticoid administration should not be offered. Recommendation (Evidence Strength- C)INTRODUCTIONPurposePurposeThis guideline‘s purpose is to provide direction to clinicians and patients regarding how to: recognize interstitial cystitis (IC)/bladder pain syndrome (BPS); conduct a valid diagnostic process; and, approach treatment with the goals of maximizing symptom control and pa-tient quality of life (QoL) while minimizing ad-verse events and patient burden. The strate-gies and approaches recommended in this document were derived from evidence-based and consensus-based processes. IC/BPS no-menclature is a controversial issue; for the purpose of clarity the Panel decided to refer to the syndrome as IC/BPS and to consider these terms synonymous. There is a continually ex-panding literature on IC/BPS; the Panel notes that this document constitutes a clinical strat-egy and is not intended to be interpreted rig-idly. The most effective approach for a particu-lar patient is best determined by the individual clinician and patient. As the science relevant to IC/BPS evolves and improves, the strategies presented here will require amendment to re-main consistent with the highest standards of clinical care. MethodologyA systematic review was conducted to iden-tify published articles relevant to the diagno-sis and treatment of IC/BPS. Literature searches were performed on English-language publications using the MEDLINE da-tabase from January 1, 1983 to July 22, 2009 using the terms ―interstitial cystitis,‖ ―painful bladder syndrome,‖ ―bladder pain syndrome,‖ and ―pelvic pain‖ as well as key words cap-turing the various diagnostic procedures and treatments known to be used for these syn-dromes. Studies published after July 22, 2009 were not included as part of the evi-dence base considered by the Panel from which evidence-based guideline statements (Standards, Recommendations, Options) were derived. A few studies published after this cut-off date provided relevant informa-tion and are cited in the text as background material. Data from studies published after the literature search cut-off will be incorpo-rated into the next version of this guideline. Preclinical studies (e.g., animal models), pe-diatric studies, commentary, and editorials were eliminated. Review article references were checked to ensure inclusion of all possi-bly relevant studies. Studies using treat-ments not available in the U.S., herbal or supplement treatments, or studies that re-ported outcomes information collapsed across multiple interventions also were excluded. Studies on mixed patient groups (i.e., some patients did not have IC/BPS) were retained as long as more than 50% of patients were IC/BPS patients. Multiple reports on the same patient group were carefully examined to en-sure inclusion of only nonredundant informa-tion. In a few cases, individual studies consti-tuted the only report on a particular treatment. Because sample sizes in individual studies were small, single studies were not considered a suf-ficient and reliable evidence base from whichto construct an evidence-based statement (i.e., a Standard, Recommendation, or Option). These studies were used to support Clinical Principles as appropriate.IC/BPS Diagnosis and Overall Manage-ment. The review revealed insufficient publi-cations to address IC/BPS diagnosis and overall management from an evidence basis; the diag-nosis and management portions of the algo-rithm (see Figure 1), therefore, are provided as Clinical Principles or as Expert Opinion with consensus achieved using a modified Delphi technique if differences of opinion emerged.1 A Clinical Principle is a statement about a compo-nent of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical lit-erature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experi-ence, knowledge, and judgment for which there is no evidence.IC/BPS Treatment. With regard to treat-ment, a total of 86 articles met the inclusion criteria; the Panel judged that these were a sufficient evidence base from which to con-struct the majority of the treatment portion of the algorithm. Data on study type (e.g., ran-domized controlled trial, randomized crossover trial, observational study), treatment parame-ters (e.g., dose, administration protocols, fol-low-up durations), patient characteristics (i.e., age, gender, symptom duration), ad-verse events, and primary outcomes (as de-fined by study authors) were extracted. The primary outcome measure for most studies was some form of patient-rated improvement scale. For studies that did not use this type of measure, other outcomes were extracted (e.g., ICPS, ICSS, VAS scales).Quality of Individual Studies and Deter-mination of Evidence Strength. Quality of individual studies that were randomized con-trolled trials (RCTs) or crossover trials was assessed using the Cochrane Risk of Bias tool.2 Because placebo effects are common in controlled trials conducted with IC/BPS pa-tients, any apparent procedural deviations that could compromise the integrity of ran-domization or blinding resulted in a rating of increased risk of bias for that particular trial. Because there is no widely-agreed upon qual-ity assessment tool for observational studies, the quality of individual observational studies was not assessed.The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence avail-able for a particular question and includes consideration of study design, individual study quality, the consistency of findings across studies, the adequacy of sample sizes, and the generalizability of samples, settings, and treatments for the purposes of the guide-line. AUA categorizes body of evidence strength as Grade A (well-conducted RCTs orexceptionally strong observational studies), Grade B (RCTs with some weaknesses of pro-cedure or generalizability or generally strong observational studies), or Grade C (observational studies that are inconsistent, have small sample sizes, or have other prob-lems that potentially confound interpretation of data). Because treatment data for this condi-tion are difficult to interpret in the absence of a placebo control, bodies of evidence comprised entirely of studies that lacked placebo control groups (i.e., observational studies) were as-signed a strength rating of Grade C.AUA Nomenclature: Linking Statement Type to Evidence Strength. The AUA no-menclature system explicitly links statement type to body of evidence strength and the Panel‘s judgment regarding the balance be-tween benefits and risks/burdens.3Standards are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be un-dertaken based on Grade A or Grade B evi-dence. Recommendations are directive state-ments that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken based on Grade C evidence. Options are non-directive statements that leave the decision to take an action up to the individual clinician and patient because the balance between benefits and risks/burdens appears relatively equal or ap-pears unclear; Options may be supported by Grade A, B, or C evidence. In the treatment portion of this guideline, most statements are Options because most treatments demonstrate limited efficacy in a subset of patients that is not readily identifiable a priori. The Panel in-terpreted these data to indicate that for a particular patient, the balance between bene-fits and risks/burdens is uncertain or rela-tively equal and whether to use a particular treatment is a decision best made by the cli-nician who knows the patient with full consid-eration of the patient‘s prior treatment his-tory, current quality of life, preferences and values.Limitations of the Literature. The Panel proceeded with full awareness of the limita-tions of the IC/BPS literature. These limita-tions include: poorly-defined patient groups or heterogeneous groups; small sample sizes; lack of placebo controls for many stud-ies, resulting in a likely over-estimation of efficacy; short follow-up durations; and, use of a variety of outcome measures. With re-gard to measures, even though the most consistently used measure was some form of patient-rated improvement scale, the scales differed across studies in anchor points, num-ber of gradations, and descriptors. Overall, these difficulties resulted in limited utility for meta-analytic procedures. The single meta-analysis reported here was used to calculate an overall effect size for data from random-ized trials that evaluated pentosan polysul-fate (PPS). No comparative procedures were undertaken.BackgroundDefinition. The bladder disease complex in-cludes a large group of patients with bladder and/or urethral and/or pelvic pain, lower uri-nary tract symptoms, and sterile urine cul-tures, many with specific identifiable causes. IC/BPS comprises a part of this complex. The Panel used the IC/BPS definition agreed upon by the Society for Urodynamics and Female Urology (SUFU): ―An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes‖.4 This definition was selected because it allows treatment to begin after a relatively short symptomatic period, preventing treatment withholding that could occur with definitions that require longer symptom durations (i.e., six months). Defini-tions used in research or clinical trials should be avoided in clinical practice; many patients may be misdiagnosed or have delays in diag-nosis and treatment if these criteria are em-ployed.5Epidemiology. Since there is no objective marker to establish the presence of IC/BPS, studies to define its prevalence are difficult to conduct. Population-based prevalence studies of IC/BPS have used three methods: surveys that ask participants if they have ever been di-agnosed with the condition (self-report stud-ies); questionnaires administered to identify the presence of symptoms that are suggestive of IC/BPS (symptom assessments); and, ad-ministrative billing data used to identify the number of individuals in a population who have been diagnosed with IC/BPS (clinician diagnosis). Not surprisingly, the use of differ-ent methods yields widely disparate preva-lence estimates.Self-Report Studies. Two large-scale stud-ies in the United States have utilized self-report to estimate the prevalence of IC/BPS. The first was conducted as part of the 1989 National Health Interview Survey (NHIS), and the second was part of the third National Health and Nutrition Examination Surveys (NHANES III), which was conducted between 1988 and 1994. The same definition of IC/ BPS was used in both studies. Participants were asked, ―Have you ever had symptoms of a bladder infection (such as pain in your bladder and frequent urination) that lasted more than 3 months?‖ Those who gave a positive response were then asked, ―When you had this condition, were you told that you had interstitial cystitis or painful bladder syndrome?‖ An affirmative answer to both questions was considered to define the pres-ence of IC/BPS. The prevalence estimates ob-tained from these two studies were virtually identical. In the NHIS, the overall prevalence was 500 per 100,000 population, and the prevalence in women was 865 per 100,000.6 In NHANES III, the prevalence was 470 per 100,000 population, including 60 per 100,000 men and 850 per 100,000 women.6 This equals approximately 83,000 men and 1.2 million women across the U.S.IC/BPS Symptoms. Multiple studies have estimated the prevalence of IC/BPS symp-toms, using a variety of different case defini-tions. A mailed questionnaire study to 1,331 Finnish women aged 17-71 identified probable IC/BPS symptoms in 0.45%.7 Another ques-tionnaire mailing study to enrollees aged 25-80 in a managed care population in the U.S. Pa-cific Northwest identified IC/BPS symptoms in 6-11% of women and 2–5% of men, depend-ing on the definition used.8 Investigators in the Boston Area Community Health study con-ducted door-to-door interviews about urologic symptoms in a sample of Black, Hispanic and White individuals aged 30-79.9 They identified IC/BPS symptoms using six different defini-tions, which yielded prevalence estimates ranging from 0.6% to 2.0%. Across these defi-nitions, symptoms were typically two to three times as common in women as men, but no clear variations were observed by race/ ethnicity. Questions about IC/BPS symptoms were included in the 2004 version of the U.S. Nurses Health Study (NHS), which was admin-istered to women aged 58 to 83 years.10 In this cohort of women, the prevalence of IC/BPS symptoms was 2.3%. The prevalence in-creased with age, from 1.7% of those younger than 65 years up to 4.0% in women aged 80 years or older. In a study of 981 Austrian women aged 19-89 at a voluntary health screening project in Vienna, the prevalence of IC/BPS symptoms was determined to be 0.3% (306 per 100,000).11 Finally, the RAND Inter-stitial Cystitis Epidemiology (RICE) investiga-tors conducted telephone interviews from a random sample of over 100,000 households across the United States.12 Using validated case definitions to identify IC/BPS, the esti-mated prevalence in adult women aged >18 ranged from 2.7% (high specificity case defi-nition) to 6.5% (high sensitivity case defini-tion).Clinician Diagnosis. Female participants in the NHS were asked by mailed questionnaires in 1994 and 1995 whether they had ever been diagnosed with ‗interstitial cystitis (not urinary tract infection)‘. In participants with a positive response, medical record reviews were performed to confirm a physician diag-nosis, including cystoscopy performed by a urologist. Using these methods, the preva-lence of IC/BPS was found to be 52/100,000 in the NHS I cohort, and 67/100,000 in the NHS II cohort.13 A subsequent study was per-formed using administrative billing data from the Kaiser Permanente Northwest managed care population in the Portland, Oregon met-ropolitan area.8 Patients with IC/BPS were identified by the presence of ICD-9 code 595.1 (‗interstitial cystitis‘) in the electronic medical record, and the prevalence of the di-agnosis was found to be 197 per 100,000 women and 41 per 100,000 men.Typical Course and Comorbidities. IC/BPS is most commonly diagnosed in the fourth decade or after, although the diagnosis may be delayed depending upon the index of sus-picion for the disease, and the criteria usedto diagnose it.14 For instance, in European studies, where more strict criteria are typi-cally used to make the diagnosis, the mean age is older than is typical for the US. A his-tory of a recent culture-proven UTI can be identified on presentation in 18-36% of women, although subsequent cultures arenegative.15, 16 Initially it is not uncommon for patients to report a single symptom such as dysuria, frequency, or pain, with subsequent progression to multiple symptoms.17, 18 Symp-tom flares, during which symptoms suddenly intensify for several hours, days, or weeks, are not uncommon. There is a high rate of prior pelvic surgery (especially hysterectomy) and levator ani pain in women with IC/BPS, sug-gesting that trauma or other local factors may contribute to symptoms.19 It is important to note, however, that the high incidence of other procedures such as hysterectomy or laparo-scopy may be the result of a missed diagnosis and does not necessarily indicate that the sur-gical procedure itself is a contributing factor to symptoms. It is also common for IC/BPS to co-exist with other unexplained medical conditions such as fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, Sjogren‘s syndrome, chronic headaches, and vulvodynia.20, 21 These associations suggest that there may be a sys-temic dysregulation in some patients. Finally, patients with IC/BPS frequently exhibit mental health disorders such as depression and anxi-ety. While these symptoms may be reactive in some IC/BPS patients, there is also some evi-dence that there may be a common biologic mechanism involved. For instance, a link be-tween IC/BPS and panic disorder has been suggested from genetic linkage studies.22, 23Conceptualizing IC/BPS. It is not known whether IC/BPS is a primary bladder disorder or whether the bladder symptoms of IC/BPS are a secondary phenomena resulting from an-other cause. Converging data from several sources suggest, however, that IC/BPS can be conceptualized as a bladder pain disorder that is often associated with voiding sympto-matology and other systemic chronic pain disorders. Specifically, IC/BPS may be a bladder disorder that is part of a more gener-alized systemic disorder, at least in a subset of patients.Initial observations suggesting this conceptualization were made by Clauw and colleagues (1997). He noted among chronic pelvic pain patients that other chronic pain disorders such as interstitial cystitis, irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia tended to co-occur.24 He suggested that there might be a common central pathogenesis and pathophysiology for these disorders. Self-report data collected by the Interstitial Cystitis Association corrobo-rated Clauw‘s findings and showed an asso-ciation between IC/BPS and other chronic pain disorders.25 Aaron and Buchwald (2001) analyzed a co-twin control study and sup-ported the findings previously reported by Clauw and colleagues (1997).26 Additional epidemiologic studies support these data and suggest that if the IC patient is properly as-sessed during the diagnostic evaluation, many of these somatic symptoms are also present.Considering these data, it has been suggested that IC/BPS is a member of a fam-ily of hypersensitivity disorders which affects the bladder and other somatic/visceral or-gans, and has many overlapping symptoms and pathophysiology.27, 28 An additional hy-pothesis is that IC/BPS might be just a part of the continuum of painful vs. non-painful overactive bladder syndrome (OAB).29, 30Challenge to Patient and Clinician: Impact on Psychosocial Functioning and Qualityof Life (QoL). The effects of IC/BPS on psy-chosocial functioning and QoL are pervasive and insidious, damaging work life, psychologi-cal well-being, personal relationships and gen-eral health.9 QoL is poorer in IC/BPS patients than in controls.9, 31, 32 Rates of depression are also higher.31-33 In addition, IC/BPS patients have significantly more pain, sleep dysfunction, catastrophizing, depression, anxiety, stress, social functioning difficulties and sexual dys-function than do non-IC/BPS age-matched women.34, 35 The impact of IC/BPS on QoL is as severe as that of rheumatoid arthritis and end-stage renal disease.9, 36 Health-related QoL in women with IC/BPS is worse than that of women with endometriosis, vulvodynia or overactive bladder.37 Given that IC/BPS causes considerable morbidity over the course of a pa-tient‘s life and loss of work during the most productive years of work and family life signifi-cant negative psychological and QoL impacts are not surprising.9Sexual dysfunction has an especially im-portant impact on the QoL of IC/BPS patients. In IC/BPS patients, sexual dysfunction is mod-erate to severe38 and occurs at high rates com-pared with controls.39, 40 In women with treat-ment-refractory IC/BPS, poor sexual function is a primary predictor of poor mental QoL.41 Pain appears to mediate sexual dysfunction and its associated effects on QoL. Adult women with IC/BPS report rates of intercourse, desire, and orgasm frequency in their adolescence that are similar to those reported by controls, but rates diverge in adulthood, when IC/BPS patients re-port significantly more pain and fear of pain with intercourse and more sexual distress.39 The strong link between IC/BPS symp-toms and psychosocial functioning and QoL make clear the critical importance of optimiz-ing treatment of IC/BPS symptoms. Success-ful treatment of the medical condition clearly brings improvement in functioning and QoL. Response to therapy is associated with im-proved overall QoL.42 In addition, response to therapy is associated with improved sexual function and sleep, with concomitant im-provements in QoL.34, 38Cost. Quantifying the economic burden ofIC/BPS on the American health care system is difficult because of the lack of an objective marker for diagnosis, resulting in uncertainty regarding its true prevalence. Direct costs as-sociated with IC/BPS are incurred through physician visits, prescription medications, outpatient procedures, and hospitalization. These costs are greater than the mean an-nual per-person direct costs of diabetes melli-tus, depression, hypertension, and asthma.43 They are also more consistent across geo-graphic regions of the United States than other urologic conditions.44 Because of the chronicity of the condition, these costs typi-cally persist over years. The indirect costs of IC/BPS, including time away from work and lost productivity while working, are particu-larly significant since the condition primarily affects working age adults, and especially women aged 25-50 years. The psychosocial costs such as social, educational and career related activities not pursued, as well as the emotional distress, depression, social isola-tion, and diminished QoL have not been。
3种不同方法治疗女性间质性膀胱炎的疗效及生活质量观察
７ ６ ． ９ ％， Ａ组 ４ ４ ． ０ ％（ Ｐ＜ ０ ． ０ １ ） ； Ｃ组排尿 次数／ ２ ４ ｈ 、 夜尿次数 、 最大膀 胱容量 、 Ｉ Ｃ Ｓ Ｉ 、 Ｐ Ｕ Ｆ均优 于 Ａ、 Ｂ组 （ Ｐ＜ ０ ． ０ ５
或 Ｐ＜ ０ ． ０ １ ） ； 生活质量评分 由低 到高（ 即生活质量 由好 到差 ） 依次为 Ｃ组 （ １ ． ３±０ ． ６ ） 分， Ｂ组 （ ２ ． ４±１ ． １ ） 分， Ａ组
间质 性 膀 胱 炎 （ ｉ ｎ ｔ ｅ ｒ ｓ ｔ ｉ ｔ ｉ ａ ｌ ｃ ｙ ｓ ｔ ｉ ｔ ｉ ｓ ， Ｉ Ｃ） 是 一 种 以 严 重 的尿 频 、 尿急 、 夜尿 、 盆 腔疼 痛为 主要 表 现 的临床
３组 年龄 比较 差异 无统计 学 意义 （ Ｐ＞ ０ ． ０ ５ ） 。 １ ． ２ 方法 Ａ组 予单 纯 阿 米替 林 口服 治疗 ， 起 始剂
将２ ０ １ １年
１ 月至 ２ ０ １ ４年 １ 月６ ７例女性间质性膀胱炎患者 随机 分为 Ａ、 Ｂ 、 ｃ ３组 ， 其 中 Ａ组 ２ ５例 ， 予单纯 口服阿米替林 药物
治疗 ； Ｂ组 ２ ６例 ， 予 口服阿米替林和膀胱灌 注肝素钠治疗 ； Ｃ组 １ ６例 ， 予膀胱液压扩张与膀胱逼尿肌 内注射肉毒素 Ａ治疗。治疗 ３个月后 比较 ３组 的疗效 、 排尿次数 、 最大 膀胱 容量 、 间质性膀 胱炎症 状指数 （ ｍｓ ｉ ） 、 盆腔 疼痛 和尿 频评 分（ Ｐ Ｕ Ｆ ） 及生 活质 量 的情 况。 结果 治 疗 ３个 月后 ， 症 状 显 著缓 解 率 由高 到低 依 次 为 Ｃ组 １ ０ ０ ％， Ｂ组
２～ ３次 ， ３个 月 为 １ 个 疗程 。Ｃ组 予 硬膜 外 麻醉 膀 胱
膀胱炎的怎么治疗方法
膀胱炎的怎么治疗方法
膀胱炎的治疗方法主要包括以下几个方面：
1. 利尿和排空膀胱：多喝水，经常排尿可以帮助清洗膀胱，排除细菌和毒素。
2. 使用药物治疗：医生可以根据病情给予抗生素来杀灭感染膀胱的细菌，常用的抗生素有氟喹诺酮类、β-内酰胺类等。
3. 缓解症状：可以使用止痛药（如扑热息痛）或非处方的尿道麻醉剂（如利多卡因凝胶）来缓解膀胱炎引起的疼痛和不适。
4. 避免刺激性食物和饮料：避免摄入刺激性食物和饮料，如咖啡、茶、辣椒、酒精等，以防止刺激膀胱加重炎症。
5. 保持个人卫生：保持外阴干燥清洁，勤换内衣内裤，不憋尿，注意避免患上感冒等感染。
6. 中医中药治疗：有些中药可以具有消炎、杀菌和抗病毒作用。
请咨询中医师或配药师的意见。
需要注意的是，如果膀胱炎症状严重或反复发作，建议及时就医，接受专业医生的医学指导和治疗。
间质性膀胱炎协会性膀胱炎协会治
对（（治NK疗于leo间间unr质质oopn性性itn膀膀in））胱胱以和炎炎及氯引引肌硝起起松安的的剂定轻中如到度安和中定间度和疼巴痛氯，芬三治环疗抗慢抑性郁疼药痛疗。效可不以错用。短此效外阿，片目类前止还痛用剂抗如痉V挛ico药d如in和gaPbearpceoncetitn 歇疼纽D.性痛,约<疼。<，痛【间19。B质9rOo性7ox年膀ky。oc胱off本n炎t文i疼n的、痛再M的S版原－可因C从和on间治ti质疗n和性>D膀>u，胱ra1炎g7e协7s－会ic1是获9长取2页效。。止】S痛a剂nt，，用GR于（治膀疗胱间炎质，性L膀pp胱in炎co引tt起－的Ra慢v性en重，度 X痛FaorL）dm其、u。a它Lraxe口、和vs服Hiny药）tr,；i包nH；括2白：阻三断止烯剂痉抑，挛制如药剂T（如aUgSariimsnegedut）和la和iZr（a抗nm副tao交cn；t感e尿l神u碱k经a化药s剂t）物B；（ic以Ditre及at和r复oPl合、ol药Dyci物tirto，rap如－anUK；rim肾a上x（腺止阻痉滞挛剂兼，镇c 可抗能抑郁需药要，联E合l使m用iro这n些；治疼疗痛方加法重。时例加如服，一一种项阿个片体类化镇的痛治药疗。计划应包括饮食调控及联合使用规律使用三环
症尿尿状并频。不：部能白除分天外患或间者夜质在间性夜频膀间尿胱出（炎现严的轻重度诊者、断每中。2度4小或时重多度达频6尿0次，）而。另早一期些或患轻者症不病出例现，起频夜尿排有尿时的是现唯象一。的不存在起夜排 尿急：感觉必须立刻排尿，可能还伴有疼痛、紧迫感或痉挛。 睾疼丸痛、：阴可囊出和现于/或盆会腔阴、疼膀痛胱以、及尿射道精或痛阴。道无。疼疼痛痛不还能经排常除和外性间交质相性关膀。胱间炎质的性诊膀断胱。炎的男性病人可能会出现 过其敏它反异应常以：及一胃些肠患道者不除适了。上间述质较性常膀见胱的炎症似状乎外和，某还些报其告它了的肌慢肉性关病节和痛疼、痛偏综头合痛症、， 如－<<5阴间7道页质前】性庭然膀炎而胱、很炎纤多：维患与肌者其肉仅它疼有慢痛膀性和胱疾肠症病激状和惹。疼综痛合综症合等症存无在法目解前释尚的无关法联解>释>的，关泌系尿。学【杂A志la增gi刊ri，，等1997年5月，52
间质性膀胱炎的诊治
间质性膀胱炎的诊治作者：罗耀辉刘乔保肖民辉杨晓华【关键词】膀胱炎【摘要】目的探讨间质性膀胱炎的诊断及治疗。
方法对16例根据犯仙0〖诊断标准确诊的间质性膀胱炎的临床资料进行分析，总结该病特点及治疗效果。
结果16例间质性膀胱炎中仅2例膀胱镜检查发现典型此而^溃疡。
无溃疡型14例（87.5%),膀胱平均容量285^1;组织病理学报告4例（25%)无炎性表现;12例膀胱呈非特异性炎性表现，其中有3例（25%)是粘膜下层组织肥大细胞明显增多。
治疗用膀胱药物灌注，膀胱水压扩张及口服药物。
12例（75%)有明显效果。
结论间质性膀胱炎诊断及治疗困难，易误诊而延误治疗，诊断主要依靠典型临床症状，膀胱镜检及病理学改变。
大多数病人采取综合治疗可获得明显疗效。
关键词膀胱炎间质炎症诊断及治疗.【Abstract】 Objective To investigate the clinical diagnosis and treatment of interstitial cystitis. Methods We retrospectively analyzed the diagnostic and treatment data ofl6cases withinterstitial cystitis, as well as summa ~ rized the characteristics and curative effects of this disease. Results Cystoscopic examination revealed2patients with classic Hunner' s ulcers andl4 (87. 5%) patients non-ulcer. Subtypes. Average bladder capacitywas285ml. Histopathological examination revealed no inflammationin4patients (6. 3%) and chronic inflammation inl2. Of them3patients(25%) were with an increase in mast cells in thesubmucosa. 12patients (75%) showed the evident effects by treatment of intravesical administration, hydrodistention and takingmedicines. Conclusion The diagnosis and treatment of interstitialcystitis is relatively difficult and apt to misdiagnosis. Diagnosis ismainly relied on specific symptoms, cystoscopy andhistopathololgy. The majority of patients may obtain the good effectsby compound therapies.Key words cyctitis interstitial inflammation diagnosis andtherapeutics间质膀胱炎（IC)是一种特殊类型的慢性膀胱炎。
间质性膀胱炎的治疗进展
间质性膀胱炎的治疗进展
*导读：IC是一个综合征而不是一个具有单一发病机制的疾病,因此不可能使用单一的治疗形式。
……
尽管文献中报告的治疗方法有183种之多,但迄今被美国食品与药物管理局(FDA)批准用于IC治疗的只有口服戊糖多硫酸和膀
胱内灌注二甲亚砜(DMSO)。
两者发挥作用的具体机制不明。
多数研究观察到口服戊糖多硫酸可以改善病情,但增加剂量并无益处,而延长治疗时间似乎有效。
近来报道使用环孢素可能比戊糖多硫酸更有效,但不良反应增加。
有研究认为使用三环类抗抑郁药阿米曲替林和局部麻醉药利多卡因进行神经调节对治疗IC有效,但是使用更特异的辣椒辣
素和树脂毒却未能获得一致结果,因此对这类药物的疗效尚需要进一步评估。
骶神经根调节是治疗尿频最成功的方法之一,但在IC治疗中的
地位仍需评估。
许多症状严重的IC患者可通过麻醉剂缓解症状,但目前对于在本病患者中长期使用麻醉剂存在争议。
其他的辅助治疗包括骨盆底部物理治疗以及对抑郁和疼痛的治疗未被充分
使用。
IC是一个综合征而不是一个具有单一发病机制的疾病,因此不可能使用单一的治疗形式。
目前常用戊糖多硫酸结合抗组胺药和三环类神经调节剂联合治疗。
尽管目前本病的治疗并不理想,但对
APF的研究有希望为本病的诊断和干预带来新的进展。
一些新的治疗,比如基因治疗、肉毒杆菌毒素和新的膀胱上皮涂层策略,
尚在进行动物实验或前瞻性研究中。
但即使采用现有的治疗方法,早期发现和治疗本病也可以改善预后并减轻患者的负担。
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
如膀胱疼痛或烧 灼不适引起的盆 腔不适、腰背酸 痛、心悸、眩晕、 头痛、焦虑、抑 郁、睡眠困难等
症 状 指 数
间质性膀胱炎患者评分 一般在6分以上
诊断(Diagnose)
治疗方案：膀胱液压扩张 （ Hydraulic distension ）
研究表明膀胱液压扩张后尿中肝素样类上 皮因子（HB-EGF）增加，有助于膀胱粘膜生长， 对膀胱容量大于150ml的患者效果更佳
结语
谢谢大家！
方法
临床症状：疼痛及尿频、尿急 水扩张后膀胱出血点或溃疡 钾离子敏感试验（PST） 排他性
膀胱镜检(Cystoscope)
目的
Hunner氏溃疡 的诊断
膀胱随机活检除外膀胱 原位癌或其他局部病理 病变
麻醉下水扩张治疗
镜检方法(Method)
麻醉下行膀胱镜检 此时膀胱无异常发现 80-100cm H2O压力向膀胱内灌注 直到水流自然停止
组织学(Histology)
缺乏特征性的 病理组织学表现
炎症反应轻微， 可见的如肥大细 胞浸润、粘膜下 肉芽组织形成、 充血水肿或出血， 部分患者可见上 皮溃疡形成或剥 脱、逼尿肌纤维 化
临床表现(Clinical manifestation)
疼痛
非膀胱症状
部位：膀胱区或下腹部、 耻骨上，也可表现为尿 道、阴道、盆底或直肠 疼痛
2
手术治疗（10%）： Hunner溃疡电切 术、骶脊神经根 切断术、膀胱周 围去神经术、膀 胱部分切除术、 膀胱松解术、膀 胱扩大术或全切 术及尿流改道术
3
治疗方案：等待观察（Observation）
对于轻度的间质性膀胱炎患者，如夜尿1-2 天，白天每2-3小时排尿一次，轻微膀胱疼痛， 对生活无明显影响者可以等待观察
治疗方案：饮食调节（Diet regulation ）
避免食用含钾丰富的食物，如橘类、西红 柿、巧克力、咖啡等，以免肾脏排钾增加而使 尿钾浓度升高，同时避免辛辣刺激性食物加重 或诱发疼痛症状
治疗方案：行为物理治疗（Physiotherapy）
行为治疗：定时排尿、逐步延迟排尿、饮 水控制和盆底肌训练等，行为治疗的近期有效 率达50%，但对症状较严重者欠佳。
保持灌注2-5min
见膀胱粘膜点状出血或/和 出现Hunner溃疡则诊断成立
水扩张后镜检
草莓样/点状出血或 Hunner溃疡（10%）
3个象限以上,尤其是前 壁和左右侧壁各出现10 个以上的出血点即可 诊断为间质性膀胱炎
敏感性 42%
膀胱水扩张后 尿液中肝素样 类上皮因子 （HB-EGF）增 加，其可修复 损害的膀胱粘 膜上皮 ,从而 使症状减轻
鉴别诊断(Distinguish)
膀胱炎
尿道憩室
1
2
3
输尿管下段结石84 Nhomakorabea前列腺炎
7
6
5
神经源性疼痛 （腰椎间盘突出）
阴道炎 盆腔脏器肿瘤 骨骼肌疼痛
治疗方案（Treatment）
目前尚无完全治 愈间质性膀胱炎 的方法，治疗的 目的是改善症状 及延缓病程进展
1
非手术治疗 （90%）：饮食调 节、口服药物、 膀胱液压扩张、 膀胱内药物灌注、 经皮骶神经电刺 激
膀胱粘膜上皮部分破坏 及通透性增加
病理生理
血尿屏障的破坏：氨基葡聚糖 （GAG），主要成分为透明质酸、肝 素、硫酸软骨素 、硫酸皮肤素、硫 酸角蛋白，可以防止尿素、钾离 子 、钙离子等尿中毒性物质损伤
粘膜下神经和肌肉
粘膜下层结缔组织中起中和毒 素、保护和修复作用的透明 质酸类物质返渗入尿中流 失，减弱了膀胱壁对毒性 物质的防御作H用unner,1915
间质性膀胱炎的诊疗策略
流行病学(Epidemiology)
年龄：30-50岁 性别：女性高发 （男女比 1:9） 种族：白种人高 发，黑种人罕见
病因(Pathogeny)
有毒物质 感染 炎症 组织缺氧 自体免疫机制
尿路上皮功能障碍
病因
神经生物学机制 肥大细胞的激活
一氧化氮代谢
尿路上皮生长被抑制
病理生理(Pathophysiology)
1 后从尿管流出。
然后灌入氯化钾溶液， 灌注过程中再让患者 评估疼痛及尿急程度， 如果前后比较大于2 分的话就提示PST 阳 性
将氯化钾溶液停留 5min(除非发生严重 的疼痛)，将尿管拔 掉后让患者排尿，再 次评分。如果整个过 程患者并无疼痛或尿 急可认为PST阴性
2
3
美国国家糖尿病、消化及肾脏病协会 (NIDDK)制定的纳入标准及排除标准
镜下表现
钾离子敏感试验（PST）
理论基础：间质性 膀胱炎患者膀胱粘 膜通透性增加，尿 中钾离子通过不完 整的粘膜屏障使粘 膜下感觉神经末梢 去极化从而产生疼 痛症状
症状缓解期PST 可为阴性
PST
敏感性80%
假阳性：急性膀 胱炎和放射性膀 胱炎
PST操作方法
患者清醒未麻醉情况 下，细尿管往膀胱内 缓慢(2-3min)注入 40ml室温无菌生理盐 水，在灌注过程中让 患者使用0-5分来评 估基础疼痛或尿急程 度，将液体保留5min
物理治疗：主要形式有生物反馈治疗和软 组织按摩，适用于间质性膀胱炎合并肛门直肠 功能异常或盆底疼痛者
治疗方案：口服药物（Oral drugs）
硫酸戊聚糖---唯一经美国FDA批准的能有 效缓解间质性膀胱炎膀胱疼痛和不适的口服药 物，有助于修复和恢复膀胱上皮结构；100 mg tid
三环类抗抑郁药：阿米替林、丙咪嗪等， 可阻止组胺的释放，降低膀胱粘膜下层感觉神 经兴奋性，起到镇痛、扩张膀胱容量的作用