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Lifestyle & Exercise > November 2002
Understanding The Pain
of IC: Physical & Emotional
Who doesn't remember
their first bout of IC? The on-going relentless pain (pressure
and/or frequency) was different than any other. It was frightening.
There seemed to be nothing to relieve it and finding the right doctor
to help was just as frustrating. Finding the right treatment or medication
added to the frustration. But in time, with the appropriate treatment
and proper diet, the painful symptoms seemed to calm down. When the
pain level decreased, there was relief, even though there seemed to
be an on-going awareness of the bladder. The relief was relative to
the intense symptoms first experienced.
of us get used to living with a level of pain. Some patients describe
an ongoing pressure, which they don't consider pain. However, this
pressure is actually considered pain. Although it may not compare
with the more severe symptoms of IC, there is a sense that it is not
normal to experience this pressure or bladder awareness. Again, compared
to a flare-up, it is bearable and we learn to live with it. But, had
we never experienced this pressure before, it would certainly get
all of our attention.
causes the pain, pressure and frequency of IC?
IC patients have increased levels of mast cells in their bladder walls.
Mast cells play a roll in allergic reactions by secreting histamine
and other substances that cause inflammation. When mast cells release
histamine abnormally, which they do in IC patients, they trigger IC
and Nerve Related Inflammation
Nerve related inflammation results from mast cell degranulation (when
mast cells release inflammatory histamine and other substances). Sensory
nerve fibers are located close to masts cells. When mast cells degranulate
they cause over stimulation of the sensory nerves. This over stimulation
causes a release of pain producing substances, such as substance P.
Substance P furthers the nerve inflammation by activating mast cells,
and the pain cycle goes on. There may be patients who may experience
nerve related inflammation from other processes.
Substance P aids the transmission of pain signals throughout the body
and is responsible for the amount of pain one feels. Substance P is
released from nerve endings when one experiences a painful stimulus.
High levels of substance P are found in patients with chronic pain
conditions, such as IC and fibromyalgia (FMS), and may cause low pain
thresholds to pain. This is not to say that patients with these and/or
other conditions aren't able to handle pain. Chronic pain patients
usually learn to handle pain incredibly well. (Substance P also appears
to trigger further mast cell activity.)
and Mast Cells
The bladder has a surprisingly high number of estrogen receptors which
make the bladder sensitive to variations in estrogen levels found
during the menstrual cycle. Why? The bladder, urethra, vagina and
vulva are all part of the urogenital sinus, and began as one small
cell in a fetus which later divided to create each organ. Thus it
is not suprisingly that the bladder can be so sensitive to estrogen.
High estrogen levels activate mast cells and can cause IC patients
to experience an increase in pain, pressure and frequency. Many IC
patients endure an increase in bladder symptoms during the times of
the month when their estrogen levels are high, particularly in the
days before their period. However, normal estrogen levels have beneficial
effects too. Estrogen helps strengthen the bladder lining, thus helping
to protect the bladder wall and nerves from bacteria, and other irritating
substances in some patients.
Patients who suffer with chronic bladder infections (urine cultures
that test positive) also suffer from the impact that bacteria has
on the sensitive bladder tissues and nerves. Bacteria can "burrow"
into the bladder wall thus creating small tunnels or wounds. Just
as with the wounds of IC, these "tunnels" lead to the sensitive
nerves and muscle. When urine enters, irritation commonly occurs.
On an IC bladder, an infection can be excruciating. Even after the
infection is gone, it may take several weeks for the inflammation
in the bladder to settle down. IC symptoms worsen when infectious
agents come into contact with the bladder wall.
Foods, Drugs, Chemicals, and the Environment
Because the lining of the bladder in IC patients is damaged (patchy
and leaky from cellular destruction), bladder tissue and nerves are
exposed to many drugs and chemicals, toxins and bacteria, acids and
amino acids in foods. These irritants invade the bladder tissues and
create an inflammatory reaction. One common source of irritation and
pain is acid (such as in cranberry juice, sodas, coffees, etc). Nearly
every IC patient learrns very quickly that they must modify their
diet to avoid irritating the bladder further, including reducing acidic
foods, alcohol and salts. Click
here for more information on the IC diet.
Inflammation in the bladder causes changes in sensory function. Even
small amounts of urine can irritate IC patients' bladder walls and
nerves, and cause pain, pressure, urgency and frequency. More advanced
IC patients may develop bladder walls that are scarred and stiff,
which greatly reduces their bladder capacity.
In general, the
bladder performs (contracts) best when it is just full enough to signal
the need to void. When it's too full, the bladder may become distended
(as it can during the night, making the first morning void difficult
to start). The opposite is also a problem, because the bladder doesn't
contract well when there's only a small amount of urine.
The pelvic floor
muscles are the only muscle group in the body involved in a major
bodily function - urination. If the muscles are weak, the patient
will likely be incontinent. If the muscles are tight, the patients
may find it difficult to urinate or to start their stream. Why? Urination
occurs through the relaxation of muscles. In IC patients, the pelvic
floor muscles are often very tight thus making it hard to urinate,
to keep a stream going, and to empty the bladder completely. Straining
to urinate should always be avoided. Straining can cause irritation,
burning, bladder and even more pelvic floor spasms that lead to urgency
and frequency. Some experts believe that pelvic floor dysfunction
(PFD) causes IC, and other experts believe that IC causes PFD. (See
our columns on Pelvic Floor Dysfunction.)
Causes A Specific Type of Pain
Medtronic describes pain as a process, which occurs when pain receptors
in the skin and other tissue send an impulse through the spinal cord
to the brain. The brain then registers the sensation of pain, not
the point of injury.
is the type of pain produced by the organs in the body. IC pain is
visceral pain. Experts suggest that IC may be a chronic visceral pain
syndrome. There is much arousal and emotion associated with visceral
pain, because it sends messages to the part of the brain called the
limbic system. The limbic system regulates arousal and emotion, pleasure
and pain, smell and sexual desire.
is different than somatic pain, which is experienced after fracturing
a bone or a surgical incision. It's not really possible to keep a
"stiff upper lip" or use "mind over matter"
with intense visceral pain. The messages from the bladder can make
a patient feel out of control, upset, emotional, depressed and hyper-vigilant
(the need to be on guard against harm). Treatments for IC are often
geared to calm the pain and the symptoms by preventing pain signals
from reaching the brain.
IC is a
Chronic Pain Condition
Chronic pain disables more people than cancer or heart disease. Chronic
pain can result from a previous injury that has long since healed,
or it can have an ongoing cause. The American
Chronic Pain Association defines chronic pain as pain that continues
a month or more beyond the usual recovery time for an illness or injury,
or pain that goes on over months or years as a result of a chronic
condition. Chronic pain conditions are not relieved by standard medical
According to the
research of Allan Basbaum at the oUniversity
of California, San Francisco, "With prolonged injury (such
as IC) progressively deeper levels of pain cells in the spinal cord
are activated. Pain nerves recruit others in a chronic-pain wind-up
and the whole central nervous system revs up and undergoes what Clifford
Woolf, M.D., Ph.D., pain researcher and director of Massachusetts
General's neuroplasticity lab, calls central sensitization."
anxiety are physiological consequences of chronic pain. There are
similar disturbances in the brain's chemistry with both chronic pain
and depression. Quality of life can diminish due to pain and lifestyle
IC requires strict coping skills. To cope with IC, a patient must
first accept that she, or he has a chronic condition that must be
dealt with (this is not to say that one has to except intense pain).
However, there are many factors that play into a patient's acceptance
of IC. These factors include background, cultural values and beliefs,
the role one plays in her, or his family, career demands, self-expectations,
age, how one has dealt with illness in the past, reactions of family,
friends, employers, co-workers, and of course, doctors.
It can be ver
helpful to participate in an IC
support group. When you meet other patients, you can offer learn
excellent coping strategies from them... especially if you are newly
diagnosed. You can find other coping and flare management strategies
in the ICN Patient Handbook!
Gaye is an author and IC patient & support group leader who
has been involved in IC work for years. In 1990 she published
"Stretch Into a Better Shape" and produced a stretching
and exercise video for IC patients in 1993. She is a specialist
in Aston-Patterning movement and muscle re-education.
over ten years of clinical and health care management position.
He is currently the Administrator of Maison Hospitaliere, located
in New Orleans. Andrew holds a Ph.D. in Special Education, a
M.A. of Health Adminstration, M.A. of Clinical Psychology.
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