Pain can be the prominent symptom of IC and can also be the 'prominent feature' of their lives. IC pain can be compared to the pain of chronic Cancer patients that are in the advanced stages.

In this chapter it will explain the pathophysiological basis for severe chronic pain.

The pain that accompanies many IC Patients is not considered normal pain. and because IC patients differ in their pain than normal pain patients it is often hard to get appropriate pain treatments.

Inflammation of the bladder can cause hypersensitization to the bladder nerves. causing hyperalgesia (perception of high intensity pain in response to low intensity pain stimulus). Because of the inflammation on the bladder nerves the nerves in the bladder generate pain signals due to the increase of intravescular pressure. (known as Allodynia)

If there is no analgesic treatment for a period of time, the pain signals that are sent to central nervous system can cause damage to the dorsal horn of the spinal cord.

If the pain is untreated, over the years the 'pain signals become embedded in the nervous system' and even if your bladder is removed you will still experience this type of pain.

Quoted from page 178 Dr. Brookoff

'Medical training, with its strong emphasis on cure, may sometimes reduce our attention to patients who can not be cured. This certainly applies to many patients long standing IC, for whom traditional therapy is often unsatisfactory (8). Patients with severe pain caused by IC may not be cured, but their pain can be healed (9). When there is no good treatment for a patient's interstitial Cystitis, there will always be an effective treatment for pain (10). To leave a patient to suffer with treatable pain is a show of disrespect for that patient and a breach of our ethics as caregivers (11). When confronted with a patient with severe pain of IC, physicians often ask themselves whether the patient should receive treatment for pain. Perhaps the question should be 'Why should this person be left in pain?' (9)'

A study was done in reference to pain with IC. The study showed that 55% of Patients had chronic pain daily and another 57% stated that their pain was severe or excruciating.

Another study that was performed at Duke University noted that the pain lasted over 7 years.

According to the McGil Pain Inventory, IC Pain can be found to be worse than patients with advanced cancer.

Because of untreated pain, IC Patients seem to have a lower quality of life.

There are 3 types of pain:

1. Somatic pain - starts in the skin, muscles and bone and is usually localized. It is caused by incision or burns or any other destructive .
2. Visceral pain - This is the most common pain found in IC Patients. The pain is caused my inflammation distention or increase amounts of pressure. It is not localized and produces stronger autonomic and affective responses.
3. Neuropathic pain- 'can be a component of the pain of IC' It is caused mostly by the disruption of nerves. This type of pain can cause the following pain symptom, burning, shooting pain and/or electric component to the pain.

When your bladder is inflamed the sensory functions of your bladder change. The captivity of the bladder gets smaller and the urge to urinate gets stronger. You may also experience that a small amount of urine will make your bladder feel full.

The urge to urinate (micturition) is associated with pain and discomfort. The inflamed bladder has a totally different type of pain that of a non-inflamed bladder. With the inflamed bladder the 'Burning' has a disagreeable character. Such as with the non-inflamed bladder the pain can be often overcome. It has been suggested that the sensations form the bladders of healthy bladders and the sensations of the inflamed bladder are carried along two different pathways.

Inflammation in the bladder of Chronic IC patients can cause hypersensitization of chemosensitive (susceptible to the action of a chemical) bladder afferent nerves.

This can be caused by one of the many combinations.

1. Exposure to of the bladder wall to urinary toxins
2. persistent infections
3. or release of other vasoactive substances by activated cells such as mast cells.

Polypeptide hormones that are formed locally in the tissues and have their chief effect on smooth muscle, they act as vasodialation of small arteries and are considered to play a major role in the inflammatory process and is an important mediator of pain in the visceral organs. This will than cause hypersensitization resulting in pain signals from a non-painful stimulus.

The bladder wall stimulates afferent pain nerves which pass from one neuron to another, which would be the dorsal horn cells in the spinal cord. The two main chemical transmitters of pain signals are glutamate and asparatate.

Stimulation of the opiod receptors in the spinal cord can slow and or stop the nerve impulses from one place to another. This is one of the methods that with a high dose of systemic or intraspinal opiods block pain.

'Pain signals from the spinal cord are processed at different sites in the brain' they are as follows:

1. the limbic system
2. the thalamus and
3. the cortex.

The pathways of the brain can explain to us the reason that pain messages can be magnified by, depression, anxiety, fear or helplessness. These reactions can influence the expression at the spinal sites because of the neuohumoral changes associated with depression, etc.

The limbic system, provides a physiological explanation on why visceral pain can cause patients to 'lose control' This can explain to us why, the treatment of trying to reduce anxiety and depression are useful components of pain treatment.

Because of this, many physicians are prone to think that when these treatments work, that it is totally 'psychological' and that the patient is imagining the pain. Many physicians also feel that this is a way for us to get intoxicating drugs.

By understanding the neuronal pathways of pain, it explained to us why there is a success rate with 'analgesics, antidepressants, anxiolytics, relaxation training, and hypnosis in decreasing pain in IC.'

Dr. Brookoff states, that ' The most important part of assessing pain is listening and believing our patients'

Many of the IC patients he has seen have been labeled 'drug seeking' because they were told by their medical providers that their pain was not real.

The following definition of pain was taken from a text book on nursing. I quote' Pain is whatever the experiencing person says it is, existing whenever she or he says it does' (57)

Functional Assessment of Pain The patients report of the sensation of pain

• a pain diary can help objectify pain
• use numerical pain scales
• Note when the pain flares (car travel etc.). This diary can identify the pain levels and help with the effective preventive pain strategies

1. Functional status at work: note the number of days a patient can work, the number of days the patient takes off from work because of pain, and the specific types of activities that seemed to promote your flare
2. Functional status at home: Pain patients seem to stop doing the important activities at home or that are done outside of the home. In some cases of successful treatment, you may have discomfort but the activity levels will rise. A journal of activities can help in the treatment progress
3. Emotional State of the patient during office visits
4. Somatic preoccupation This is when the patient seems to focus mainly on the bodily symptoms and does not focus on other issues. It is recommended that a family member assess this.
5. Use of analgesic medications 'If the patient is given as adequate supply of effective short acting 'as needed' pain medications and told to use them whenever there is pain then the number of pills consumed becomes a measure of pain.'

Setting goals are a very important factor. It involves the doctor taking time to evaluate the life of the patient. It also involves, find out the missing links of the patients life so that they can be restored.

Also the pain intensity, this enables the patient and doctor to notice the urgency in which pain relief is needed. It contributes to the medication selection, the dose and the route of administration.

'The goal of pain treatment is to enable the patient to reclaim their life.'

The following segments of this chapter are related to:

1. morphine (MS Contin)
2. hydro morphine (Dilaudid)
3. levorphanol (Levo--Dromoran)
4. methadone (Dolophine)
5. fentanyl (Sublimaze)
6. oxycodene
7. hydrocodene

For moderate opiod medications are as follow:

1. oxycodene w/ acetaminophen or aspirin
2. hydrocodene w/ acetaminophen or aspirin
3. Codeine

Long Acting Opioids

1. levorphanol
2. methadone
3. fentanyl patch

Titration of Opioids

Patients who are taking long acting opiods (time released) should also be supplied with a 'rescue drug' and prescribed as an 'on needed basis' These are given to treat the pain that breaks through the regular medication cycle.

Also in this section are the following Categories: Side effects of Opioid Medications & Tolerance to Opiods

Physical dependency on opioid drugs can become a factor to many that are taking these drugs for a period of time. Dependency is defined as' a condition in which, after continued use, abrupt withdrawal or reversal of a medication will cause physical symptoms (ie., withdrawal symptoms)

This can be overcome by tapering off on the medication.

Because of the factor of drug abuse, physicians do not feel comfortable prescribing these medications.

Drug abuse is, using a medication for unauthorized medical problems and for own personal use.

If a patient is using these drugs, to maintain life, promote function, and to provide comfort from pain so they can get back their life, than the are using these drugs appropriately.

If a Person is using these drugs to escape, existing problems such as family problems, social problems or financial problems, than the patient is abusing theses medications.

Addiction comes by abusing drugs, Medical treatments which require opioids does not cause the development of addiction. If you are prescribed a medication for the relief of pain, and become addicted to it, you than have previously, before starting the use of the pain meds were a addict.

The labeling of a patient as a drug abuser can alienate a person from family and the medical profession and cause isolation. But the most important fact, is that it can prolong the pain of suffering.

Because many physicians, will accuse patients, of being addicts because they feel that the patient is manipulative or obsessive, are denied proper pain treatment. This is known as Pseudoaddiction. Pseudoaddiction related to untreated pain can be treated effectively and legitimately.

The next few sections regard :

1. Antidepressants : Amitriptyline, imipramine and doxepin
2. Anticonvulsants and Antiarrhythmics for treatment of neuropathic pain.

• Intravenous lidocaine
• lidocaine
• Mexiletine
• Carbemazepine

1. Benzodiazepines
2. Other drugs with Analgesic Effects

• Hydroxyzine (antihistamine)
• Clonidine
• Phenothiazines

1. Local Anesthetic Procedures

The TENS Unit or neurostimulators, can interrupt the pain signals found in IC. There has been success with IC Patients that tend to have smaller bladders that are ulcerated.

Relaxation training, hypnosis, and cognitive therapy (pertaining to the mental process of perception) Support groups, Spiritual Help etc.

Dr. Brookoff writes about the history of pain treatment, and states that 'the concern of physicians for pain relief is relatively new in our history'

The primary role of medicine was to save lives and the fact to control pain was secondary.

He ends his chapter with this statement.

'for many patients who have suffered with severe pain from Interstitial Cystitis for years, it isn't the pain that has been intractable, it is the physician.

Our Acknowledgements