January 2022 Issue

CPE Monthly: The Science on Interstitial Cystitis and Bladder Pain Syndrome
By Tony Pipkin, MS, RDN
Today’s Dietitian
Vol. 24, No. 1, P. 46

Suggested CDR Performance Indicators: 8.2.3, 8.2.4, 10.2.14, 10.5.3
CPE Level 1

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Few conditions remain as elusive in medical care as interstitial cystitis (IC). Multiple attempts at classifying the enigmatic condition have been made since Alexander Skene initially identified the condition in 1887. Subsequent work in 1915 by Guy Leroy Hunner, a Johns Hopkins gynecologist, identified IC as erythematous patches of ulceration, and further nomenclature evolved to describe the condition as “Hunner” (less common and usually more painful) or “non-Hunner” lesions. In 1949, research by John Hand described IC as the hemorrhagic damage to the bladder’s submucosal layers. He graded the lesions into three sequential disease stages with a progressive diminution in bladder storage capacity.1

Other names for IC include bladder pain syndrome (BPS), painful bladder syndrome, hypersensitive bladder, and ulcerative bladder (Hunner and non-Hunner). Unfortunately, the condition is a diagnosis of exclusion, and no definitive straightforward treatment protocol exists. The number of global guidelines developed in recent years attest to the challenges in adequately describing the disease, including accepted definitions, pathology, diagnostic tools, and evidence-based therapies.2-4

The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction define IC/BPS as a collection of varied symptoms that aren’t exclusive of one another. Symptoms may include urgent and frequent need to urinate, recurrent nocturia, and pelvic pain in the absence of proven genitourinary infection or other pathology (eg, cancer) with a minimum six weeks’ duration. Some patients describe the associated pain as being moderate to excruciating, with symptoms often having an ebb and flow, while some experience no pain at all. The bladder urothelium is a highly sensitive sensory tissue, and inflammation and hypersensitivity are suspected to be the underlying causes of IC/BPS.5-8

This continuing education course reviews the challenges of diagnosing, classifying, and treating IC, also known as BPS, and provides counseling strategies for clinicians to use when working with patients.

Etiology
The etiology of IC/BPS is multifactorial and includes a variety of malfunctions including pelvic floor dysfunction, aberrant immune or inflammatory signals, nerve hypersensitivity, and alteration of the protective proteoglycan/glycosaminoglycan (GAG) lining of the bladder.5,6 The distinction between visceral and somatic nerve conduction also may be used to describe IC/BPS as a visceral pain condition. Visceral nerve conduction is slower than that of somatic nerves, and multiple nerves of the pelvic organs have overlapping innervation. Pelvic pain due to nonbladder conditions, such as irritable bowel syndrome (IBS), may result in neural and visceral sensitization, which, over time, can result in the inability to discern the exact location of symptoms and pain.9

Research connecting diet and IC/BPS is limited, yet studies exist that show certain foods can trigger or worsen symptoms.10 The 2019 Global International Cystitis, Bladder Pain Society (GIBS) meeting featured research on the etiology of IC/BPS, results of which suggested C-fiber neuroplasticity changes, neurogenic inflammation, urothelial defect, and hypersensitive neurons as potential causes of IC/BPS.11

Pathophysiology
The pathophysiology of IC/BPS is poorly understood, but researchers have developed several theories. Genetics haven’t been adequately researched, but in one of the few studies, conducted by Warren and colleagues, adult female first-degree relatives of IC/BPS patients had 17 times the risk of prevalence compared with the general population. They also reported a greater frequency of IC/BPS among monozygotic vs dizygotic twins. Another theory is inflammation contributes to mast cell activation with subsequent sensory neural stimulation and suprapubic pain and urination problems.12,13

Deficient GAG urothelium lining of the bladder that results in permeability and irritation is a third theory of IC/BPS.12 The GAG lining normally contains heparin, and its unexplained absence is suspected as the cause of enhanced permeability. An interruption of the protective lining enables diffusion of urinary solutes across the suburothelium, irritating nerves and generating pain and hypersensitivity. The damage may yield incorrect mastocyte stimulation in bladder suburothelial layers.

A fourth concept by Davis and colleagues is associated with the Tamm-Horsfall protein, which is of renal origin and known to protect the urothelium lining of the bladder. Defects in this protein are suspected to result in inflammation and pain.12 Finally, chronic bacterial infections, malfunctioning autonomic nervous system, and autoimmune disorders are other suspected causes.1

Evidence continues to mount on the gut microbiome’s health significance and interaction with various organs. Recent microbiota research has alluded to a relationship between the gut and IC/BPS. Magistro and colleagues posit that a dysbalanced gut microbiome has an essential role in the pathogenesis and management of IC/BPS.14,15 And urinalysis studies have shown that the urinary tract has its own unique microbiota; samples from healthy controls have shown stark differences compared with samples from those with urge urinary incontinence, neurogenic bladder dysfunction, IC/BPS, and nonbacterial prostatitis.16,17

Prevalence and Diagnosis
International disparities in nomenclature, diagnostic definitions, and treatment guidelines for IC/BPS continue. A 2018 review of guidelines by Malde and colleagues included unique and varying definitions of IC/BPS. Numerous organizations, including the AUA, Canadian Urological Association, European Association of Urology, International Society for Study of BPS, International Association for the Study of Pain, International Consultation on Incontinence, International Continence Society, East Asian guideline, and Royal College of Obstetricians and Gynecologists/British Society of Urogynecology, all provide varied information and recommendations.4

A 2009 study determined that the US incidence of IC/BPS is 2.7% to 6.5% among adult women (3.3 million to 7.9 million).18 The incidence is five-fold greater in women than in men. However, Suskin and colleagues enhanced the existing definition and added the NIH-Chronic Prostatitis Symptom Index criteria to determine that the prevalence and overlap between IC/BPS and chronic pelvic pain syndrome/chronic prostatitis in men is 2.9% to 4.2% for IC/BPS and 1.8% for chronic pelvic pain syndrome/chronic prostatitis, equating to a much higher incidence in men than previously believed.19,20

The presence of recurrent symptoms of urinary tract infections accompanied by negative bacterial cultures suggests IC/BPS. In addition, patients presenting with subacute or chronic pelvic pain who are otherwise undiagnosed should be considered as having IC/BPS. The validated Pelvic Pain and Urgency/Frequency Index is a useful screening tool. The O’Leary-Sant Interstitial Cystitis Symptom and Problem Index, as well as the Interstitial Cystitis Symptom Index, can be completed by the patient and are useful tools in diagnosis; all are available from the Interstitial Cystitis Association (ICA). The O’Leary-Sant index includes four domains—pain, urgency, nocturia, frequency—that assist in determining the severity of symptoms and guide the treatment plan.1,9,11,21,22 Recommendations stemming from the GIBS meeting stated that, in addition to a thorough history and physical examination, a cystoscopy is required for a definitive diagnosis of IC/BPS.11,22

Comorbid Conditions
The frequency of comorbid conditions with IC/BPS is of interest to dietitians, as medical care often overlaps and clinicians must integrate the multiple conditions into the nutrition care plan. The overlap of conditions can generate additional pain separate from IC/BPS yet indistinguishable to the patient.23

Comorbid conditions include fibromyalgia, migraine headache, vulvar/vaginal pain, sexual dysfunction, chronic fatigue syndrome, pelvic floor dysfunction, constipation, and IBS, which is the most common (~39% of IC/BPS patients). IBS symptoms include abdominal pain/distension, sensation of incomplete defecation, bowel straining/urgency, and changes in gastrointestinal motility.7,8,24-26

Management and Treatment
Global guidelines for management and treatment vary, and divergence in recommendations is common. For example, some diagnostic steps recommend hydrodistension (filling the bladder with water) and bladder biopsy, while others consider it discretionary and some even dissuade the procedure.4

For the purposes of this course, the guidelines and recommendations follow the 2015 AUA-amended clinical framework for the diagnosis and treatment of IC/BPS. The treatment plan is designed initially to be the most conservative and progress to the least conservative over the following six stages18:

• First-line: diet education, stress/behavioral management, bladder training, and pain control;
• Second-line: first-line treatments in addition to physiotherapies and oral medications (amitriptyline, cimetidine, hydroxyzine, pentosan polysulfate);
• Third-line: cystoscopy with hydrodistension, pain control, fulguration of Hunner’s lesions if present, intravesical therapies;
• Fourth-line: intradetrusor botulinum toxin A injections, sacral neuromodulation;
• Fifth-line: cyclosporine A; and
• Sixth-line: surgical diversion with or without cystectomy, substitution cystoplasty.

Several other organizations have developed approaches to the management and treatment of IC/BPS, using various guidelines and algorithms. Consensus among the recommendations includes an initial baseline approach to conservative therapies including dietary intervention, behavioral therapy, physical therapy, and stress relief.27,28

The AUA recognizes that frontline therapies are noninvasive, conservative, and behaviorally focused, citing treatments such as cognitive behavioral therapy and stress reduction, physical therapy, and dietary modifications.11,14 GIBS meeting experts recognized that a compilation of individually varied treatments typically is needed for each patient depending on symptomology, age, and comorbid conditions.11

First-Line Therapies

Nutrition Education
The relationship between diet and IC/BPS symptoms has been investigated for many years, with some success in identifying foods that may trigger or aggravate symptoms.

The ICA has identified four concepts hypothesized to explain the relationship between foods and IC/BPS symptoms. The damaged bladder wall is susceptible to toxic substances in the urine, which exacerbate the inflammation and irritation upon contact, causing increased pain. Secondly, some researchers propose that sensitive terminal nerve fibers in the bladder are irritated upon contact with urine. Thirdly, some researchers have found an increased number of pain receptors in the bladder, which, when in contact with certain compounds (eg, capsaicin), result in increased pain. Lastly, there’s the concept of organ cross-talk, which is based on the hypothesis that foods irritating the gastrointestinal tract use similar nerve pathways and send pain signals to the bladder with resultant inflammation of the bladder.1,7,10,29

Although offending compounds in foods are thought to communicate with the sensitized bladder neurons in IC/BPS and result in exacerbation of IC/BPS symptoms, successful nutrition intervention is thought to positively affect IC/BPS through this same concept of “neural cross-talk” between the pelvic organs and the intestines.7,23

There also may be a connection between IC/BPS and food allergies; some clinicians are discovering that 35% to 40% of their IC/BPS patients have food allergies.30 The ICA conducted a survey of more than 1,000 IC/BPS patients inquiring about gluten sensitivity and celiac disease. Of those responding, 12% reported having celiac disease and another 15% stated their IC/BPS flare-ups were exacerbated by gluten-containing foods. In addition, studies at Baylor College of Medicine identified a link between gluten sensitivity and IC symptoms.10,30,31

The role of diet in treating symptoms of IC/BPS is based on limited evidence, primarily anecdotal reports. A validated 2007 survey of 104 female patients identified numerous offending foods, including coffee, tea, carbonated beverages, alcohol, hot peppers, citrus fruits and their juices, and tomatoes.7

Urinary pH levels can be manipulated by eliminating foods that result in more acidic urine (eg, chocolates, carbonated beverages, specific citrus fruits, coffee). Some foods inflame the sensitized bladder neurons (eg, caffeine, alcohol, carbonated beverages, certain spices) and should be excluded. Known allergenic foods (eg, those with soy, gluten) may need to be eliminated, too. The kidneys control potassium excretion based on dietary potassium intake. Rapid urinary excretion occurs after potassium intake, so restricting high-potassium foods (eg, tomatoes) will decrease bladder wall irritation and reduce pain.7,11,32

Most IC/BPS patients benefit from some type of dietary modification. While some patients suffice with minor dietary changes, others require extensive, ongoing adjustments to keep the painful symptoms under control. Bladder flare-ups are caused by not only the foods themselves but also the quantity and frequency of their consumption. While most IC/BPS patients are female, male patients with chronic pelvic pain syndrome and persistent prostatitis can be counseled to adopt dietary changes that help alleviate symptoms.33

In December 2020, the American College of Gastroenterology published its first-ever clinical guideline on the management of IBS. Clinicians are advised to approach IBS with a positive diagnosis strategy vs a diagnostic strategy of exclusion. Recommended tests and nutritional modifications, including a low-FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet, are included.34 Additional nutrition interventions for IBS must be integrated with the IC/BPS care plan. Suggested low-FODMAP modifications include limiting fat to between 20% and 35% of calories and restricting gas-forming foods (eg, beans, garlic, onions, Brussels sprouts), sugars (especially fructose), alcohol, sugar alcohols, caffeine, and lactose, even when these foods would otherwise be acceptable on an IC/BPS diet.23

Experts at the AUA and GIBS meetings recognize that diet is a first-line treatment for IC/BPS, with many resources available to patients and clinicians.6,10,28 In a 2017 study by Oh-oka, participants were randomized to follow a control diet (nonintensive) or an IC/BPS diet (intensive) that omitted tomatoes, tomato products, soybean, tofu, spices, excessive potassium, citrus, and high–acidity-inducing substances for 30 days. After follow-up at three months and one year, the intensive group reported significant improvement in IC/BPS flares vs baseline compared with the nonintensive group.6,35

Oh-oka reported at the International Continence Society annual meeting in 2018 that a follow-up study extended the parameters to include a 1.5-year follow-up. The intensive diet group showed significant improvement in IC/BPS symptomology compared with the control group, and some patients were able to decrease oral medications (eg, amitriptyline).36

A comprehensive nutrition assessment that addresses foods that trigger or worsen symptoms and other comorbid conditions is appropriate. An effective tool for determining food sensitivity and patient comprehension is the Shorter-Moldwin Food Sensitivity Questionnaire.37

Of additional importance in dietary management is adequate hydration. IC/BPS patients may elect to limit fluid intake to avoid urinary urgency, but this may result in increased urine concentration and irritation/inflammation of the bladder urothelium. Constipation is common in IC/BPS due to decreased fluid intake, use of certain medications (eg, antidepressants, NSAIDs, opioids), and decreased physical activity, which may further exacerbate the pain associated with the condition.7

The first component in dietary management of IC/BPS begins with an elimination diet. Friedlander identified that more than 80% of IC/BPS patients exhibit sensitivity to particular foods.14 The elimination diet removes foods that may trigger or aggravate symptoms for a minimum of one month before reintroduction.

Foods and beverages that have been most strongly associated with IC/BPS symptoms include coffee (regular and decaffeinated), carbonated beverages (regular and diet), caffeinated tea, alcohol (eg, wine, beer, champagne, spirits), certain fruits (eg, grapefruit, lemon, orange, pineapple), fruit juices (eg, grapefruit, cranberry, orange, pineapple), tomato and tomato products, hot peppers, pickles, sauerkraut, spicy foods, chili, horseradish, vinegar, MSG, artificial sweeteners (eg, aspartame, saccharin), salad dressings, and pizza. Notably, Mexican, Indian, and Thai foods commonly include peppers, which are rich in capsaicin and can be proinflammatory to the bladder lining.

Foods and beverages less likely to aggravate or trigger symptoms include milk, plain water, certain fruits and dried fruits (eg, bananas, blueberries, honeydew melon, pears, raisins, watermelon), vegetables (eg, asparagus, broccoli, Brussels sprouts, cabbage, carrots, cauliflower, celery, cucumber, mushrooms, peas, radishes, squash, zucchini, white and sweet potatoes), proteins (eg, chicken, eggs, turkey, beef, pork, lamb, shrimp, tuna, salmon, mild cheeses), oats, rice, popcorn, and pretzels.7,10,36,38

Reintroducing foods that may trigger symptoms requires meticulous effort and often takes several months. It’s also important for clients to continue previous routines of exercise and healthful mindfulness during the reintroduction period. During the reintroduction phase, clients should record symptoms, which can appear as soon as 20 minutes or as late as four hours after ingesting a food. It’s helpful to reintroduce foods in three stages: very small portions followed by half-size portions the next day, and, if no flare-ups occur, then a full-size portion on the third day. Patients may find certain foods need to be eliminated long term to prevent painful symptoms.7,10

An integrative medicine approach to IC/BPS should aim to enrich the gut microbiome with anti-inflammatory and antioxidant foods containing flavonoids (eg, parsley, bananas, buckwheat, blueberries, peanut) and omega-3 fatty acids (eg, salmon, mackerel, lingonberry, eggs). Nondigestible comestibles (prebiotics) and appropriate foods, eg, low-fat yogurt and buttermilk, mozzarella cheese, mild cheddar cheese, and low-fat cottage cheese (probiotics) will help bolster a healthy gut.

Medications and Supplements
In addition to dietary interventions, the use of over-the-counter medications and supplements may provide some benefit to IC/BPS patients. Before a meal, the use of calcium glycerophosphate (Prelief) and sodium bicarbonate together or independently has been reported to ameliorate IC/BPS symptoms. Other research has shown that aloe vera concentrate, glucosamine, and chondroitin also may minimize bladder flare-ups. Oral preparations of the aloe vera plant purportedly work to replenish the deficient GAG bladder lining, which minimizes urine irritation. Use of these products may provide presymptomatic relief when consumed before a meal.39

A 2011 study by the ICA included 59 completed surveys from IC/BPS patients with 96% of respondents confirming that specific beverages and foods exacerbated their symptoms. The study identified over-the-counter products such as calcium glycerophosphate and sodium bicarbonate as providing some relief when taken with these foods.7,23,38,40

Pain relief is another area where first-line medications can help. Progressive oral medications for pain should be incorporated into the care plan, with proper precautions taken to address any food-drug interactions (eg, opioids’ side effect of constipation).

Stress and Behavioral Management
Due to the pain associated with IC/BPS, mental and physical distress are common among patients, and the social impact is significant.41 In a small study (n=15), patients with IC/BPS collectively expressed that the condition is chronically disabling, the flare-ups and pain are unpredictable and endless, and, most notably, suicidal ideation was verbalized in each cohort.42

Flare-ups occur frequently, often around menstruation and after coitus. Urination averages 16 times per day but may be as high as 40 to 60 times per day. Such symptom patterns aren’t only physically and mentally taxing but also can be embarrassing when they occur in professional, social, or intimate situations.11,27,40,41

Cognitive behavioral therapy, which is meant to help individuals challenge their thinking patterns and gain coping skills, can help IC/BPS patients understand and acknowledge the role the painful syndrome plays in their lives and develop cognitive resilience as they work through their treatment plan.11,14

Stress management exercises also can help patients cope with their condition. Mindfulness-based stress reduction, a paradigm that incorporates yoga and meditation, has been successful in managing psychosocial stressors associated with IC/BPS. An ICA-conducted internet survey revealed IC/BPS patients (n=1,967) reported symptom reduction after yoga (61%), meditation (67%), and stress reduction (81%) therapies.39,43-45

Bladder Training
Training to increase the time between urination has been successful with many IC/BPS patients when combined with other behavioral therapies. The patient focuses on suppressing the urge to urinate with a goal of extending the time between voids.39,46

Second-Line Therapies

Physical Therapy
Physical therapy is an important treatment for IC/BPS. The muscles of the pelvic region support the bladder, rectum, uterus, and prostate and attach to the sacrum, pelvis, and the terminal of the spine. Contraction of these muscles helps control bladder and bowel activity, but spasms and muscular knots (trigger points) generate varying degrees of pain for IC/BPS patients. Returning the sacrum and ilium to a natural muscular pressure confers stability to the pelvic muscles.47,48

Manual physical therapy, including pelvic floor massage, teaches pelvic floor relaxation and has been reported to be beneficial. However, exercises to strengthen the pelvic floor (eg, Kegel exercises) are contraindicated.1,48

Acupuncture
Acupuncture has been studied with some success in relieving pain in refractory IC/BPS patients. Sönmez and colleagues conducted acupuncture research over a five-week period with amelioration of symptoms at the first and third month post acupuncture. Unfortunately, the results diminished to baseline at 12 months.49

Oral Medications
In addition to drugs used for pain relief, other oral pharmacologic agents may help mitigate some IC/BPS symptoms. Pentosan polysulfate, a weak anticoagulant, is believed to strengthen the GAG lining of the bladder wall, but the medication is associated with diarrhea, nausea, upset stomach, and pain. The antihistamine and antacid cimetidine reduces gastric secretions and subsequently may decrease bladder pain. Amitriptyline, an antidepressant, blocks the reuptake of neurotransmitters serotonin and noradrenaline, therefore blocking pain neurotransmission. Side effects include constipation and abdominal weight gain.50 The antihistamine hydroxyzine affects mast cell degranulation of the bladder wall and reduces urinary frequency, nocturia, and pain; constipation and dry mouth are potential side effects.18,51

Third-Line Therapies
More aggressive therapy is an invasive cystoscopy with hydrodistension under anesthesia, which is used to confirm bladder wall pathology with fulguration of ulcerative Hunner’s lesions if present, although less than 10% of patients have been documented with these lesions.1 Intravesical therapies involve the instillation of various pharmacologic agents directly into the bladder via catheter. Agents infused have varying grades of recommendation and require close medical management. Examples of agents include dimethyl sulfoxide, onabotulinumtoxinA, pentosan polysuflate, hyaluronic acid, chondroitin sulfate, heparin, lignocaine, and oxybutynin.4,52

Fourth-Line Therapies
The fourth-line therapies include injections, which aren’t without risk of developing acute inflammatory reaction, hematuria, and urinary tract infection. Neurogenic bladder can be treated with injections of onabotulinumtoxinA, vs bladder infusions, into the intradetrusor (smooth muscle) wall of the bladder. The sensory nerves are blocked, resulting in reduced incontinence, nocturia, and urgency. Sacral neuromodulation, a process in which mild electrical impulses are sent to sacral nerves to disrupt pain signals from the bladder, can be accomplished with external or implanted stimulators.53,54

Fifth-Line Therapies
Continued medical approaches include immunosuppressants. Wang and colleagues conducted a systematic review that determined the oral drug cyclosporine A can be a successful adjunct in IC/BPS treatment. Close medical monitoring is required and complications such as abdominal pain, diarrhea, nausea, elevated serum creatinine, and hypertension can occur.55

Sixth-Line Therapies
Surgical options are limited to patients with disabling IC/BPS for whom previous therapies have failed; they should be considered as a last resort. These treatment options include: 1) urinary diversion with or without bladder removal; 2) orthotopic diversion in which a bladder is constructed from bowel tissue; 3) augmentation cystoplasty, which uses bowel tissue and reconstructs the bladder in a combination of existing bladder wall and bowel. A final option is cystectomy with urinary diversion to an ostomy.1,5,14

Research Gaps
The lack of comprehensive treatment protocols and definitive diagnostic criteria or biomarkers has resulted in extensive ongoing research to help provide relief to the millions of IC/BPS patients. The Multidisciplinary Approach to the Study of Chronic Pelvic Pain research network, which was developed by the National Institute of Diabetes and Digestive and Kidney Diseases in 2008, features diverse researchers, including clinicians and epidemiologists, working collectively to develop consistent diagnostic guidelines and treatment protocols.4,56 Of interest to dietitians are investigations into the microbiome and studies to elucidate organ cross-talk and identify IC/BPS potential biomarkers to determine subtypes of the disease and streamline treatment algorithms.11,14

The Shorter-Moldwin Food Sensitivity Questionnaire has potential to be aggregated and analyzed for clinical studies to assess the impact foods may have on pain and IC/BPS symptoms. Herbal and supplemental products are other treatments that have been only minimally researched.7 However, complementary and alternative medicine approaches to IC/BPS are encouraging and further research into this field of study is warranted.6 Pharmacological research with messenger RNA into intravesical therapies also is promising and may provide yet another treatment option for IC/BPS patients.52

Putting It Into Practice
RDs are essential in developing a conservative approach to minimize symptoms, integrating restrictions for comorbid conditions, and ensuring a nutritious diet for those with IC/BPS. A comprehensive nutrition assessment should involve patients recording food and beverage intake, voiding occasions, and symptoms. An individualized plan is paramount, and IC/BPS patients benefit from education on how to read labels for offending ingredients.

Dietitians should work with patients to set achievable goals for a nutrient-rich diet and IC/BPS symptom relief. As members of a multidisciplinary health care team, RDs should engage with practitioners such as behavioral/mental health professionals and physical therapists to encourage a holistic approach to IC/BPS management. Further interest in IC/BPS management on the part of clinicians, researchers, and patients will help with a better epidemiological understanding and improved therapeutic interventions.

— Tony Pipkin, MS, RDN, is a Little Rock, Arkansas–based freelance writer focused on MNT topics.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Employ the current body of evidence on the prevalence and diagnosis of interstitial cystitis/bladder pain syndrome (IC/BPS) to aid in the recognition of the disorder.
2. Counsel clients on the relationship between certain foods and IC/BPS symptoms.
3. Provide recommendations for evidence-based nutrition counseling for management of IC/BPS.

CPE Monthly Examination
1. What’s the most common comorbid condition associated with interstitial cystitis/bladder pain syndrome (IC/BPS)?
a. Fibromyalgia
b. Irritable bowel syndrome
c. Constipation
d. Pelvic floor dysfunction

2. The Interstitial Cystitis Association hypothesized four concepts that might explain the relationship between food and IC/BPS symptoms. Which of the following is one of these concepts?
a. Hematuria
b. Acid reflux
c. Organ cross-talk
d. Pancreatic insufficiency

3. An IC/BPS nutrition assessment should include a food sensitivity questionnaire. Which of the following is a recommended survey instrument?
a. Shorter-Moldwin
b. USDA What We Eat in America
c. National Health and Nutrition Examination Survey Food Frequency
d. Malde-Palmisani

4. What is the prevalence of IC/BPS in men?
a. 2.9% to 4.2%
b. 3.5% to 5.5%
c. 5.5% to 7%
d. 7.5% to 9.5%

5. Which of the following theories is believed to play a role in the pathophysiology of IC/BPS?
a. Deficient Horrs-Whitsfeld protein from the kidney
b. Deficient GAG urothelium lining of the bladder
c. Alkaline diet
d. Inflammatory bowel disease

6. What percentage of IC/BPS patients also reported having celiac disease?
a. 3%
b. 9%
c. 12%
d. 15%

7. Which of the following foods has been shown to aggravate or trigger symptoms in IC/BPS patients?
a. Watermelon
b. Asparagus
c. Broccoli
d. Soy

8. The elimination diet phase of the IC/BPS nutrition care plan is recommended to last for a minimum of how many days?
a. Seven
b. 21
c. 30
d. 60

9. Which of the following is an example of a flavonoid-rich food that can be used to enrich the gut microbiome?
a. Buckwheat
b. Chocolate milk
c. Golden delicious apple
d. Avocado

10. The American Urological Association’s 2015 guidelines for IC/BPS treatment include how many stages?
a. Two
b. Six
c. Eight
d. 10

References
1. Rovner ES. Interstitial cystitis. Medscape website. https://emedicine.medscape.com/article/2055505-overview#a1. Updated December 4, 2020.

2. Meijlink JM. Interstitial cystitis and the painful bladder: a brief history of nomenclature, definitions and criteria. Int J Urol. 2014;21 Suppl 1:4-12.

3. Pape J, Falconi G, De Mattos Lourenco TR, Doumouchtsis SK, Betschart C. Variations in bladder pain syndrome/interstitial cystitis (IC) definitions, pathogenesis, diagnostics and treatment: a systematic review and evaluation of national and international guidelines. Int Urogynecol J. 2019;30(11):1795-1805.

4. Malde S, Palmisani S, Al-Kaisy A, Sahai A. Guideline of guidelines: bladder pain syndrome. BJU Int. 2018;122(5):729-743.

5. Imamura M, Scott NW, Wallace SA, et al. Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis. Cochrane Database Syst Rev. 2020;7:CD013325.

6. Jia X, Crouss T, Rana N, Whitmore KE. Complementary and alternative medicine for the management of interstitial cystitis/bladder pain syndrome: a recent update. Curr Bladder Dysfunct Rep. 2020;15(3):214-218.

7. Gordon B, Shorter B, Sarcona A, Moldwin RM. Nutritional considerations for patients with interstitial cystitis/bladder pain syndrome. J Acad Nutr Diet. 2015;115(9):1372-1379.

8. Homma Y, Ueda T, Tomoe H, et al. Clinical guidelines for interstitial cystitis and hypersensitive bladder updated in 2015. Int J Urol. 2016;23(7):542-549.

9. Kahn BS, Lombardi T. Interstitial cystitis: simplified diagnosis and treatment. Contemporary OB/GYN website. https://www.contemporaryobgyn.net/view/interstitial-cystitis-simplified-diagnosis-and-treatment. Published May 1, 2016. Accessed November 23, 2020.

10. Interstitial cystitis and diet. Interstitial Cystitis Association website. https://www.ichelp.org/living-with-ic/interstitial-cystitis-and-diet/. Updated March 22, 2019. Accessed November 23, 2020.

11. Rahnama'i MS, Javan A, Vyas N, et al. Bladder pain syndrome and interstitial cystitis beyond horizon: reports from the Global Interstitial Cystitis/Bladder Pain Society (GIBS) Meeting 2019 Mumbai, India. Anesth Pain Med. 2020;10(3):e101848.

12. Davis NF, Brady CM, Creagh T. Interstitial cystitis/painful bladder syndrome: epidemiology, pathophysiology and evidence-based treatment options. Eur J Obstet Gynecol Reprod Biol. 2014;175:30-37.

13. Warren JW, Jackson TL, Langenberg P, Meyers DJ, Xu J. Prevalence of interstitial cystitis in first-degree relatives of patients with interstitial cystitis. Urology. 2004;63(1):17-21

14. Colemeadow J, Sahai A, Malde S. Clinical management of bladder pain syndrome/interstitial cystitis: a review on current recommendations and emerging treatment options. Res Rep Urol. 2020;12:331-343.

15. Magistro G, Marcon J, Eismann L, Volz Y, Stief CG. [The role of the microbiome in urology]. Urologe A. 2020;59(12):1463-1471.

16. Arora HC, Eng C, Shoskes DA. Gut microbiome and chronic prostatitis/chronic pelvic pain syndrome. Ann Transl Med. 2017;5(2):30.

17. Braundmeier-Fleming A, Russell NT, Yang W, et al. Stool-based biomarkers of interstitial cystitis/bladder pain syndrome. Sci Rep. 2016;6:26083.

18. Hanno PM, Erickson D, Moldwin R, Faraday MM; American Urological Association. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol. 2015;193(5):1545-1553.

19. Suskind AM, Berry SH, Ewing BA, Elliott MN, Suttorp MJ, Clemens JQ. The prevalence and overlap of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome in men: results of the RAND Interstitial Cystitis Epidemiology Male Study. J Urol. 2013;189(1):141-145.

20. Berry SH, Elliott MN, Suttorp M, et al. Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. J Urol. 2011;186(2):540-544.

21. Barr S. Diagnosis and management of interstitial cystitis. Obstet Gynecol Clin North Am. 2014;41(3):397-407.

22. Engeler DS, Baranowski AP, Dinis-Oliveira P, et al. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431-439.

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