Interstitial Cystitis Advice

By Jessica Cangiano

Each day most of us with IC will void – also known as pee – exceedingly more than the general public does. The ravishing affects of Interstitial Cystitis leaves many IC patients voiding in excess of 40, 60+ times a day! But have you ever paused to consider exactly what urine is? Aside from obviously being the secretion of liquid waste from our bodies, urine is a composition of many chemicals. And its eventual expulsion from our bodies is a fascinating process.

In this article we will take a look at what urine is (besides being really darn annoying to most ICers) and touch on the role it plays in IC bladders. As a mammal, humans produce urine in liquid form. It is largely comprised of metabolic wastes. The liquid itself comes primarily from the blood through a process called glomerular filtration.

“Healthy” urine should be a transparent, amber hued liquid with a distinctive scent. From a chemical viewpoint urine is made up primarily of inorganic salts (like sodium chloride), urea (molecules created by carbon dioxide and ammonia, urea is a good source of nitrogen), and uric acid. Urine is about 95% water, and 5% urea, amino acids, electrolytes, and uric acid.

Through out history the distinctive amber colour of urine was thought to come from gold, leading alchemists to attempt in vain to extract the supposed gold from the urine. No gold ever showed up, but scientist did discover other substances in urine, such as white phosphorus (discovered in 1669 by Hennig Brand). Urea was stumbled upon when a French scientist in 1773 was boiling urine to the point of complete dehydration.

If urine is not healthy it can contain substances such as (higher than usual levels of) sugar (this can occur with diabetes), albumen (occurring with a condition called Bright’s disease) bile pigments (as in Jaundice), higher than normal levels of the usual “ingredients” of urine, pus, and even blood (a potential sign of kidney problems, kidney stones, UTIs, or in some extreme cases bladder/urethral cancer and even IC. Please note however that blood should never be present in your urine, and it is not a typical sign of IC, but instead a testament to how inflamed and “raw” the IC bladder can become).

In order for urine to exit the body as new urine is continually produced, the urine start its journey in the kidneys. Next it flows through the ureters (the two tubes which attach the kidneys to the bladder), the bladder, and out of the body through the urethra. The act of producing urine is essentially a process of filtration, re-absorption, and tubular secretion.

Most people believe urine to be a filthy substance, and while the majority of us have no desire to touch or be around urine, it is worth understanding that urine is in fact not “unclean”. With the exception of urinary tract infections (UTIs), urine does not contain (known) bacteria and is for all intensive purposes sterile. Upon leaving the body (and whilst in the body) urine has very little scent. It is external bacteria which mingle with the urine that produces the distinctive (often over powering) sent associated with urine, especially urine with any age to its name. It is largely the ammonia (created by the urea) that gives urine its telltale smell. The urine of IC patients does not contain any known bacteria (or fungi or viruses) that may be responsible in part or whole for the symptoms that ICers experience. Theories have been put forth that IC could be linked to bacteria, perhaps in very low quantities. But to date no conclusive evidence has supported these ideas.

After being “created” in the kidneys urine is carried to the bladder through the utters, two narrow tubes (one attached to each kidney) which permeate through the bladder wall for about 2 centimetres and then into the lumen (the bladder cavity, where the urine is stored). Utters are comprised of three layers; the inner layer is made of epithelial tissue, the middle layer muscle, and the outer layer of fibrous tissue.

Once the body has (voluntarily or involuntarily, as in the case of incontinence or childhood bedwetting) decided to expel urine it leaves the bladder through the urethra (a muscular tube). The male urethra is considerably longer than the female, averaging about 20 centimetres in length, while the female urethra is about 4 centimetres long.

Before leaving the body the urine is stored in the bladder. Typically the bladder expands and stretches (somewhat like a balloon being inflated and deflated) to house an average of 300 to 400 cc’s of urine. In both sexes the bladder is located behind an area called the pubic symphysis. The female bladder is positioned above the uterus. In males it is above the prostate gland and in front of the seminal vesicles. The bladder is held in place by ligaments that attach to surrounding muscles.

A normal bladder (on average a healthy adult bladder can hold up to 1 ½ cups of urine, and passes about a quart and a half of urine a day, although this will vary depending on the amount of food and drink each individual consumes daily) has no problem holding a significant amount of urine comfortably. The urge to void (urinate) arises and progressively increases only when the bladder is relatively full. With IC however, this is rarely the case.

While it is possible to have IC with and retain a “normal” or even increased (higher than average) bladder capacity, a large percentage of ICers have a diminished capacity. This may be minute or extreme; in some cases the bladder shrinks to a size no bigger than that of a walnut shell. Forcing the ICer to continually void very small quantities of urine. This can lead to the bladder not being able to (ever) properly fill. Which in a circular process further shrinks the bladder, as expansion is needed to help the bladder retain its size and shape. The exact cause of this odd and painful symptom is largely speculated as no known cause or causes of IC have thus been conclusively identified.

A lot of study into what causes IC has focused the bladder lining and one of the things which has been determined, is that ICers almost always have an irritated/inflamed bladder wall (either with Hunner’s ulcers in about 10% of the IC population or pinpoint bleeding known as glomerultion which is present in about 90% of IC cases). As a result of this inflammation the bladder can develop scar tissue, stiffen and decrease in size – these factors leading to further increases in urinary frequency and urgency.

The interior surface of the bladder is comprised of a mucous membrane lining that is often referred to as the GAG lining (from the presence of glycosaminoglycans). It is this layer that normally guards the bladder against the toxic effects of urine and the substances carried by urine. However researchers at UCLA, San Diego have found that the bladder lining is “leaky” in many ICers. In their study, about 70% of the IC patients they studied had bladder linings that were found to be leaky. Meaning that urine (a somewhat noxious substance) was penetrating through the bladder wall and into underlying bladder tissue.

In turn this “leakage” is thought to potentially produce IC symptoms (this was supported by the fact that non-IC research subjects, upon the chemical removal of their bladder surface mucin had symptoms which mimicked those of IC). In a sort of catch-22, the presence of urine in areas of the bladder where it is not meant to be could lead to imminent inflammation. Inflammation then potentially further damaging the bladder surface lining in a viscous, painful circle.

In a “healthy” bladder the tissues are protected from toxic (and/or harmful) substances (in the urine) by a natural coating (the glycocalyx) that discourages the growth of harmful bacteria on the interior bladder wall. When this layer is jeopardized by deterioration (such as “leakage”) a person is at a much higher risk of developing a bladder (UTI) infection. UTIs are a frequent problem for many ICers, especially in the time preceding their IC diagnosis and the start of treatment. This leads me to personally wonder if people taking medications like Elmiron to help guard the bladder lining (or instillations like DMSO), and who are experiencing positive results are developing fewer (or no) UTIs, as opposed to those who are not on IC aimed treatments, especially those like DMSO and Elmiron which work to shield the bladder lining from anything that enters the bladder. Thusly allowing the underling bladder lining to attempt to “heal” itself, and regenerate.

It can virtually be assumed that urine plays an important role in IC. At the very least it fills our bladders, leading (in a roundabout way) to urgency and frequency. As well as carrying some of the remnants of what we eat and drink through our bladders (which is likely why some foods/beverages bother IC bladders so much, especially those with high acid contents like citrus fruits and tomatoes. One has only to conjure up the memory of lemon juice on a paper cut to imagine how acid feels on the damaged/inflamed/irritated inner GAG layer of the bladder.). Or urine itself (or substances found secreted through or produced in the urine) may be largely responsible for IC symptoms.

Urine is unique substance, and though it is rightfully loathed by many an ICer, it is vital to life. And no matter how painful it is (many ICers experience a sensation of pain and/or burning upon urination ranging from dull to mind numbingly strong) it cannot be stopped, even if the bladder is surgically removed, urine will still be filtered out of the body artificially.

In time research may find concise IC markers in urine, thus rendering a lot of the current IC diagnosis methods unnecessary. Research to this extent is already underway. But for the time being patients are being diagnosed with IC on the basis of their urine primarily in terms of negative bacteria testing (urinalysis), coupled with findings and conclusions from other diagnostic testing like cystoscopy and hydrodistension. These types of tests allow doctors to directly look at the inner walls of the bladder and see if in fact you do have IC.