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The naturopathic management of interstitial cystitis: A case study.

Introduction

Interstitial cystitis (IC) is a chronic inflammatory condition of the urinary tract with a common clinical presentation of urinary frequency, urgency and pain (1). Specific aetiology is unknown; however, there is some semblance to urinary tract infection (UTI) but without presence of bacteria on urine cultures, and without response to antibiotic therapy (2). IC is commonly associated with thinning of the bladder epithelium (3), altered nerve signalling (4) and increased apoptosis in urothelial cells (3).

Associations between clinical characteristics of IC, and mood and personality traits were explored in a study in 2016 (5). Researchers found a significant correlation between the pain of IC and anxiety, depression and interpersonal problems, highlighting the potential benefits of a holistic naturopathic approach (5). Persons with IC commonly present with associated anxiety and depression (5), and report a decrease in quality of life and social wellbeing (6). A holistic naturopathic approach includes consideration of all aspects that may impact on a person's health and wellbeing, including pathology, physiology, as well as social and environmental factors.

In IC, the intensity of urinary symptoms such as urgency and pain are positively correlated with increased stress levels (7), and sympathetic nervous system (SNS) dominance is a common underlying mechanism of pathogenesis (3).

The following case study illustrates the whole person implications in the naturopathic management of a 54-year-old woman with symptoms associated with chronic IC. Alleviation of symptoms occurred following naturopathic treatment that incorporated methods to reduce chronic stress and inflammation.

Case description

The client, Rose *, is a 54-year-old female. Rose initially presented to the Wellnation student clinic in March 2018 with lower urinary tract symptoms (increased urinary urgency and frequency), and anxiety. She explained a need to urinate over 15 times per day and was experiencing incomplete voiding. There was no marked increase in urine volume (polyuria). She would pass urine only to feel a sense of urgency to urinate again less than five minutes later. Pain was present only if she had to 'hold on'. These symptoms began 2-3 years prior and Rose could not identify any specific event occurring at that time. Since onset she had gradually reduced her water intake down to 1-2 glasses per day. She believed water was exacerbating her symptoms. Rose had not sought treatment from her general practitioner (GP) and noted she had experienced 1-2 incidents of cystitis over 20 years previously; however, she felt her current symptoms were different and unrelated.

Rose described delayed sleep onset (1-3 hours) due to ruminating thoughts, and disturbed sleep due to nocturia and restless legs. She woke unrefreshed approximately three times per week. Oedema was present in her ankles and lower legs.

Rose's urinary tract symptoms were causing her increased anxiety and fear. She had modified some of her behaviours to accommodate her symptoms, avoiding places without easy access to a bathroom and always assessing the proximity of the nearest bathroom in new places. Her symptoms resulted in her feeling anxious and fearful about new situations. Rose described depressive-type symptoms of lethargy and feeling unmotivated and unenthusiastic. She was experiencing increased stress at work, and occasional constipation, which she associated with an increase in consecutive shifts. Rose had worked full time in a high-stress, 24/7, shift work environment for many years. Her diet consisted of processed and refined foods, and she described a habit of snacking on junk foods, which included sweets and potato chips. She said she frequently felt hungry between meals, particularly at work. She had identified that citrus, hot and spicy foods, and soft drink aggravated her symptoms. Rose was not taking any medications and had no reports from pathology testing. Her blood pressure was 125/85.

Case assessment

Rose's work environment was noted as a cause of ongoing emotional and mental stress. Shift work and chronic stress may result in sympathetic nervous system (SNS) dominance, and occasional constipation, which in Rose's case occurred specifically when she was at work. SNS dominance is defined as prolonged activation of the hypothalamus-pituitary-adrenal (HPA) axis and may result in a myriad of imbalances, including cortisol dysregulation (8). Shift work (specifically sleep loss and circadian disruption) is a physiological stressor, and may disturb cortisol regulation, and contribute to systemic inflammation (9).

Inflammatory cascades are self-perpetuating and in instances of chronic inflammation treatments aimed at breaking inflammatory feedback mechanisms may be relevant (10). There is a range of causative mechanisms of chronic inflammatory states; however, stress is noted as a common predisposing, exacerbating and sustaining factor (10).

Therefore, although Rose's symptoms presented in the urinary tract, it was considered they were being exacerbated and sustained by her chronic stress and complicated by chronic systemic inflammation. Holistic naturopathic treatment incorporated these aspects as foundational aims of treatment, and utilised herbal medicine to reduce symptoms, provide stress relief and reduce inflammation, and improve Rose's vitality and capacity to incorporate healthy behavioural and lifestyle changes.

Treatment

Herbal medicine was targeted to support healthy nervous system function, and to reduce inflammation. Behavioural recommendations included improved sleep hygiene and stress-reducing self-administered rituals (baths, aromatherapy, reading, breathing exercises, warm showers, and limited screen time before bed) aimed to promote relaxation. An increase in water consumption was also recommended, along with a decreased dietary intake of aggravating foods (spicy food, citrus and soft drinks).

The liquid herbal formula (Table 1) was created and Rose was instructed to take 7.5 mL twice daily in a small amount of water. The herbal tablet formula (Table 2) was prescribed at 4 tablets per day (2 x am, 2 x pm) with food.

Treatment outcome

Rose reattended the clinic in March 2018, two weeks after her initial appointment. She reported increased energy levels and vitality and described a marked reduction in the frequency and urgency of her urinary symptoms. Sleep onset and quality had also improved, and she was no longer experiencing restless legs. The oedema in her feet and ankles had decreased. Rose felt more energetic and capable of managing daily events and noted a significant benefit from the 'unwinding' routine before sleep.

Discussion

The unknown aetiology of IC can be a cause for confusion in identifying mechanistic treatment strategies (22). Numerous suggestions for the pathophysiologic mechanisms in IC have been proposed, including epithelial dysfunction, mast cell activation, and neurogenic inflammation (8). Although it remains unclear whether altered neural mechanisms and inflammation are causative, or resultant, they are an important consideration in treatment as neural upregulation plays a role in the chronic presentations of urgency and frequency in urinary tract symptoms (8). A naturopathic approach that incorporates multifactorial aspects of the individual case can facilitate consideration of the 'whole person' and simultaneously treat several potential aetiologies of chronic IC.

Lower urinary tract symptoms may also be associated with diabetes mellitus type 2 (DM2) and given the client's urinary tract symptoms, dietary habits, and sedentary lifestyle (23), this differential diagnosis was an important consideration. Although Rose described increased urinary frequency and urgency, she did not describe polyuria (increased urine volume) commonly associated with DM2 (23). Rose's symptoms included a lack of thirst and decreased water intake, as well as normal range blood pressure. In DM2 there is commonly increased thirst and water intake, and elevated blood pressure (24). Therefore, although undiagnosed, the client's symptom profile was considered to correlate more closely with those of IC, and short-term treatment aimed to address these symptoms and their underlying drivers.

There is a positive association between stress and abnormalities of the HPA axis, and an increase in the occurrence of bladder symptoms (8), as well as an increase in intensity and severity of existing symptoms, such as pain and urgency (7). Chronic stress has been linked with a wide array of adverse health outcomes, many of which are chronic in nature, and complicated by chronic inflammation (25). Supporting the nervous system to reduce excessive stress and anxiety to improve mood and potentially inflammation was pivotal in the successful management of this case.

Antidepressants are sometimes utilised in the medical treatment of IC based on the inhibition of the synaptic reuptake of serotonin and norepinephrine. This treatment may also improve mood, and pain perception (2). The tricyclic amitriptyline is commonly recommended and has been effective in reducing symptoms of pain and urgency intensity (26). Amitriptyline decreases mast cell activity and blocks Hl-histaminergic receptors; however, its use is also commonly associated with significant side effects of dry mouth, dizziness and gastrointestinal complaints in up to 88% of patients (2). Research indicates low acceptability in the use of amitriptyline, with higher dropout rates than comparators, despite findings of superior effect (27,28). Many people prefer treatment options with fewer side effects.

Herbal medicines with demonstrated efficacy for reducing depression and improving mood may provide a natural alternative without the side effects of pharmaceuticals for treatment of IC. The action of Crocus sativus may increase synaptic cleft serotonin concentration and reduce neuroinflammation (16) and Hypericum perforatum has been found to have clinical efficacy comparable to selective serotonin reuptake inhibitors (SSRIs) in symptoms of depression (29). Adaptogens, or herbal medicines that may improve resilience such as Eleutherococcus senticosus and Schisandra chinensis, were used traditionally in herbal medicine to regulate stress response and provide additional benefits of increasing concentration, performance, and endurance in fatigue states (13,30). Scutellaria lateriflora was traditionally used as a nervine and anxiolytic; however, its additional anti-inflammatory, spasmolytic, antimicrobial, and antioxidant actions, may all have further benefited this client (31).

The prescription of Herbal Mix 1 aimed to reduce symptoms by supporting the client's nervous system, regulating neural pathways and stress responses to improve mood, decrease anxiety and increase the client's sense of control over her body and health.

Herbal Mix 2 was prescribed to reduce urgency and frequency of urinary tract symptoms.

Inhibition of inflammatory cascades and mast cell stabilisation associated with extracts from Boswellia serrata (32) may reduce inflammation and halt complex feedback loops associated with IC (10), decreasing urinary urgency and frequency and inhibiting the formation of oxygen radicals capable of causing further inflammation and damage to the urinary tract (18,33). Zingiber officinale and Curcuma longa also inhibit multiple pro-inflammatory pathways particularly relevant in IC and possess sound safety profiles (34).

The holistic nature of naturopathy in case analysis and treatment decisions and its consideration of the interdependence of all body systems including exacerbating and compensating factors, is well suited to the treatment of complex and chronic disease states. The broad scope of the naturopathic consult and resultant treatment plan (a unique treatment approach informed by individual case characteristics) may provide treatment at multiple levels at the same time. In this case, herbal medicines, dietary changes and the inclusion of self-care rituals and behaviours were used to empower and engage the client, reduce inflammation and stress, balance nervous system physiology, and improve urinary tract symptoms and risks of progressive disease.

This case study provides an example of the potential benefits of a naturopathic approach and the importance of treating the nervous system and applying stress management, as well as effective treatment of symptoms in people with complex and chronic physical conditions.

Limitations of this case include uncertainty regarding exactly which parts of the complex treatment correlate with the therapeutic effects. Naturopathic treatment involves extended consultations, active listening and validation of the client's concerns. This incidental counselling may provide therapeutic effect, which has not been directly accounted for in this case study. Another limitation is the short time frame of the case management. This case spans two weeks of treatment and long-term effectiveness has not been described; nevertheless, the significant alleviation of symptoms and the subsequent improvement in quality of life in that time warrant dissemination and discussion.

This case highlights the broad-ranging actions of herbal medicines, from their many and varied constituents, potentially providing benefits at multiple levels, addressing symptomology and interdependent aspects of pathophysiology, which remain poorly understood.

Conclusion

This case describes the benefits of treating symptoms of IC with naturopathy where the treatment strategy was underpinned by naturopathic philosophy and addressed the complex interplay of aspects relevant in a person with chronic disease. Despite the multifactorial aetiology of IC, herbal medicine addressed the presenting complaints and associated conditions in a prompt and timely manner.

Note

* The patient's name has been changed to preserve her anonymity.

References

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

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(5.) Chen W-C, Lee M-H, Wu H-C. Relationship among symptoms, mood, and personality traits in patients with interstitial cystitis/ bladder pain syndrome. Urol Sci 2017;28(3):147-151.

(6.) Vasudevan V, Moldwin R. Addressing quality of life in the patient with interstitial cystitis/bladder pain syndrome. Asian J Urol 2017;4(1):50-54.

(7.) Lai H et al. Correlation between psychological stress levels and the severity of overactive bladder symptoms. BMC Urol 2015;15(1):14.

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(14.) Brock C et al. American skullcap (Scutellaria lateriflora): A randomised, double-blind placebo-controlled crossover study of its effects on mood in healthy volunteers. Phytother Res 2014;28(5):692-698.

(15.) Panossian A, Wikman G. Pharmacology of Schisandra chinensis Bail: an overview of Russian research and uses in medicine. J Ethnopharmacol 2008;118(2):183-212.

(16.) Khazdair MR et al. The effects of Crocus sativus (saffron) and its constituents on nervous system: A review. Avicenna J Phytomed 2015;5(5):376.

(17.) Akhondzadeh S et al. Crocus sativus L. in the treatment of mild to moderate depression: a double-blind, randomized and placebo-controlled trial. Phytother Res 2005;19(2):148-151.

(18.) Iram F, Khan SA, Husain A. Phytochemistry and potential therapeutic actions of Boswellic acids: A mini-review. Asian Pac J Trop Biomed 2017;7(6):513-523.

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(20.) Al-Asmari AK, Athar MT, Kadasah SG. An updated phytopharmacological review on medicinal plant of Arab region: Apium graveolens linn. Pharmacogn Rev 2017;11(21):13.

(21.) Kooti W, Daraei N. A review of the antioxidant activity of celery (Apium graveolens L). J Evid Based Complementary Altern Med 2017;22(4):1029-1034.

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(23.) Egan AM, Dinneen SF. What is diabetes? Medicine 2014;42(12):679-681.

(24.) Barrett T. Type 2 diabetes mellitus: incidence, management and prognosis. Paediatr Child Health 2013;23(4):163-167.

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(26.) van Ophoven A et al. A prospective, randomized, placebo controlled, double-blind study of amitriptyline for the treatment of interstitial cystitis. J Urol 2004;172(2):533-536.

(27.) Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018;391(10128):1357-1366.

(28.) Van Ophoven A, Hertle L. Long-term results of amitriptyline treatment for interstitial cystitis. J Urol 2005;174(5):1837-1840.

(29.) Ng QX, Venkatanarayanan N, Ho CYX, Clinical use of Hypericum perforatum (St John's wort) in depression: A meta-analysis. J Affect Disord 2017;210:211-221.

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(32.) Ammon H. Modulation ofthe immune system by Boswellia serrata extracts and boswellic acids. Phytomedicine 2010;17(11):862-867.

(33.) Sant GR et al. The mast cell in interstitial cystitis: role in pathophysiology and pathogenesis. Urology 2007;69(4):S34-S40.

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Amy Taylor BHSc Naturopathy (final year student), BJourn [1], David Casteleijn MHSc Herbal Medicine [1,2], and Sophia Gerontakos BHSc Naturopathy [1]

[1] Endeavour College of Natural Health, Fortitude Valley Brisbane, QLD, Australia

[2] University of Technology Sydney, Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, Ultimo, NSW, Australia

Contact information

Amy Taylor, Endeavour College of Natural Health, Level 2, 269 Wickham St, Fortitude Valley, Brisbane, QLD 4006

Email amy.elyn@hotmail.com
Table 1: Liquid herbal formula

Herbal mix 1--liquid herbal formula

    Botanical          Common           Actions          Dose

Hypericum            St John's     Anxiolytic,          20 mL
perforatum           Wort          antidepressant
                                   (11,12)

Eleutherococcus      Siberian      Adaptogen,           30 mL
senticosus           Ginseng       immunomodulator,
                                   tonic (13)

Scutellaria          Skullcap      Nervine,             20 mL
lateriflora                        spasmolytic
                                   (14)

Schisandra           Schisandra    Adaptogen,           30 mL
chinensis                          antioxidant
                                   (15)

Crocus               Saffron       Serotonergic,        10 mL
sativus                            anti-
                                   inflammatory,
                                   antioxidant,
                                   antidepressant,
                                   neuroprotective
                                   (16,17)

Dose

7.5 mL twice daily (am/pm) in a small amount of        110 mL
water

Table 2: Tablet herbal formula

Herbal mix 2--tablet herbal formula (per tablet)

 Botanical       Common            Actions            Dose

Boswellia      Boswellia    Anti-inflammatory        1.9 g
serrata                     (18)

Curcuma        Turmeric     Anti-inflammatory,       2.0 g
longa                       Antioxidant, anti-
                            neoplastic
                            neuroprotective (19)

Apium          Celery       Antioxidant, anti-       1.0 g
graveolens                  inflammatory, anti-
                            spasmolytic (20)

Zingiber       Ginger       Anti-inflammatory,       300 mg
officinale                  digestive stimulant
                            (21)

Dose

Two tablets twice daily (am/pm) with food
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Title Annotation:Case study
Author:Taylor, Amy; BJourn; Casteleijn, David; Gerontakos, Sophia
Publication:Australian Journal of Herbal Medicine
Article Type:Clinical report
Date:Dec 1, 2018
Words:3070
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