pain can be caused by many processes. When pelvic pain is caused
trigger points, treating sleep disorders, hormonal problems, and infections
and offering nutritional support can be very helpful. In this column,
we'll review vulvodynia, interstitial cystitis, endometriosis,
Interstitial Cystitis (IC) is a bladder problem that causes severe discomfort
in approximately 500,000 Americans. Ninety percent of people affected are
women, and the condition often occurs in association with other illnesses
such as fibromyalgia. Onset of symptoms is often between the ages of 40 and
60. On average, people see five doctors before they find one who is able
to make the diagnosis. IC is characterized by severe urinary urgency, frequency,
burning, and pain. These symptoms in mild form are common in Chronic Fatigue
Syndrome (CFS), fibromyalgia, and chronic pain and are not what I am discussing
here. IC is diagnosed when these symptoms are your predominant problem and
are often so severe that patients want to have their bladders removed.
There are two main categories of IC. The more common is non-ulcerative and
is most often seen in young to middle-aged women. It is associated with normal
or increased bladder capacity. The cause of IC is not known, but there are
many theories. In all likelihood, it is caused by a number of different problems.
One possibility is that there are infectious triggers, which either irritate
the bladder directly or cause an autoimmune reaction in which the body attacks
itself. The autoimmune theory has recently been getting more support. For whatever
reason, the protective inner lining of the bladder (called the GAG or glycosaminoglycan)
gets damaged, resulting in severe bladder irritation and pain, urinary urgency
and frequency, and decreased bladder capacity. Again, it is important to note
that the above symptoms in mild form are very common and are not IC. IC is
often associated with vulvar pain and painful intercourse (see "Vulvodynia" below).
There is no definitive test for IC, and the diagnosis is based on clinical
symptoms and bladder cystoscopy (looking into the bladder with a tube). Other
infections need to be ruled out, as does cancer.
Although there is currently no cure for IC, there is much that can be done
to relieve the symptoms. Once bacterial infections have been ruled out, I add
Elavil 25 mg at bedtime, plus Neurontin. If these are ineffective, a trial
of Sinequan and the other anti-seizure medications are worthwhile. The medications
Pyridium, which numbs the bladder and turns the urine and sweat light orange,
and Urispaz, an anti-spasmodic, can be helpful as well.
I would also treat the patient for presumptive Candida with oral Diflucan for
at least three months, which may help as well. Although it has not been well-studied,
many physicians suspect that yeast overgrowth, like some other infections,
may contribute to IC. A critical part of the anti-yeast/anti-fungal protocol
is avoiding sugar, which feeds yeast.
Interestingly, Dr. Ward Dean had noted
that one person's IC cleared up when she used Xylitol, which looks and
tastes like sugar, as a sugar substitute. It is not clear if the Xylitol helped
or if simply avoiding the sugar was the reason for the patient's relief.
Either way, Xylitol is a good sugar substitute with multiple health benefits,
including preventing cavities and osteoporosis, and is worth trying.
It is important to avoid certain foods and also to recognize that vitamins,
especially the B vitamins and any that are acidic, can dramatically irritate
the bladder in some patients with IC. Because of this, supplements, especially
one as powerful as the Energy Revitalization System vitamin powder, should
be tried in extraordinarily tiny doses (e.g., stick a finger in the powder
and lick it) first to make sure they are tolerated. Then, slowly increase the
dose if you are able. Take any B vitamins with a large amount of water. Otherwise,
they can achieve high concentrations in the bladder. In most people, this causes
no problem, but can be irritating in those with IC or bladder spasm. B vitamins
are bright yellow, and you can tell when they are concentrated in the urine.
Other treatments include avoiding foods that may aggravate symptoms. Urologists
can also put different medications in the bladder, such as DMSO, Heparin, and
Elmiron, all of which can be helpful. I recommend Elmiron; it may take three
months to work. Take a 100 mg capsule three times a day with water at least
one hour before or two hours after eating.
Dr. Stanley Jacob, MD, the physician who helped to get FDA approval for the
use of DMSO (instilled into the bladder) for IC has also explored the use of
Methyl Sulfonyl Methane (MSM) to treat IC patients. Although MSM takes longer
to work (several months), it is better tolerated than the DMSO, which is irritating
and results in a garlicky body smell. Dr. Jacob estimates that 80% of his IC
patients improve with MSM. He has his patients make a formula of 15% MSM in
deionized sterile water and use a catheter to put the solution in their bladders
(two to five times a week), holding it in their bladder as long as is comfortable.
He gives the MSM intravenously and by mouth (starting with one gram a day and
increasing to 18 g daily). For more information, see Dr. Jacob's book,
MSM – the Definitive Guide.
Surgery should be a very rare and final resort. Even after the bladder has
been removed, half of the IC patients will continue to suffer from pain.1 The
good news is that most patients I have seen with IC have received significant
relief using some combination of the above treatments.
In another study, lower morning cortisol levels were associated with increased
symptoms of IC.2 Many fibromyalgia patients get marked improvement in their
IC as part of the overall improvement of their fibromyalgia. One of the treatments
I often give is cortisol in a very low dose.
Another natural remedy that has been shown to be helpful in IC is the amino
acid L-arginine 500 mg three times a day for three months. In one study of
53 patients with IC, half were given the L-arginine and the other half a placebo.
At the end of three months, 29% of the patients on L-arginine were feeling
better with less pain and urgency as compared to eight percent in the placebo
group. L-arginine helps to make nitric oxide, which can relax the bladder muscle.
The enzyme that makes nitric oxide has been shown to be low in interstitial
cystitis patients. In another open study using 1500 mg of L-arginine daily,
a similar effect was seen. Another study using higher amounts did not show
benefit, so more is not better.3
Some health practitioners have found that patients with interstitial cystitis
often have chronic extremely alkaline urine. This can be aggravated by excessive
coffee and cola intake. PH strip paper can be obtained cheaply at most pharmacies,
and one can test multiple urine samples at home to see if the pH is regularly
over 7.0. In addition, certain enzyme therapies have been found to be very
helpful. They can be obtained from the Enzyme Formulations Company. For interstitial
cystitis, use the enzyme URT (enzyme product No. 24). Take four capsules, five
times a day between meals; and add the enzyme product called KDY, two capsules
every 20 minutes, as needed during flares. In two to four weeks, the symptoms
may subside and the products can then be taken just as needed.
Although I have not yet used it for interstitial cystitis, it would be worth
trying the herbal saw palmetto, 160 mg twice a day for six weeks, as this relaxes
the bladder muscle in those with urinary retention and an enlarged prostate.
Research shows that this safe herb promotes smooth muscle (i.e., the bladder
muscle) cell relaxation by a number of different mechanisms. It takes six weeks
Vulvodynia is defined as chronic vulvar itching, burning, and/or pain that
is significantly uncomfortable. In this condition, vulvar/vaginal pain can
either occur only during intercourse or be constantly present. It used to
be thought that vulvodynia was fairly rare. Recently, the National Institutes
of Health (NIH) funded a study to see how common vulvodynia is. According
to Dr. Harlow, associate professor of gynecology at Harvard Medical School, "The
preliminary data suggests that possibly millions of women may be affected
at some point during their lifetime." The International Society for
the Study of Vulvovaginal Disease has proposed several names to describe
the different types of vulvodynia. These include the following:
1. Generalized vulvar dysesthesia (VDY) – characterized by pain that
can occur anywhere on the vulva
2. Localized vulvar dysesthesia – characterized by pain that can be consistently
localized by pushing on certain area(s) of the vulva
3. Mixed dysesthesia – a combination of both of the above
Symptoms can occur anywhere from the pubic bone to the anus. It may be present
all of the time, sporadically, or only with intercourse. Many women feel like
they have a chronic yeast infection. In others, it feels raw, swollen, or like
they are sitting on a hard knot. Burning, electric shocks, and tingling are
also often seen. If the area around the urethra (where the urine comes out)
is involved, the woman may feel like she has a chronic bladder infection. She
may have recurrent urinary urgency, frequency, and burning despite having negative
urine cultures. Painful intercourse (dyspareunia) is common, and pain may even
occur from tight slacks or underwear.5 Some patients have found that for painful
intercourse, topical 0.2 % nitroglycerine cream can give temporary relief (made
by a compounding pharmacist in a base without any irritating additives).
In my experience, vulvodynia seems to occur as three main types:
1. Neuropathic This pain appears to be caused by nerve irritation and is sharp,
burning, and/or shooting (like nerve pain). In this case, begin with tricyclic
anti-depressants (nortriptyline, desipramine, imipramine, doxepin, or Elavil)
at 25 to 150 mg each night and/or Neurontin (100 mg to 3600 mg daily) and proceed
from there. Be sure to use a sufficient dose of the medications and give them
enough time to work; results may take three months. In addition, topical lidocaine
(Novocain) gel can be helpful (e.g., EMLA cream). In severe cases, opiates
may be necessary.
2. Inflammatory This pain is associated with local inflammation/irritation.
In this situation, I would avoid topical creams, etc., especially if they contain
parabens, propylene glycol, fragrance, or sorbic acid. Also, do not use topical
antifungals or over-the-counter creams. Instead, I routinely give at least
a three-month trial of oral Diflucan, 200 mg a day, to be sure any chronic
vaginal yeast is eliminated. Occasionally, long-term Diflucan treatment is
needed. In this case, check liver blood tests occasionally, because this medicine
can cause liver inflammation. Some patients find that avoiding oxalates can
help decrease symptoms. In a small subset of patients, one can see a narrow
ring of inflamed tissue which reproduces the pain when touched (e.g., with
a Q-tip). In these patients, surgically removing that small area of tissue
3. Muscle pain If the pain is deep-seated and not triggered by touching the
outer vagina, it may be coming from spasm of the deep pelvic muscles. In this
situation, the pain may occur or be accentuated during the deep thrusting of
intercourse. For this pain, the general principles for treating muscle pain
apply. In addition, EMG biofeedback of the pelvic floor muscles may help. Muscles
that are often involved include the obturator internus and pubococcygeus. The
sacroiliac joint and disc/spine disease (which can be treated with IV colchicine)
also refer pain to the pelvic and rectal areas. Any injury or condition affecting
these can trigger pelvic pain.
In general, it is good for patients with vulvodynia to take certain precautions.
As noted above, these include avoiding any direct chemical contacts that can
irritate the vulva such as sprays, creams, or mini-pads. In addition, it is
a good idea to wear loose comfortable clothes and to avoid thong underwear
and biking shorts. Sitz baths can also be helpful. Menopausal women should
use topical natural estrogen (e.g., estradiol) to prevent atrophy.
Many of my patients with fibromyalgia also have vulvadynia. Like IC, it seems
that symptoms of vulvodynia often resolve as their fibromyalgia resolves. I
put almost all women with pelvic pain on tricyclics such as Elavil or nortriptyline
combined with Neurontin.
Endometriosis is a complex disorder affecting women during their reproductive
years. In this disorder, the tissue that lines the inside of the uterus and
sheds each month during the menstrual cycle(called the endometrium) escapes
the uterus and attaches to inappropriate areas within the pelvis and abdomen.
These growths then respond to changes in estrogen just as tissue does within
the uterus. Because of this, women will often get pelvic and abdominal pains
that are worse around one's period. These pains are usually worse than
menstrual cramps. In addition to pain, women with endometriosis often experience
a myriad of other symptoms similar to fibromyalgia (e.g., fatigue, insomnia,
widespread achiness), which responds well to our CFS/Fibromyalgia protocol
of treating "SHIN": Sleep, Hormonal support, Infections, and
Nutrition (see full RCT study report at www.vitality101.com). Although the
cause of endometriosis is unknown, there are many theories.
Most doctors forget to consider this diagnosis in evaluating abdominal and
pelvic pain. The diagnosis is made by laparoscopy. During this surgical procedure,
a small incision is made and a tube is inserted through which the internal
organs can be seen and evaluated for endometrial implants. If these implants
are seen, the diagnosis is made, and treatment is given with hormonal therapies
that attempt to stop ovulation. In addition, other pain medications are given
as well. Pregnancy often causes a temporary remission of symptoms. Many alternative
therapies are also available.
Prostatitis and Prostadynia
Even in the absence of a full-blown attack of prostatitis, which is usually
not subtle and is easily diagnosed and treated, prostate pain is fairly common
in men. When no infection is found, it is called prostadynia. It is also
known as chronic nonbacterial prostatitis, or chronic pelvic pain syndrome
(CPPS). Unfortunately, when doctors do not know what is causing a problem,
we often presume it must be psychological (i.e., "I don't know
what's wrong with you, so you must be crazy!"). This is what
has occurred with prostadynia.
I suspect that prostadynia often occurs because of subtle infections that do
not grow on our culture media. These commonly include fungal infections and/or
other slow growing antibiotic sensitive infections. In the latter case, the
prostate is mildly boggy (indents like a ripe fruit) instead of firm and is
tender on examination; to the patient without prostate problems this normally
feels like one has to pee, but the prostate is not tender/painful when pressed
on. Unfortunately, most doctors consider such an exam normal despite the prostate
symptoms. These symptoms include urinary urgency, without there necessarily
being much urine present, and burning on urination. The discomfort is often
felt on the tip of the penis. Because the infection is not overt, most doctors
offer no treatment.
My suspicion is that this is indeed an infectious problem in many cases. This
suspicion is bolstered by a recent study showing that Mepartricin (40 mg per
day for two months), an antibiotic with antifungal and antiparasitic properties,
decreased symptoms by 60% in these patients.6 The study does not totally support
infection as the cause, however, because the medication also lowers estrogen
levels in the prostate and can work in that way as well. In the study, the
authors theorized that lowering estrogen caused the improvement. My experience,
however, shows that patients also improve with antibiotics and antifungals
that do not lower estrogen. Treatment needs to be given for many months, since
anti-infectious agents have difficulty getting into the prostate.
The bioflavonoid vitamin Quercetin (500 mg, twice a day) also decreases prostate
symptoms in both prostadynia and prostatitis. In one study, 30 men with severe
prostadynia lasting an average of 11 years were treated with either Quercetin
500 mg twice a day or a placebo for one month. There was an average 37% decrease
in symptoms with over two-thirds of patients feeling they gained a meaningful
benefit.7 Quercetin 500 mg is present in the Energy Revitalization System vitamin
1. Mulkey VH. Interstitial Cystitis. Continuing
Education Topics and Issues. Jan 2001; 1114.
2. Journal of Urology. 2002;167: 1338-1343.
3. Korting, GE, et al. A randomized double-blind trial of Oral L – arginine
for treatment of interstitial cystitis. Journal
of Urology. 1999;161:558-565.
4. Gutierrez, M, et al. Mechanisms involved in the spasmolytic effect
of extracts from Sabal serrulata fruit on smooth muscle. Gen
5. Stewart, E.G. Diagnosis and management of generalized vulvodynia.
Practical Pain Management. May/June 2004;38-41.
6. Urology. 2004;63: 13-16.
7. Shoskes, DA, et al. Quercetin in men with category 3 chronic prostatitis:
a preliminary prospective, double-blind, placebo-controlled trial.
Urology. 1999; 54: 960-963.
Jacob Teitelbaum is the Medical Director
of the Fibromyalgia and Fatigue Centers of America (www.fibroandfatigue.com),
which is expanding rapidly
and currently recruiting MDs and DOs; senior author of the landmark
studies "Effective Treatment of Chronic Fatigue Syndrome and
Fibromyalgia – a Placebo-controlled Study" & "Effective
Treatment of CFS & Fibromyalgia with D-Ribose."; and author
of the best-selling book From Fatigued to
Fantastic! and the recently
released Pain Free 1-2-3 – A Proven Program to Get YOU Pain Free! (McGraw Hill, 2006).