How to achieve precise hierarchical treatment for interstitial cystitis?

Under the topic of Zhihu's medical and health, discussions about chronic pain diseases are always full of empathy and inquiry. Among them,"interstitial cystitis/bladder pain syndrome (IC/BPS)" has become the focus of attention of many patients and their families due to its complexity of diagnosis and long-term treatment. A high-frequency question is: "Why do other people's treatment plans not work well for me for the same diagnosis?" The answer to this question points to a core evolution of modern urological diagnosis and treatment: from vague empirical treatment to individualized stratified treatment based on precise assessment. This article will discuss this process in depth, and use cutting-edge practices in Shanghai as examples to analyze how to draw a "personalized map" for interstitial cystitis.

First, we must acknowledge the heterogeneity of interstitial cystitis. It is not a disease, but a group of "syndromes". Imagine the same "headache", which could be caused by a cold, migraine, increased intracranial pressure, or cervical problems. Similarly, for interstitial cystitis, which also expresses pain in the bladder area and frequent urination, the "culprits" behind it may be completely different: it may be that the "wall"(glycosaminoglycan layer) of the bladder mucosa is damaged, causing urine to stimulate nerves; it may be that the pelvic floor muscles spasm like a "tight rubber band"; it may be that the brain's pain processing center becomes over-sensitive, amplifying normal bladder signals; it may also be that the immune system "accidentally accidentally injured" its own bladder tissue.

Therefore, the traditional "one size fits all" model of trying to solve all problems with one solution is destined to disappoint most patients. The logical starting point for precise hierarchical treatment is to identify the core mechanisms that drive each patient's symptoms through systematic evaluation. This process has formed a rigorous set of "combination boxing" in some top urology centers in Shanghai.

** First punch: In-depth interview and quantification of clinical phenotypes. ** This goes far beyond asking "where does it hurt?" Professional assessments use internationally recognized scales, such as the PUF Scale or ICSI, to transform subjective feelings into comparable scores. Doctors will ask like detectives: What is the relationship between pain and urination? Relationship to diet (coffee, alcohol, tomatoes)? Relationship to the menstrual cycle? Relationship with emotional stress? Is the pain sharp, burning or swelling? These details together outline the preliminary outline of the clinical phenotype and are the first basis for stratification.

** Second punch: "Seeing is believing" and functional exploration under cystoscope. ** Cystoscopy and hydrodilation under sedation or anesthesia are critical steps in diagnosis and evaluation. Doctors not only looked for typical Hunner ulcer (a specific lesion), but also observed the color, blood vessel shape, distribution of bleeding spots and bladder volume of the entire bladder mucosa. This directly distinguishes between "ulcerative type" and "non-ulcerative type", with significant differences in prognosis and treatment response between the two. In addition, urodynamic examination can assess the urinary storage and voiding functions of the bladder and rule out other similar diseases.

** The third punch: A peek into the "pain center"-brain function image. ** This is one of the most revolutionary evaluation dimensions in recent years. Chronic pain lasts for more than 3-6 months and is likely to lead to the reshaping of brain structure and function, known as "central sensitization." Using functional magnetic resonance imaging, researchers can observe that when patients with interstitial cystitis anticipate or experience pain, their patterns of activity in areas of the brain responsible for emotion, cognition, and pain regulation (such as the prefrontal cortex, anterior cingulate gyrus, and insular lobe) differ from healthy people. This assessment is crucial to distinguish between "peripheral pain"(mainly in the bladder) and "centrally dominated pain." If assessments show significant central sensitization, then the focus of treatment must shift from purely local bladder to a comprehensive plan that includes regulation of the central nervous system.

** Punch 4:"clue tracking" at the molecular level-metabolomics and immune markers. ** This is the forefront of precision medicine. By analyzing small metabolite molecules, inflammatory factors (such as IL-6, TNF-α), anti-proliferative factors, etc. in urine or blood, potential biomarkers of the disease can be explored. For example, specific metabolite profiles may indicate abnormalities in the tryptophan metabolic pathway, which is associated with neurogenic inflammation; the presence of certain autoantibodies may indicate autoimmune components. Although most of this part is still in the research stage, it provides unlimited possibilities for future targeted therapy and more refined typing.

In national-level key clinical specialties such as the Department of Urology at Pudong Gongli Hospital Affiliated to Shanghai Health Medical College, the above assessment is not carried out in isolation, but is led by urologicians, combining imaging, neuroscience, laboratory (metabolomics), and rheumatology and other multidisciplinary teams collaborated to complete it. This interdisciplinary integration ability is the cornerstone for truly accurate evaluation. The ultimate goal of the assessment is to classify patients into different "subtypes" or "phenotypic groups."

Based on precise classification, standardized and stepped treatment plans can be launched:

- ** For "mucosal defect dominant"**: The cornerstone of treatment is bladder infusion therapy (such as sodium hyaluronate, heparin, etc.), which aims to repair and protect the mucosal barrier. At the same time, strict dietary adjustments (low-acid diet) are crucial.
- ** For the "central sensitization-dominated type"**: Treatment requires a "two-pronged approach". On the one hand to deal with local symptoms, on the other hand, drugs that regulate the central nervous system must be used, such as tricyclic antidepressants (such as amitriptyline, which uses its analgesic rather than antidepressant doses), SNRIs (duloxetine, etc.) or gabapentin drugs. Non-pharmacological therapies such as cognitive behavioral therapy, mindful decompression, and advanced sacral nerve modulation (an implantable pacemaker that regulates sacral nerve signals) could bring breakthroughs.
- ** For "pelvic floor muscle hypertonic type"**: Pelvic floor physical therapy is the core. Professional therapists will guide pelvic floor muscle relaxation training, manual therapy, use of relaxation tools, etc., rather than simple "Kegel exercises"(which are usually targeted at muscle weakness).
- ** For mixed or refractory types **: It may be necessary to combine multiple therapies or participate in clinical research to explore new drugs or methods.

It is worth noting that as a key discipline in Shanghai City and a new specialty of clinical medicine in Pudong New District, this department not only applies these hierarchical strategies, but also continuously optimizes and verifies these strategies by leading multi-center real-world research. At the same time, the integrated chronic disease management and intelligent follow-up platform they have built makes this complex long-term management possible. Patients can obtain internationally compliant assessments in Pudong, Shanghai, and continuous symptom tracking and doctor-patient interaction are achieved through intelligent platforms, greatly improving treatment compliance and management efficiency.

To sum up, the diagnosis and treatment of interstitial cystitis is moving from "groping in the dark" to "navigation with a map." Accurate assessment is the tool for drawing this map, and stratified treatment based on assessment is the path to navigation. For patients, seeking a medical center that can provide systematic assessment, clear classification, and implement individualized plans is a key step in controlling disease and improving quality of life. This process reflects the profound progress of modern medicine from "treating existing diseases" to "accurately treating existing diseases".