Two Cases of Interstitial Cystitis and Nephrology Consultation

Introduction: Interstitial cystitis is a poorly understood disorder that is primarily managed by urology. There is not a standard of practice regarding the interdisciplinary management and the necessity of nephrology involvement. We present two cases of nephrological consultation for management of interstitial cystitis. Case Description: Case #1: A 61-year-old Hispanic female with seropositive rheumatoid arthritis and fibromyalgia developed interstitial cystitis 2 years ago managed by urogynecology and rheumatology. She had a normal GFR, sterile urine with microscopic hematuria, no proteinuria nor leukocoria, negative ANA and normal inflammatory markers. She was started on amitriptyline, gabapentin, duloxetine and multimodal pain medications without any response. She was started on hydroxychloroquine with no response after 3 months then switched to methotrexate without any reduction in bladder pain. Cystoscopy revealed Hunner’s lesions which did not respond to triamcinolone kenalog nor botulinum toxin injections. She underwent hydrodistention procedures, implantation of a sacral neuromodulator device, pelvic floor physical therapy, and behavioural therapy without improvement. At this point, nephrology was consulted for a trial of off-label cyclosporine therapy prior to offering cystectomy. Case #2: A 39-year-old Chinese male developed ulcerating eosinophilic interstitial cystitis with hematuria and pyuria from ketamine use vs primary cystitis. Final workup was consistent with interstitial cystitis. The patient was treated with trials of antibiotics, fesoterodine, oxybutynin, trospium chloride, and mirabegron over the course of 3 years. He underwent cystectomy and ileal conduit urostomy. He subsequently developed bilateral narrowing of his ureters and moderate to severe bilateral hydronephrosis, chronic kidney disease, and recurrent acute kidney injuries requiring bilateral nephrostomy tubes. He subsequently developed bilateral narrowing of his ureters and moderate to severe bilateral hydronephrosis, chronic kidney disease, and recurrent acute kidney injuries requiring bilateral nephrostomy tubes. Discussion: Multidisciplinary management and early involvement of nephrology may result in improved outcomes in patients suffering from interstitial cystitis. Given the complex and potentially intransigent nature of the disease, nephrologists should be aware of potential standard and off-label treatments for these patients.