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Q:

2/4/2014
I have a patient sent to me from the urologist for allergy testing because of severe interstitial cystitis. Should I do food and/or inhalant skin testing on this patient? I have not been able to find much evidence in the literature on this. Should I instead recommend avoidance trial of certain foods with out testing? Like soda/acidic/coffee/tea/spicy foods. No lab testing has been done. Should I perform autoimmune testing? (ANA?)

A:

Thank you for your inquiry.

Unfortunately, I am not going to be able to give you a definitive answer because the issue of the relationship between allergy and interstitial cystitis is unsettled and shrouded as much by myth as elucidated by science. There is a body of literature (I have shared examples with you below) dealing with the potential role of diet and atopy in the pathogenesis of interstitial cystitis, particularly eosinophilic interstitial cystitis. Articles dealing with this issue are peppered throughout the Urology literature, but there has been very little if any definitive work done on this putative relationship and, to my knowledge, there is no consensus standard to guide one in their approach to the problem.

In my own personal opinion, there is very little support for skin testing in this disorder. But because such cases have only been studied in small numbers, and there is, at least to my knowledge, no consensus, the best I can do for you is to give you a "taste of the literature" to help you come to your own conclusion. The articles that I have copied for you below are selected examples of such literature.

Two excellent articles available to you free of charge in their entirety are those by Whitmore (which discusses diet) and Yamada (which advocates for a role of allergy in interstitial cystitis). The putative relationship may well have been generated by the fact that elevated levels of tryptase and eosinophils have been found in the bladder in patients with cystitis (see Hellstrom, et al., copied below). But when others have looked critically at this issue (see Pearson, et al., copied below), a relationship between allergy and interstitial cystitis has been challenged.

In summary, there is no definitive answer. The articles will hopefully help you come to your own conclusion, but in my opinion, a relationship between allergy and interstitial cystitis has not been firmly established and appears to be tentative. But until larger, more disciplined studies have been performed, I do not feel comfortable completely ruling out such a relationship, and therefore ruling out skin tests completely, based upon what literature is available.

Thank you again for your inquiry and I am sorry to be so indecisive, but the literature does not justify a decisive opinion at this point.

Kristene E Whitmore, MD. Complementary and Alternative Therapies as Treatment Approaches for Interstitial Cystitis, Rev Urol. 2002; 4 (Suppl 1): S28–S35.

YAMADA T. Significance of complications of allergic diseases in young patients with interstitial cystitis. International Journal of Urology Volume 10, Issue Supplement s1, pages S56–S58, October 2003.

Pearson D et al. FOOD ALLERGY: HOW MUCH IN THE MIND?: A Clinical and Psychiatric Study of Suspected Food Hypersensitivity. The Lancet, Volume 321, Issue 83366, 4 June 1983, Pages 1259–1261.

Justin I. Friedlander et al: Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU International Volume 109, Issue 11, pages 1584–1591, June 2012.

Hellstrom HR, Davis BK, Shonnard JW. Eosinophilic cystitis. A study of 16 cases.
American Journal of Clinical Pathology [1979, 72(5):777-784]
The authors describe 16 examples of eosinophilic cystitis. Cases were predominately in older men, and usually were associated with other conditions of the bladder or prostate. In contrast, most of the 21 cases reported in the English language were in women and children who had a low incidence of associated bladder conditions, but often had allergic disorders and eosinophilia. It appears that either bladder injury or allergy predisposes to eosinophilic cystitis. The bladder-injury type probably occurs fairly commonly and can be misdiagnosed both clinically and pathologically. In most of the present series, the clinical diagnosis was carcinoma of the bladder, and some biopsy specimens superficially resembled specimens from cases of nonspecific chronic inflammation. There was muscle necrosis in most examples, and significant replacement fibrosis of muscle in all the latter sometimes masquerading as mucosal fibrosis. Giemsa stain for eosinophils and trichrome stain for muscle fibrosis are helpful diagnostic aids. Also, eosinophilic cystitis appears related to allergic cystitis and interstitial cystitis.

Sincerely,
Phil Lieberman, M.D.

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