Did your IC start with recurrent UTIs? This is one way in which IC may start, although, certainly not the only way. It seems that some may be separating these conditions and it is my opinion that they are not at all separate, but in fact different versions of the same thing.

 

Chronic conditions of the bladder did not start out being chronic. They started out being sporadic, typically, or, there were other signs that were uncorrelated. In chronic conditions of the bladder, there are what I refer to as Precipitating Factors (PF) of IC and Trigger Factors (TF). IC is a condition of many different patterns as the Precipitating Factors and Trigger Factors vary as much as the Constitutions And Genetic Factors (CAGF), Life-style Factors (LF), and Environmental Factors (EF) do. So when all of these are put together, one may get a clearer picture of what factors created the opportunity for a chronic condition to occur and what ultimately led to it's final onset.

 

The following is an excerpt taken from Dr. Matia Brizman's dissertation (may be found on Amazon) :

 

Treating Interstitial Cystitis with an Integrative Model of Classical Chinese anD Western MedicineS

 

 

Precipitating Factors

 

Precipitating factors include factors that begin to alter mucosal integrity throughout the body, referred to as hyperpermeability. This occurs primarily in the GALT (Gut-Associated Lymphatic Tissue), but may often occur in other body tissues such as urogenital tissue through MALT (Mucosa-Associated Lymphatic Tissue). Other tissues that often become involved are sinus, ears, eyes, lungs, and throat. Precipitating factors also may cause microbiological imbalancing such as the increase of indigenous flora including Enteroccocus, E. coli, and Candida Albicans. If these factors create changes in mucosal integrity of the intestines, it is referred to as hyperpermeability, and if it causes microbial changes in the intestines, it is referred to as SIBO (Small Intestinal Bacterial Overgrowth). Either condition may lead to the other. Furthermore, these conditions then in turn lead to LGS (Leaky Gut Syndrome), Bacterial Translocation (BT) or Microbial Translocation (MT). The dynamics of these syndromes are very similar and involve the abnormal transference of antigens into systemic circulation from the imbalance in the small intestine. In the case of BT or MT the transference is thought to be occurring through the normal physiological pathway of transcytosis entering from the M cells on Peyer’s Patches that are groupings of lymphatic tissues that line the small intestine, (Berg et. al, 1993) This is the pathway through which the mucosal system (MALT) communicates. And, LGS is said to leak antigens through paracellular migration, (Rona, 2006; Galland, 2006).

Many may agree that once the system becomes imbalanced all of these factors are generally involved but in different proportions. Other tissues then are often consequently affected from the imbalance in the small intestine such as, the mesenteric lymph nodes, urogenital tissue, reproductive tissues, eyes, ears, nose and throat, lungs and organs such as the spleen, liver, and kidneys (that ultimately affect the urinary bladder). The connections between the small intestine imbalance and the system tissues occur through the MALT.

In IC, the urogenital tissue may be primarily affected and not be stemming from a primary imbalance in the small intestine in some cases. However, it is more common for the small intestine to be the primary source of the imbalance.

These changes occur over time due to numerous and various factors. This author is of the opinion that these factors are numerous because primarily these factors have arisen due to the negative aspects of modern advances in health, medicine, and diet and are pervasive elements of our society.

Precipitating Factors are:

1. Poor diet that includes the over-consumption of sugar or sugar substitutes, and/or alcohol (and other substance abuse); or dietary practices such as anorexia, bulimia, vegetarianism.

2. Over-use of or inappropriate use of supplements such as laxatives, weight loss products, and others.

3. Overuse or inappropriate use of antibiotics, antifungals, steroids, NSAIDS, hormone prescriptions, and many other medications such as anti-depressants and anti-anxiety medications.

4. Chronic stress that may go as far as childhood and involve issues of bonding.

5. Certain repetitive exposures to chemicals such as those found in hair dyes, tooth whitening products, and, chlorine through water supply.

Changes to urogenital environment:

1. Transmission of sexual fluids containing certain pathogenic organisms.

2. Hormonal changes such as menopause creating mucosal and microbiological imbalances.

3. Changes in gastrointestinal balance affecting urogenital tissue through MALT.

There are numerous researchers focusing on the various kinds of imbalances referred to above occurring relative to chronic illness. In an effort to clarify these theories, while drawing conclusions regarding IC and other chronic disease from them, this author cites from the following researchers at the forefront of their fields, the first compilation of which is general followed by more specifically organized statements below it:

“Each organism lives in a continuous interaction with its environment: this interaction is of vital importance but at the same time it could be life-threatening. The largest and most important interface between the organism and its environment is represented by surfaces covered by epithelial cells. Of these surfaces mucosae represent in humans about 300 m² while skin covers approximately 2 m² surface of the human body. Starting from first hours after the delivery from the sterile uterine environment (mammalian foetuses are born germ-free) the interaction of the macro-organism with micro-organisms begins: the main portal of entry of microbes is skin and mucosal surfaces of the gastrointestinal, respiratory and urogenital tracts. Physiologically occurring interaction with bacteria leads to colonization of epithelial surfaces and this co-existence is usually harmonious, and beneficial for the host (commensalisms). A complex, open ecosystem, formed by resident bacteria and transiently present microbes interacting with macro-organism is founded. However, under some conditions the interaction with “endogenous” microbes can be harmful for the host (parasitism) and opportunistic infections can occur. The microflora interacts with its host both locally and systemically. (Tlaskalová-Hogenová, p. 97, 2006).

“While the skin surface is protected mechanically by several epithelial layers, surfaces of the gastrointestinal, respiratory and urogenital tracts, conjunctivae and outlets of endocrine glands are mostly covered with a single-layered epithelium and require, therefore, a more extensive protection: this is represented by a complex of mechanical and chemical agents responsible for effective degradation and removal of heterogeneous substances. In addition, both mucosa and internal environment of the organism are protected by a most effective innate and highly specific immune systems. Basic functions of the mucosal immune system are protection against pathogenic micro-organisms and prevention of penetration of immunogenic components from mucosal surfaces into the internal environment of the organism (barrier and anti-infectious functions). Another important function is induction of unresponsiveness of the systemic immunity to antigens present on mucosal surfaces (“oral, mucosal tolerance”) and maintenance of the homeostasis on mucosal surfaces (immunoregulatory function). Among the basic features of mucosal immunity differentiating it from systemic immunity, are strongly developed mechanisms of innate immunity and existence of characteristic populations of lymphocytes that differ from, e.g. blood lymphocytes in origin, phenotype and secreted products. Other features characteristic of mucosal immunity are: colonisation of mucosal surfaces and exocrine glands by cells originating from lymphatic follicles of intestine or bronchi (migration and homing of mucosal lymphocytes establishing the so-called “common mucosal system”) and the well-known epithelial transport of polymeric immunoglobulins produced by mucosal plasma cells through the epithelium (secretory immunoglobulins, mainly IgA isotype). A balance in intestinal mucosa may be disturbed by pathogenic micro-organisms and their toxins, or by inadequately functioning components of the mucosal immune system. On the other hand, an expression of pathologically increased immunological activity may induce various inflammatory processes. Thus, numerous chronic diseases may occur as a result of disturbances of mucosal barrier function or of changes in mechanisms regulating mucosal immunity. This may involve infectious diseases, inflammatory diseases (allergies), multiorgan failure but also autoimmune diseases developing either in their initial phase or throughout on mucosal surfaces” (Tlaskalová-Hogenová, p. 98, 2006). “The main mechanical barrier of mucosal surfaces is formed by a layer of epithelial cells covered with glycocalyx composed of complex glycoproteins. The epithelium of most mucosal surfaces consists of a layer of interconnected, polarised epithelial cells separated by a basal membrane from the connective and supporting tissue surrounding various types of cells present in the lamina propria. Intestinal epithelial layer is reinforced by tight junctions present in paracellular spaces of epithelial cells and forming an interconnected network. Tight junctions were found to act as a dynamic and strictly regulated port of entry that opens and closes in response to various signals (e.g. cytokines) originating in the lumen, lamina propria and epithelium. Tight junctions participate in preserving cellular polarity and are regarded as key elements in intestinal diffusion mechanisms.” (Tlaskalová-Hogenová, p. 99, 2006).

“It has been recently found that intestinal epithelial cells as an important part of the innate immune system are directly involved in various immune processes, in addition to their absorptive, digestive and secretory functions. (Tlaskalová-Hogenová, p. 99, 2006).

1. SIBO: (Lin, 2004) “Bacterial translocation, a known complication of SIBO, isthe

movement of gut bacteria from the lumen across the mucosalbarrier. In rats, experimentally induced SIBO leads to theappearance of gut bacteria in the mesenteric lymph nodes andvisceral organs. A potentially important consequence of bacterialtranslocation is immune activation. In a report of 11 patients,an increase in the number of intraepithelial lymphocytes wasobserved as mucosal evidence of this immune response to confirmedbacterial translocation. This adverse outcome could explainwhy the normal gut has defensive mechanisms in place to keepthe bacterial flora away from the small intestine, particularlythe bowel proximal to the ileum. It is well recognized that there is a high degree of overlapbetween IBS, fibromyalgia, interstitial cystitis, and chronicfatigue syndrome. While interstitial cystitis andIBS are diagnoses associated with hypersensitivity at thelevel of the bladder and gut, respectively, fibromyalgia maybe considered a kind of hypersensitivity at the musculoskeletallevel. Although the cause of the hypersensitivity in thesedisorders is not well understood, the striking overlap of hypersensitivityin these functional disorders suggests the possibility of aunifying explanation.

Lin (2004) has been correlating IBS, previously a symptom based diagnosis with a bacterial overgrowth in the small intestine. If we take this research which supports the argument for gastrointestinal disruption due to bacterial imbalance and combine it with the above information regarding the leaking of bacteria into the circulatory and lymphatic systems, it is very easy to see how bacteria may invade the body systemically and translocate into other organ systems, including the bladder. IBS commonly presents with a host of other problems, such as chronic fatigue syndrome, fibromyalgia visceral hypersensitivity, autonomic dysfunction, immune activation, and others, which, in the past have been regarded as separate issues. This practice is making increasingly less sense, challenging researchers to find the common thread that binds these conditions and may be the reason that such separation may be becoming “an artifact of medical specialization”. Small Intestine bacterial overgrowth (SIBO) may be that common finding. These researchers have verified that translocation of bacteria from the small intestine is possible and may travel to mesenteric lymph nodes as well as visceral organs as well as the presence of intraepithelial lymphocytes, substantiating the idea that the small intestine may become hyperpermeable, a controversial condition referred to as “leaky gut syndrome”. Lastly, sleep disturbance, flu-like symptoms of fatigue, anxiety, depression, and impaired cognition were among the immune responses linked with this abnormal condition of the small intestine disrupting the immune and autonomic nervous systems, (Lin, 2004).

(Rodriguez, 2005) has found in his practice that a disruption in gastrointestinal flora is the starting point for most chronic illnesses. He finds that this disruption weakens immunity and triggers the otherwise normally occurring trillions of non pathogenic bacteria and fungi into pathogenesis mode that create numerous chronic illness such as IBS, CFS, chronic anemia, skin disorders, and many others including chronic cystitis.

2. LGS: This is understood as a condition that provides passage between enlarged spaces, (also known as paracellular translocation) in the lining of the small intestine of “bacteria, fungi, parasites and their toxins, undigested protein, fat and waste normally not absorbed into the bloodstream in the healthy state” “Due to the enlarged spaces between the cells of the gut wall, larger than usual protein molecules are absorbed before they have a chance to be completely broken down as occurs when the intestinal lining is intact. The immune system starts making antibodies against these larger molecules because it recognizes them as foreign, invading substances. The immune system starts treating them as if they had to be destroyed. Antibodies are made against these proteins derived from previously harmless foods. (Rona, 2006). “Leaky Gut Syndromes are usually provoked by exposure to substances which damage the integrity of the intestinal mucosa, disrupting the desmosomes which bind epithelial cells and increasing passive, para-cellular absorption, (Galland, 2006).

3. Hyperpermeability: Numerous researchers are exploring issues of gastrointestinal hyper-permeability. This hypothesis is based upon the small intestine housing “the gut-associated lymphatic tissue (GALT), the largest lymphatic organ of the body” (Tlaskalová-Hogenová et al., 2004) and its central role in chronic disease. Due to the fundamental role of the small intestine in health, it’s imbalance becomes pivotal to the disease process affecting the body systemically including immune, nervous, endocrine and exocrine systems. Referring to imbalances of the small intestine, (Tlaskalová-Hogenová et. Al, 2004), states that, “A balance in intestinal mucosa may be disturbed by pathogenic micro-organisms and their toxins, or by inadequately functioning components of the mucosal immune system. On the other hand, an expression of pathologically increased immunological activity may induce various inflammatory processes. Thus, numerous chronic diseases may occur as a result of disturbances of mucosal barrier function or of changes in mechanisms regulating mucosal immunity. This may involve infectious diseases, inflammatory diseases (allergies), multiorgan failure but also autoimmune diseases developing either in their initial phase or throughout on mucosal surfaces.” “The intestinal epithelium represents the primary site for active transport of fluid and electrolytes from the gut lumen through the transcellular pathway; however the predominant route for passive transpithelial solute flow is the paracellular pathway. Gut mucosa serves as the main barrier to the passage of macromolecules, that is, foreign antigens entering the host via the oral route, components of commensal flora such as toxins. The majority of luminal proteins cross the intestinal barrier through the transcellular pathway, followed by lysosomal degradation. Lysosomal degradation changes proteins into nonimmunogenic peptides. Small but immunologically significant amounts of antigens cross the barrier intact form through the paracellular pathway. The paracellular pathway involves a subtle regulation of intercellular tight junctions that leads to antigen (mucosal) tolerance. When the integrity of the tight junctions is compromised for example, as a consequence of prematurity, exposure to toxins, drugs, or radiation, aberrant immune reactions to environmental antigens occur and could lead to inflammatory and autoimmune diseases.”(Tlaskalova-Hogenova et. Al, 2005, p.4). “The balance in intestinal mucosa may be disturbed by pathogenic microorganisms and toxins attacking the mucosa by qualitative or quantitative changes in the composition of mucosal microbiota, or by inadequately functioning components of the innate or adaptive immune system occurring in cases of dysregulated mechanisms of mucosal immunity or in immunodeficiencies. An expression of pathologically increased immunological activity may induce inflammatory processes of a different character, depending on the type and mediators of inflammation. Thus, numerous chronic diseases may occur as a result of disturbances of mucosal barrier function or of changes in mechanisms regulating mucosal immunity. The main characteristics of chronic ‘idiopathic’, inflammatory, and autoimmune diseases are tissue destruction and functional impairment as a consequence of immunologically mediated mechanisms that are principally the same as those functioning against dangerous (pathogenic) infections).”(Tlaskalova-Hogenova et. Al, 2005, p.4).

According to Crandall (2002), Candida grows on the contents of the intestine, and also penetrates the intestinal mucosa, disrupting the wall structure. This makes the gut wall more permeable, allowing the passage of microbial cells, partially digested food particles, and other molecules from the intestine into the blood stream. When higher than normal amounts of Candida antigens cross the ‘leaky’ intestinal wall and enter the bloodstream, they induce the synthesis of higher than normal levels of anti-Candida antibodies. Then these antibodies combine with the Candida antigens circulating in the bloodstream, forming immune complexes (Crandell, 2002, p. II-3).

Woodcock et al correlates a decrease in IgA with an increase in bacterial translocation outlining the barrier that IgA creates in reinforcing the intestinal mucosal barrier. Peyer’s Patches also are involved in the formation of IgA, an immunoglobin responsible for assisting in gastrointestinal barrier integrity. This author contends that as small intestinal health is altered, the Peyer’s Patches being a fundamental part of this dynamic can no longer produce adequate amounts of IgA, (Baugmart, 2002). IgA is used as one major marker in the diagnosis of gastrointestinal hyperpermeability (Galland, 2006; Miller, 2006).

4) MT or BT: Berg: Bacterial translocation may stem from 1) small intestine bacterial overgrowth, 2) immune deficiency, or 3) mucosal injury of the gastrointestinal barrier (Berg, 1995). “Bacterial translocation is defined as the passage of viable bacteria from the gastrointestinal tract to extraintestinal sites, such as the mesenteric lymph nodes complex, liver, spleen, and blood stream.” (Berg, 1995, p. 149). The same dynamic applies to Candida Albicans and other fungal microbes and is referred to as microbial translocation.“MLN is the first organ encountered in the translocation route from the GI lumen, is readily promoted by intestinal bacterial overgrowth. In fact, the degree of translocation of certain species of enterobacteriaceae to the MLN is directly related to their levels in the small intestine and cecum. The bacteria that translocate at the greatest efficiency from the GI tract to the MLN of monoassociated ex-germ free mice are Pseudomonas Aeruginosa and gram negative, facultative, aerobic enterobacteriaceae such as Klebsiella Pneumoniae, E.coli, and Proteus Mirabilis. Gram-positive, oxygen tolerant bacteria, such as Staphylococcus Epidermis and Lactobacillus Brevis, translocate at an intermediate level.” (Berg, 1995, p.149). “…it has also been suggested that macrophages and polymorpho- nuclear leukocytes engulf particles, including bacteria, at mucosal surfaces and transport them to abscesses, lymph nodes and other sites. Much more investigation is required to delineate the roles of cell-mediated immunity in the pathogenesis of bacterial translocation.” (Berg, 1995, p.151). “In the intestinal bacterial overgrowth model…indigenous bacteria translocate through the epithelial cells (intracellularly), rather than by interrupting tight junction to pass between enterocytes (extracellularly). Even overtly pathogenic organisms such as salmonella typhimurium and Candida Albicans are seen by microscopy to cross the mucosa intracellularly through intestinal epithelial cells.”(Berg, 1995, p.150). Berg goes on to correlate the affects of antibiotics and steroids with small intestinal bacterial overgrowth.

In fact, “In healthy individuals, bacteria are continually crossing the intestinal mucosa and are then transported into lymph and extra-intestinal sites, including the mesenteric lymph nodes, liver, kidney, spleen, and bloodstream. This phenomenon is known as bacterial translocation and occurs at very low rate and involves very small numbers of microbes in healthy individuals—most of the organisms being killed by the normal host defence mechanisms. The organisms most often associated with bacterial translocation are: E.coli, K. Pneumoniae, Enterobacter spp., Pr. Mirabilis, Enterococcus, Streptococcus spp., and Candida Albicans.” (Wilson, 2005, p.312). These bacteria have commonly been found in stool and broth urine cultures ordered by this author of her patients having IC.

“The passage of indigenous bacteria colonizing the intestine through the mucosa to local lymph nodes and internal organs is termed bacterial translocation and is a critical step in the pathophysiology of various disorders, from inflammatory bowel disease and sepsis to heart failure…What is more, bacterial translocation can also be detected in healthy people, with a frequency as high as 5% of the population assayed.”(Gorski et al., p.313, 2006)

4. Combination of the above phrases: “Intestinal barrier function regulates transport and host defense mechanisms at the mucosal interface with the outside world. Transcellular and paracellular fluxes are tightly controlled by membranes pumps, ion channels and tight junctions adapting permeability to physiological needs. Food and microbial antigens are under constant surveillance of the mucosal immune system. Tolerance against commensals and immunity against pathogens require intact antigen uptake, recognition, processing, and response mechanisms. Disturbance at any level, but particularly bacterial translocation due to increased permeability and breakdown of oral tolerance due to compromised epithelial and T cell interaction, can result in inflammation and tissue damage.” (Baumgart et. Al, 2002, p.685). (Riordan et al. 1997) finds that small intestine hyperpermeability occurs in SIBO and that Enterobacteriaceae are amongst the most common bacteria involved with this process. This bacterium is the one that this author finds to be the most commonly occurring in broth cultures of those having IC. The following quote comes from a study on microbial translocation specifically focused on Ecolab and Candida Albia’s, “ However, in many specimen, Candida were found to be budding both within macrophages and in the extracellular spaces. Perhaps 20-30% were within extracellular spaces, many of these free within lymphatics…. in the sub mucosal lymphatics, the organisms were found both free and within macrophages, sometimes associated with leukocyte aggregates…examples were seen in which a high frequency of translocation occurred through the mucosal epithelium covering Peyer’s Patches.” (Alexander et.al 1990, p. 503). “The most important finding of our study is that both large (C. Albicans) and small (E. coli) intact microbes and endotoxin translocated directly through morphologically intact enterocytes through a similar mechanism, which is different from classical phagocytosis and exocytosis.” (Alexander et.al 1990, p. 508). “While the current studies do not address the clinical relevance of translocation, they provide evidence that translocation of viable microbes and endotoxin occurs with great frequency through morphologically intact enterocytes.” (Alexander et.al 1990, p. 510). Some hypothesize that “absorption of antigens via intestinal lymphatic may be a significant source of systemic autointoxication” (McMillin et. Al, 1999 p.3). Autointoxication, the theory of intestinal toxins entering systemic circulation is an ancient theory that recently has sprouted routes with theories such as multiple chemical sensitivities and endotoxins (McMillin et. Al, 1999). McMillin et. Al correlate lymphatic absorption of antigens with psoriasis and other autoimmune diseases. They base their opinions on the concept of bacterial translocation that ultimately leads to multiple organ failure (MOF) and death. However, McMilllin et. Al are of the position that that autoimmune inflammatory responses are activated by bacterial translocation, and that MOF is the extreme result, and chronic disease is what lies between that extreme and health. (Husebye, 2005, p.2) in his review of bacterial translocation says, “The consequences (of bacterial translocation) of the host vary from none to life-threatening complications caused by electrolyte deficiencies and septic manifestations”.

These research studies illuminate the fundamental issues underlying the pathology of IC and other chronic diseases that often accompany the condition as theorized by this author. To further substantiate this connection, this author finds that the urine cultures conducted on her patients are often positive for the microbes commonly associated with MT above, i.e. E.coli, Enterococcus, K. Pneumonniae, Proteus Mirabilis, and/or Candida Albicans. And, (Keay et al, abstract, 1995) a researcher at the forefront of the field of IC found that “These data do not provide evidence that IC is associated with infection or colonization by a single microorganism. However, they do generate the hypothesis that the prevalence of microorganisms, especially bacteria at low concentrations, is greater in the urine of IC patients than of control subjects. If these results are confirmed by other controlled studies, the question of whether the presence of these organisms is a cause or a result of IC should be addressed.”

This author finds that there is often a different result between standard agar culture and broth culture urinalysis, however. Broth analysis is usually required in order to isolate the pathogens present in IC. This is a controversial issue, however, the consistency of results among patients warrants a need for a more research in this area.

Once homeostasis has been upset and this process is put into motion, pleomorphism can occur as well, complicating the process further (Appleton, 2002). (Palermo, 2003), of Washington University School of Medicine in St. Louis, is researching the issue of biofilms as a reason for ineffective antibiotic treatment in resistant and chronic infections. He describes the multicellular organism formed by thousands of bacteria working together that become a force too strong for the immune system and the antibiotics given to treat the infection. He further argues that the bacteria often reside within the tissues of the bladder rather than free flowing within the bladder organ often rendering negative results with urinalysis.

It is this author’s belief that we may only be on the cutting edge of discovering the numerous adverse affects that modernly used chemicals in medicine, diet, and other practices are having on the mucosal barrier that protects the internal environment from the external environment, and that this is the root of many chronic disorders including IC. It is this author’s opinion that if we alter many of our current practices, this disorder as well as many others may be eliminated.

Trigger Factors

 

The body will endeavor to protect itself against the precipitating factors through Compensation and store the pathology in its attempt to maintain Latency. Eventually, the body will be unable to continue the processes of Compensation and Latency because either too much Latency has accumulated or the body has become too depleted of the physical stores required to maintain the Latent state. In some cases, the trigger factor is so strong that precipitating factors are not required, but that is the exception, not the rule.

Basically what occurs during the precipitating phase is a change in the GALT affecting the MALT. The Western concepts of SIBO, LGS, MT and BT are the CCM processes of Compensation and Latency. Inflammation ensues from these conditions and affects other body tissue. As we said earlier in this text, Compensation and Latency present as chronic disorders involving inflammation primarily in areas such as muscles and joints (arthritis); eyes, ears nose and throat (allergies, chronic sore throats and ear infections, migraines); the pelvis (endometriosis, fibroids, cysts, PMS); skin (chronic skin conditions such as seborrhea, eczema, psoriasis); genital (chronic vaginitis, jock itch, vulvadynia); digestive system (chronic bloating and gas and IBS) to name a few examples.

The Trigger factor is the final onset of the disease process. The only exception is the acute onset of the sexually transmitted model. However, that too was created over time in the person the transmission originated from.

Trigger factors are identical to precipitating factors, the only difference being that it is the final step prior to the onset of the IC. Precipitating Factors and Trigger Factor may be the same or different. The Trigger Factor is the factor that finally brings the pathology to the urinary bladder itself, marking the time that the patient associates the onset of the disease. The only factors that are not precipitating factors but may be trigger factors are:

1. Childbirth: hormonal imbalance triggering an onset.

2. Surgical or medically invasive procedure that introduces a biofilm into the body

or triggers MT or BT.

The precipitating and trigger factors determine the course this disease takes and exactly how it will manifest itself coupled with, of course, the emotional and physical constitution and imbalances of the person.

The more suppression that has occurred, the more the pathology becomes complicated. Inappropriate treatments may also trigger Compensatory reactions as well.

The above trigger factors are non-issues for those with a healthy body. Childbirth, sexual activity, and menopause, for example will not cause problems for healthy persons. A surgical procedure, although traumatic, will not trigger IC without the precipitating factors in place first unless the way in which the procedure incited disease was the introduction of a biofilm.

Basic IC Syndromes

Syndromes involving direct change to GALT through its affect on mucosal tissue or microbiological balance:

1) Dietary factors are widely involved in adversely affecting the gastrointestinal system ranging from protein malnutrition (Berg, 1995) to the ingestion of chemicals. “In this age of widespread synthetic chemical production, our harmful environmental exposures are increasing at an alarming rate. Many of these toxic substances find their way into the intestinal tract through food, water and a variety of products that get into our mouths (e.g., toothpaste, mouth wash, dental amalgams, etc.). These substances damage the intestinal tract cells, thereby lowering host resistance to the microflora itself. A wide variety of pharmaceutical drugs such as steroids, birth control pills, NSAIDs, some chemotherapeutical agents, antacids, [H.sub.2] blockers, etc., can have profound effects on the balance of the gut microflora. Both of these factors can create an environment that favors changes in the ecological balance of the intestinal tract, thus setting the stage for the development of dysbiosis” (Saputo, 2006, p.6). Chemicals in foods that we ingest such as pesticides, sugar substitutes, preservatives have been implicated in contributing to disease and certainly food choices make a significant impact on the health of the gastrointestinal system. This author finds, as does researcher (Rona, 2006) that the combination between poor diet consisting of an overabundance of sugar and alcohol and processed foods containing chemicals contribute to gastrointestinal changes that lead to LGS. (Soffriti et. Al., 2005) published an article outlining the carcinogenicity of aspartame and the need to reevaluate its approval for use. (Newberne et.al,1988) correlates adverse morphological and functional changes in the lower gastrointestinal tract as well as other organs and tissues with sugar alcohols and some other foods substances.

2) Inappropriate Use Of Supplements

Inappropriately prescribed herbs and supplements can create pathology. Ephedra has been restricted for use by licensed Chinese medical practitioners by the FDA (acupuncturetoday.com, 2005) because of its misuse. Any herb, vitamin or supplement has the potential to adversely affect the gastrointestinal system that may create the underlying changes that lead to IC and other chronic conditions if improperly prescribed or not well-balanced to prevent potential adverse reactions. This author has drawn such conclusions through her experience with numerous case studies involving the use of ephedra (for weight loss), L-lysine (for herpes), and chronic laxative use. She has further noted numerous adverse affects during treatment with a full range of herbs and vitamin supplements that substantiate the impact they may have in health, specifically in this case of the bladder. Some informal sources have speculated the increase in histamine reaction that folic acid causes. This vitamin is commonly prescribed for women planning on becoming pregnant. For those newly recovering from IC, or for those with Precipitating Factors in force it is not, perhaps, a wise choice, as the increased histamine reaction may reignite the inflammatory response. This author has found this to be true. For cases further along in recovery, this does not seem to be a problem.

3) Medications

Many researchers underscore the connection between the adverse gastrointestinal affects with the use of certain kinds of medications, including: SIBO caused by antibiotics (Lin, 2004), LGS caused by antibiotics and NSAIDS, (Fratkin, 2006; Miller, 2006), MT and BT caused by antibiotics and immunosuppressive drugs (Berg, 1995; Miller, 2006), NSAIDS causing LGS (Galland, 2006; Miller, 2006), Increase of Gastrointestinal Candida from drugs that cause Candida such as Candida leading to MT (Birdsall, 1997; Berg et.al., 1993), (Galland, 2006) includes the following causes for gastrointestinal hyperpermeabilty: viral, bacterial and protozoan agents, ethanol, NSAIDS, anti-inflammatory drugs, cytotoxic drugs, hypoxia of the bowel, elevated levels of reactive oxygen metabolites (biliary, food-borne or produced by inflammatory cells). (Rona, 2006) includes most of the preceding information and adds to the list prescription hormones, diets that include refined carbohydrates, and chemicals in processed foods. (Saputo, 2006) also implicates hormone prescriptions among the medications capable of adversely affecting gastrointestinal balance.

The practice of poor diet coupled with the overuse of certain medications is a prescription for chronic disease such as IC. The following is interesting insights:

The PDR (2001) cites side effects such as Lupus-like syndrome. “Hypersensitivity reactions represent the most frequent spontaneously reported adverse events in world wide post marketing experience with nitrofurantoin formulations” (PDR, p. 2676), a commonly prescribed antibiotic in urology. Other antibiotics may cause renal failure, urethral bleeding, candiduria, vaginal candidiasis, intestinal perforation (which supports the correlation between chronic antibiotic use and leaky gut syndrome), oral candidiasis, and more. Candidiasis is seen in the severely immune compromised patients such as AIDS. With this in mind, these side effects support the idea of immune suppression. Other alarming side effects correlated with other commonly used antibiotics such as macrodantin may include irreversible lung damage or chronic active hepatitis, and pseudomembranous colitis, (PDR). NewScientist.com, (May, 2004) also correlates substantial side effects from compromised immune function to tissue degradation after chronic use of antibiotics.

In CCM philosophy, antibiotics are considered to be Bitter and Cold, and drive the pathogen in further and produce more “Compensatory” reactions causing Latency (Yuen, Oncology, 2002), mutating the Yin and Yang physiology. Through the cycle of Compensation and Latency the use of antibiotics creates a worsening of pathology.

The numerous studies this author has cited through this work have substantiated the once the immune system is weakened, it cannot adequately protect a person when faced with a new virus or bacteria, and the body may then suffer from repeated attacks of sickness, requiring more and more extensive treatment protocols (Keep AntibioticsWorking.com, 2003). The chronic use of antibiotics changes the internal environment in the gastrointestinal system (PDR, 2001, p. 3069), the consequent changes to that become the mechanism causing disease.

It has also been more recently understood that certain antibiotics actually disrupt hormonal activity. Nitrofurantoin, often prescribed for urinary infections (Gillespie, 1996), is one example of an antibiotic that disrupts hormonal functioning. This particular antibiotic shares some side effects such as life threatening colitis with other antibiotics (PDR, 2001). Fungicides also disrupt hormonal production. Fungicides inhibit the formation of fatty compounds known as sterols. Without sterols, cell membranes become “leaky,” which in turn allows toxins to enter tissues that would otherwise be protected from them, (Gillespie, 1996, p.104). Tissues become compromised by the overuse of antibiotics (Gillespie, 1983, p.104) coupled with the side effects of candidiasis that antibiotics are documented to cause (PDR, 1994;Crandall, 2002). Once this process has been set into motion, the Candida may be able to penetrate through tissue cell membranes and reach the inside of epithelial cells, which may provide safe haven for microbes, preventing effective treatment by antifungal agents. Crandall (2002) refers to this condition as “latent intracellular yeast” (p. II), interesting terminology in light of the current work. This author and researchers, Schilling, Mulvey & Hultgren (2001) contend that this same process may occur with bacteria as well.

5) Stress

“The intestinal barrier includes physical diffusion barriers, regulated physiological and enzymatic barriers, and immunologicalbarriers, all of which are under neurohormonal control and thereforepossible targets for influence by stress. The continuous epithelialcell layer, interconnected by tight junctions, restricts bothtranscellular and paracellular permeation of molecules, thus constitutingthe principal component of the intestinal barrier. In addition, ^the epithelium exerts an important physiological defense by secretionof fluid and mucus, together with secretory IgA, into the lumento dilute, wash away, and bind noxioussubstances. A disturbance of intestinal barrier function has been suggested as an etiologic factor in Crohn's disease andfood allergy. In several other disease states, anincreased mucosal permeability is implicated in pathogenesis anddevelopment of complications, e.g., viral and bacterial gastroenteritis,ulcerative colitis, and multiple organ dysfunction syndrome inpatients with sepsis and trauma. "Leaky gut syndrome" is a currenttopic of interest on the Internet. In this syndrome, uptake ofvarious noxious substances from the gut lumen is considered tolead to a range of disorders; however, few of the claims are substantiatedby conclusive scientificevidence.”(Soderholm et al., p. G-7, 2001).

Gastrointestinal permeability changes and elevations in barrier-altering strains of E. coli have also been linked to stress induction, (Baumgart et al, 2002) found that corticosteroids induced by stress impair wound healing by the inhibition of the migration and proliferation of epithelial cells. They theorize also that there may be a connection between mast cells secreting steroids and the central nervous system. Lastly this review article discusses the affects of surgical stress on the gastrointestinal phenotypes and properties of microflora that is capable of negatively influencing gastrointestinal barrier. Numerous other researcher link stress as a trigger for “Our results indicate that psychological components of social stress facilitate the translocation of indigenous bacteria into the host, thus identifying an additional facet through which stressors may impact health.”(Baily et al, p.29, 2006).

“The studies reviewed here indicate that various types of physical and psychological stress have an impact on several componentsof intestinal barrier function, (Soderholm et al., p. G-12, 2001)”.

Chronic stress that may go as far as childhood and involve issues of bonding is a frequently occurring problem with IC. The idea that the emotions may have an effect on the gastrointestinal system as well as the entire body is not new, but, many with IC are told that this condition is psychosomatic, prompting feelings of guilt and generating a negative sense of self. While Chinese medicine contends the mind and body are inseparable, manifestations of IC pathology are real and not imagined. However, emotions may play a role in both the precipitating and complicating factors by the impact they have on a person’s physiology in the opinion of this author based on her experience coupled with the results of the studies cited within this text.

In the experience of this author there are common family histories of the IC patient. Often one parent, typically the mother, was not nurturing and frequently was in addition over controlling. The person may have gown up feeling a lack of maternal caring, feeling like nothing that they do can ever possibly be good enough. They tend to strive for validation in every relationship in which they engage, which is a reflection and an extension of the void caused by and remaining from childhood. This author hypothesizes that this personality trait sets up various physiological responses that occur from chronic stress.

Within the paradigm of classical Chinese medicine, there is a strong correlation between a lack of nurturing by the primary caretaker and the development of bowel problems and cystitis. Often childhood is the beginning of the “breakdown” of various systems in the body, starting with the hypofunctioning of these two organs to process toxins outside of the body. If constipation sets in, and chronic bowel aids are required, this becomes part of the precipitating effects of disease.

If we look at some of the kinds of disruptions in physiology that may occur from a Chinese medical perspective, a few examples are interruptions in critical meridian system functions such as the Ren or Dai meridians. Interruptions in body energy systems may ultimately lead to Compensatory conditions such as Yin Fire, the accumulation of Damp Heat in the Dai Meridian, or Kidney/Liver imbalances affecting urinary function. These are only a few examples of imbalances that may be caused by the emotions that may lead to the development of IC.

Chronic stress and adrenal over activity may be translated as an increase in Yang in Chinese medicine. Over time, this may deplete Kidney Yang according to Yuen (Endocrine, 2004), an affect that may compromise both the function of the Kidneys themselves as well as immune function. This increase in adrenaline, Yang, in turn makes the blood more acidic. Responding to the increased acidity, the parathyroid gland endeavors to neutralize it by pulling calcium from the bones and sending it to the blood, (Yuen, Gynecology, 2004). This is a common endocrine imbalance resulting from the chronic stress that a person having IC experiences. For this reason, these kinds of patients have imbalances in their body’s Ph, which translate into Chinese medical terms as imbalances in Yin and Yang. Once identified, these imbalances may be treated appropriately, instead of purposefully taking supplements to alkalinize the blood, which puts a person at risk for slowing down the blood and leading to such things as high blood pressure, high cholesterol levels, and other disease cased by stagnancy of the blood such as tumors (Yuen, 2004). Furthermore, constant emotional strain is said to cause “Liver Qi constraint” in Chinese medicine, which, in turn, can produce Heat and if untreated, eventually Fire Toxins, which, in turn, may consume Blood (Yuen, Oncology, 2003). Ultimately these processes affect Yin, Jing, and Body fluids, leading to the degradation of tissue and body fluids in the body, another very common issue among those with IC, affecting the GI and urogenital tissue triggering IC. We see examples of this within many aspects of Chinese medicine; one example is within Divergent theory where the Blood becomes exhausted from long-term depletion of body fluids due to the body endeavoring to expel retained pathogens from the body (Yuen, DM). The depletion of body fluids further weakens Wei Qi, immune system and Jing. It is interesting to note that many chronically ill patients find that they no longer perspire normally. In IC, reduced or absent perspiration is a common phenomenon. These patients are very often dehydrated from the immune system becoming weaker over time and having drawn on other body resources to combat internal pathogens. In IC, the depletion of body fluids also leads to dehydration of urogenital and intestinal tissue.

Because of the emotional symptoms frequently exhibited by those having IC, symptoms that often accompany IC include high anxiety, chronic low-grade anxiety, obsessive-compulsive thought patterns, phobias, sleep disturbances, and depression. If the IC is treated correctly, one should expect the anxiety and the depression to subside to tolerable levels at minimum but optimally to go away completely. Debilitating fears of such things such as driving on freeways, heights or flying should not be further experienced once the bladder ceases to exhibit the symptoms of the disease.

In an article reviewing correlations between the brain-gut axis, (Mayer et. Al, 2006), discuss the connection between the brain and the gut and the complex role this relationship plays in homeostasis and chronic pain disorders. It includes the bi-directional affect that emotions and physiology (including food intake and the effects of metabolic products of enteric flora) play on one another. Such Western conceptualization of this dynamic perhaps offers a different credibility to the previous paragraphs regarding the connection between emotion and its involvement in IC.

6) Chemical Or Toxin Exposure

This author has found through her experience that reactions to certain chemicals can spur on dramatic increases in symptom levels. Included in these kinds of reactions are water that is not bottled spring water, tooth-whitening products, and hair dyes that are high in peroxide.

Other researchers have noted the following regarding this issue: Gillespie (1986) indicates that researchers have correlated high incidence of IC in areas known for toxicity in ground water. “…certain pharmaceuticals are now attracting attention as a potentially new class of water pollutants. Such drugs as antibiotics, anti-depressants, birth control pills, seizure medication, cancer treatments, pain killers, tranquilizers and cholesterol-lowering compounds have been detected in varied water sources.” (Arizona Water Resource, 2000, Vol 9, No.1).

Make sure the patient is not drinking chlorinated water or using peroxide in his or her healthcare products. "Long-term drinking of chlorinated water appears to increase a person's risk of developing bladder cancer as much as 80%," according to a study published in the Journal of the National Cancer Institute. "The drinking of chlorinated water has finally been officially linked to an increased incidence of colon cancer. An epidemiologist at Oak Ridge Associated Universities completed a study of colon cancer victims and non-cancer patients and concluded that the drinking of chlorinated water for 15 years or more was conducive to a high rate of colon cancer." “The strong oxidizing effects of chlorine cause hydrogen to split from water in moist tissue, resulting in the release of nascent oxygen and hydrogen chloride which produce corrosive tissue damage. The oxidation of chlorine may also form hypochlorous acid, which will penetrate cells and react with cytoplasmic proteins to destroy cell structure” (Department of Health, N.Y. State, 2006).

In UK publication, Daily Mail (2007), an article refers to findings that chlorine exposure drinking, bathing, and swimming is elevating the chances of bladder cancer by enormous percentages varying between 57-83% depending on the type of exposure. Scientists are now exploring other methods of water purification.

“But in 1974, scientists discovered that when chlorine is used to disinfect water, it can react with natural organic matter to form chemicals known as disinfection by-products. Chronic exposure to chlorine and chlorine by-products may cause liver, kidney, heart, and neurological damage, as well as effects to unborn children, according to the EPA.” “Environmentalists say that clean water is worth the cost of increasing regulations, and that too many Americans are drinking inadequately treated water. The nation's supplies still contain dangerous contaminants, including synthetic organic chemicals, lead, arsenic, and fecal wastes, possibly bringing increased risks of cancer, birth defects, and infections. Industrial toxic wastes are discharged into rivers and streams or disposed in landfills, pits, lagoons, and dumps where they can leak into shallow water tables connected to lakes and streams, and eventually into aquifers. Oil and other contaminants run off streets and parking lots into waterways. And pesticides and fertilizers spread on lawns and cropland filter through the soil into the water table or wash directly into lakes and streams, which supply half of the nation's drinking water.” (Tibbetz, 1995, Vol 103, No. 1).

“We are quite convinced... that there is an association between cancer and chlorinated water,” wrote The Medical College Of Wisconsin research team, and further indicated, “The long-term effects of chlorinated drinking water have recently been recognized. According to the U.S. Council Of Environmental Quality, ‘Cancer risk among people drinking chlorinated water is 93% higher than among those whose water does not contain chlorine.’” (May 15, http/:www.cancer prevention.net). This citation along with the two that were cited earlier in this work regarding chlorines propensity to cause specifically bladder and colon cancer in addition to its corrosive properties provides enough compelling information to back up the argument for the need for a further look into water being some contributing factor in IC.

Topical administration of harsh substances may also have severe adverse reactions on the body. One such example is hair dye that may have similar adverse effects. Hair dyes contain peroxide, ammonia, and resorcinol, which have been linked to bladder cancer, “We believe these results provide further evidence supporting a causal association between permanent hair dye use and bladder cancer risk,” said Manuela Gago-Dominguez, M.D., Ph.D., researcher in preventive medicine at the Keck School and USC/Norris Comprehensive Cancer Center and lead author of the study (National Institute Of Environmental Health Sciences, 2005) and most tooth whitening products contain heavy amounts of peroxide.

Environment plays an important part in a person’s health and in some cases may cause illness. This author has had experience with the home environment being contaminated with mold and potentially contributing to their disease. The problem of mold has been the subject of many recently published studies in the United States, with a number of authors noticing the correlation of mold with high allergen counts in the populous, such as the article published in the Patriot News by David Wenner regarding Harrisburg, Pennsylvania. Numerous companies test homes for molds and toxins if one suspects the home as a source of toxicity for the patient. Suggesting that a patient’s home is wise to identify cause and the prevention of cyclical re-infection.

7) Surgery or medical procedures may also insight the translocation of bacteria or introduce bacteria into the system and commence the disease process understood as biofilm, a multicellular organism co-existing in a “matrix like eggs in a carton”, (Pallermo, p.A30, Los Angeles Times, 2003). In a study published in The Journal Of Clinical Pathology, (Woodcock, et al) substantiate bacterial translocation in normal patients undergoing certain surgical procedures. Many may agree that underlying factors, this author refers to the term “precipitating factors”, are required for a person to be vulnerable to the penetration of a biolfilm in order for it to be successful in attaching itself to the tissues of that person.

Changes to mucosal or microbiological balance of the urogenital environment:

1) Transmission of sexual fluids containing certain pathogenic organisms.

This syndrome may occur insidiously or acutely. If it occurs insidiously, it is usually because the sexual fluids of the partner of the person having contracted IC contain low-level pathogenic microorganisms due to the imbalance described above. Eighty percent of men carry microbes in his sperm according to Wilson (2005). This author theorizes that repeated exposure to such organisms might ultimately lead to IC because the mechanism causing the infection has not been addressed. Although the initial infection may be effectively treated with antibiotics, if reinfection continues to occur and numerous cycles of antibiotics are prescribed the condition of IC will likely occur through the consequent affects of this dynamic on the urogential and systemic chemistry.

The acute aspect of this syndrome is similar but hastened, often due to the strength of the pathogen and the relative weakness of the person infected. These kinds of infections often are owing to indigenous pathogens such as Enterococcus, Candida Albicans, and E.coli, but are not limited to those specifically. Ureaplasma is one pathogen that also may be transferred in this way. As previously mentioned, biofilm formation may further complicate this kind of infection creating resistance and chronicity.

Some pathogens that are sexually transmitted are not specifically screened for such as Ureaplasma. In such situations, the infectious process is often misdiagnosed and mistreated. Because of this misdiagnosis, ineffective antibiotics are administered that are not effective against the organism allowing it more time to proliferate, while the antibiotics themselves create more microbial translocation side effects and chronic disease ensues from that point. Although Warren et al disproved Ureaplasma as a causative factor of IC because he found that only a small percentage of his test studies were positive for the bacteria. However, if one is open to IC not being caused by one pathogen or factor, but rather a pathogenic process involving various pathogens and similar factors, then one may rethink Warren’s results.

“Most mycoplasmas that infect humans and other animals are surface parasites, adhering to the epithelial linings of the respiratory and urogenital tracts. Adherence is firm enough to prevent the elimination of the parasites by mucous secretions or urine. The intimate association between the adhering mycoplasmas and their host cells provides an environment in which local concentrations of toxic metabolites excreted by the parasite build up and cause tissue damage.”(Razin, 2006). “Mycoplasmas can even cause RNA and DNA mutation of the host cells and have been linked to certain cancers for this reason. Mycoplasmas can also invade and live inside host cells that evade the immune system, especially white blood cells. Once inside a white blood cell, mycoplasmas can travel throughout the body and even cross the blood/brain barrier, and into the central nervous system and spinal fluid.”(Taylor, 2001). This is another example of transcellular migration and is not unlike what this author hypothesizes is happening in the process of IC.

Sexually transmitted Candida Albicans may also have a similar pattern, as it is not widely acknowledged as a sexually transmitted pathogen that may cause problems to the degree that is experienced in IC. But, in this author’s opinion and is the opinion of some others cited within this text, it can indeed cause such systemic reactions.

In this author’s experience, treatment of these organisms can be long and tedious, much like treating the type of IC involving the presence of resistant strains of organisms. Ureaplasma and mycoplasma are highly resistant organisms often asymptomatically present. They are frustrating and time-consuming to treat, both with antibiotics and herbal therapy. Diagnosis is critical in order to formulate a treatment plan strong enough to resolve the problem.

Identifying the underlying mechanism behind the disease process and cross-referencing it with the pathogen or pathogens present facilitates a more effective treatment.

2) Hormonal changes affecting vagina

“The flora of the vagina and the urinary tract consists of a well-balanced system of about fifty bacterial strains. Lactobacilli dominate the healthy flora of premenopausal women. They are believed to protect the host against infections by means of several mechanisms, including: (1) occupation of specific adhesion sites at the epithelial surface of the urinary tract; (2) stabilisation of a low pH and the production of antimicrobial substances like acids, hydrogen peroxide and bacteriocines; (3) the degradation of polyamines; and (4) the production of surfactants, which have anti-adhesive properties against the adhesion of pathogen. The balance can be disturbed by the overgrowth of indigenous bacteria of the vagina like Gardnerella, Bacteroides, Peptostreptococcus, Prevotella spp. or aerobic cocci, or by the invasion of foreign micro-organisms, such as Escherichia coli, Enterococcus faecalis, enterobacteriaceae, staphylococci or candida.” (deVrese et. Al., 2002, p.60). Atrophic vaginitis, vulvar pruritis and burning, chronic desire to urinate, and painful urination are all possible consequences of a changing vaginal chemistry (Natchtigall, 2002; Razz, Stamm, 1993). Due to the proximity of the urethra to the vagina, the urethra is often involved in this imbalance. Estrogen receptor cites may be stripped by some medications such as antibiotics causing general estrogen deficiency in the area of the urethra, vagina, and bladder, (Gillespie, 1986; Natchtigall, 2002). Other medications – such as, antidepressants or antihistamines – may also cause drying in the body, which ultimately may lead to urinary disturbances (Natchtigall, 2002).

The following is from an article discussing the many aspects involving microbial and hormonal balance in the vagina “A recurrenttheme is that various factors, including nutrients, antimicrobials,and arriving bacteria, change the properties and the compositionof the biofilms. In women, other factors such as hormonal concentrations,particularly estrogen, as well as changes induced by oral contraception,glycogen content, vaginal pH, steroid therapy, immunosuppression,and diseases (e.g., diabetes mellitus) all influence the compositionof the bacterial biofilms,” (Reid, p.440, 2001).

Crandall, (2002) discusses the difficulty in treating vaginal Candida in this setting. Chronic antibiotic use often causes vaginal Candida, which in turn is treated with antifungal medication. Fungicides also disrupt hormonal production. The two often are involved in a cycle, which becomes repetitious. If the cycle occurs and both medications cause a disruption in hormone balance as well as gut flora, hormonal changes complicate the syndrome (Gillespie, p.104).

Hormonal deficiencies, such as those found in menopause, are basically “Kidney essence deficiencies in its Yin or Yang aspect”, (Maciocia, 1998, p.742) marked by estrogen deficiency causing such pronounced changes such as vaginal dryness, (Maciocia, 1998). The most common problems associated with menopause are atrophy of the urogenital epithelium and skin, vasomotor instability (hot flash), and osteoporosis, (Harrison’s 1994).

In Chinese medicine we say that the Jing, Yin, and Blood are in a state of decline. This is a normal physiological process called aging, (Yuen, 2003). However, this process has the ability to cause problems. If the vaginal area becomes dry, the change in its chemistry will likely activate the present but otherwise benign bacteria in that area. These bacteria and yeast can become pathogenic, creating vaginosis and urethritis, (Nachtigall, 2002). Although estrogen in some cases is often an effective method of treatment for this condition, in chronic conditions involving overabundance of bacteria and Candida, it is this author’s belief that supplementing with estrogen alone will make the patient feel worse. Simultaneous treatment directly addressing these pathogens must be used in addition to the estrogen.

Younger women may have menopausal-like patterns of imbalance with or without clinically low serum hormone levels. In this author’s experience, these cases as well as with some older women having clinically lowered estrogen, treatments without estrogen may be more effective.

Determining the level of Deficiency (hormone deficiency or tissue affect) vs. Excesses (microbial presence) by using Western and Chinese diagnoses to formulate an opinion provides a more thorough approach in treatment in consideration of breaking the underlying mechanism behind the condition.

Hormonal imbalances are also created by the use of chemical birth control. Injections of Depo-Provera for the suppression of gonadotropins prevent follicular maturation and ovulation, resulting in endometrial thinning, which all in turn prevent menses and ultimately, pregnancy, (PDR, 2001, p.2596-8). The use of chemicals of this nature may lead to urinary urgency and frequency slowly over time.

Stimulation of progesterone only birth control therapies are antagonistic to estrogen, leads to a drying of the tissues in the body overall (PDR, 2001). Estrogen is repairing and healing in nature. Without the abundance of estrogen, the tissues become more vulnerable to microbiological changes, tissue integrity, and infection (Razz & Stamm, 1993). Birth control pills may be correlated with changes in cervical erosion and secretion (PDR, 2001). Once this chemistry change has occurred, the balance will be altered. The bacteria and yeast, which are present in lesser quantities in the vagina, will become overabundant and take advantage of the then-compromised tissues. Most importantly, birth control pills are correlated with having the propensity to cause both vaginal candidiasis and “cystitis-like syndrome” (PDR, 2001, p. 2377) and are the result of the dynamic of disruptions in estrogen to progesterone balance.

To explain this theory further, the most basic premise of Chinese medicine is the balance of Yin and Yang (Kaptchuck, 1983). These two energies need to be balanced in each organ system for that system to work. The term “organ systems” is used because each organ is related to more than what we understand the organ to be from a Western medicine point of view. For example, one of the physiological functions related to the Kidneys from Chinese medicine’s viewpoint is hormonal activity. (The Kidneys are also related to many other functions, but hormonal activity is one of the main systems.) If the Kidneys are not healthy, an imbalance will occur in each system to which it is related. The Urinary Bladder is anatomically connected to the Kidneys. With this physical connection in mind, it is not a far stretch to associate anything happening to the Kidneys as affecting the Urinary Bladder. Even in Western terms, Kidneys may be affected, with birth control pills linked to impaired renal function and even hemolytic uremic syndrome (PDR, p.2377).

As the pill or Depo-Provera shot is introduced into the body, it falsely regulates the hormone production, thereby, altering the body’s own, real production of hormones, (PDR, 2001, p.2596-8). However, the implications of the body’s own hormone production being manipulated is larger when looked at from the perspective of Chinese medicine. As mentioned above, the hormonal system correlates to the Kidneys, which, in turn, correlate to numerous other body systems. Manipulation of the hormones affects not only the hormone production, but also, everything that falls under the system of the Kidneys.

Surgical removal of the ovaries can create the onset of menopause and sudden loss of estrogen. Total hysterectomies often involve oopherectomy, and this can spur on estrogen deficient changes in the vagina and urethra and urinary consequences. This is another example of a hormonal balance that may underlie the consequent pathology of IC.

During pregnancy and after child birth there is a change in the hormonal chemistry that for a healthy woman will not lead to any abnormal reactions. The body will rebalance itself naturally. However, in a woman having precipitating factors in place, pregnancy and childbirth can act as a Trigger Factor due to the combination between the Precipitating imbalances coupled with the temporary hormonal changes during this time affecting the microbes in the vagina.

3) Changes in urogenital environment secondary to gastrointestinal changes.

“Both pathogenic and probiotic microorganisms may enter the urogenital tract by a variety of different routes. They come mainly from the colon and rectum via the perineum. However, when the immune system is stressed, translocation of gut bacteria through the intestinal wall is possible. Probiotic lactobacilli given orally can act via immunostimulation or inhibition of bacterial translocation. After entering the colon, they may alter the colonic microflora positively, and certain strains may reach the vagina and the urinary tract in a viable state. Alternatively, probiotics can be applied locally using appropriately treated tampons or gel beads, for example.” (deVrese et. Al., 2002).

“The mucosal barrier helps to maintain symbiosis between microbes residing in the gut and the host animal, and the integrity of this barrier is regulated by a complex network of physical, physiological, and immune factors which include dietary influences, the host environment (which can be modified by age, external factors such as antibiotics, and immune competency), and the indigenous microbial flora of the gut. Modification and/or breakdown of these factors leads to ineffective clearance or degradation of harmful ingested antigens and/or disruption of regulatory cell function resulting in mucosal damage, increased gut permeability, and overgrowth of harmful pathogens.”(Acheson et. Al., p.388, 2004).

Lymph tissue is associated with Mucosa-Associated Lymphoid Tissue (MALT) that is scattered throughout the mucosal surfaces of the body and further differentiated by its location as follows: Gastrointestinal-Associated Lymphoid Tissue (GALT), Bronchial/Trachial-Associated Lymphoid Tissues (BALT), Nose-Associated Lymphoid Tissue (NALT), and Vulvovaginal-Associated Lymhoid Tissue (VALT). These areas of lymphoid tissues form the lining between the inner and outer aspects of the human body that protects it from antigens, (Wikipedia, 2007). Peyer’s Patches within GALT develop during gestation, whereas, secondary lymphoid tissues such as NALT and BALT develop after birth (Spahn et. Al , 2007).

The small intestine houses “the gut-associated lymphatic tissue (GALT), the largest lymphatic organ of the body” (Tlaskalová-Hogenová et al., 2004). The lymphatic tissue in the small intestine is referred to as Peyer’s Patches and function as part of the digestive and immune systems. As part of their immune function, they serve as inductor sites that affect distal mucosal tissue. Tissue in the urogenital region is affected by GALT and NALT, (Brandtzaeg, 1999). In accordance with this and previous studies cited within this text, one can connect changes in the gastrointestinal environment and the affect it has on urogenital health.

As the organic changes take place in the small intestine and lymphatic pathways, the resulting disease will manifest differently in the human body depending on the factors that took place prior to the occurrence of such changes, the constitution and emotional tendencies of the individual, and how that person managed his or her physical responses to these factors. This is where one may see patterns within Chinese medical conceptualization as a useful tool in the application and treatment of IC in combination with the understanding of the Westernized pathogenesis.

Correlating Chinese medical relationships between the Small Intestine and the Urinary Bladder, coupled with CCM concept of Compensation and Latency with the Western dynamic of gastrointestinal changes, microbial translocation, and chronic inflammatory responses, creates a model for chronic disease that works well with IC and other related chronic illnesses.

Integrative Approach for Interstitial Cystitis: Formulation of Clinical Picture and Treatment Protocol

General Pathophysiology

The clinical picture may be formulated by a thorough intake providing insight into the syndrome creating the underlying process of the disease coupled with any applicable Western bio-analytical analysis such as hormone panels, blood tests, or cultures.

Treatment protocol rarely if ever, remains constant. As normal physiology is dynamic, the body in the diseased state is as well. The protocol should follow the changes of treatment. Recognizing the need for adjustments to the protocol is important in that one may otherwise presume that treatment has become ineffective.

Very different responses will be elicited to the same formulation at different times in treatment. It is not uncommon for a patient for a patient to feel attached to a given protocol and then to be dismayed by the negative changes that occur from it weeks or months later. This is due to the dynamic aspect of normal physiology as well as the dynamics of rebalancing the human body in chronic disease patterns.

Initial intake must identify the underlying process of disease, focusing on the following factors:

1. Determine whether the primary source of the pathology is the patient or the sexual partner of that person.

2. If the primary source is the patient, determine if the pathology is due only to the small intestine or hormonal changes effecting vaginal chemistry. Both may often be involved.

3. Estimate the levels of Deficiency (hormonal deficiencies or tissue erosion), and Excess (tissue inflammation or microbial presence) are involved in the clinical picture. Compensation and Latency should be accounted for through CCM diagnosis and cross-referenced with any Western bio-analytical information.

4. Factor in any other chronic diseases involved in the diagnosis and treatment plan. Common examples are Fibromyalgia, TMJ, CFS, Vulvadynia, or IBS. This will help guide proper diagnosis and treatment protocol.

5. Determine the degree to which a person’s emotions are involved in his or her pathology and recommend psychotherapy if applicable.

6. Assess any health issues that may be involved with the patient’s home or work environment such as mold.

Once the above facts are compiled, treatment may begin. Treatment must be based upon re-implementing homeostasis and slowly unraveling Latency.

The protocol is started with a diet used to allow the body to begin the rebalancing process, restrict adverse reactions, stabilize the internal environment, and optimize the effectiveness of supplementation.

The herbal and/or supplemental formula should be designed to delicately begin the process of addressing the conflict between the deficiencies and excesses by attacking the underlying pathology directly. This gentle approach will slowly “Decompensate” Latency and commence the return of the homeostasis.

Each case will be different, but the premise is the same. One must identify the problems and endeavor to treat the tonification and sedation issues simultaneously in designated percentages until the body slowly returns to a homeostatic state. This outline is good guide to developing treatment.

The rebalancing of Chinese or Western diagnosed imbalances with:

1) Sedation, to discharge Latency from the body, of Chinese or Western diagnosed excesses through:

A) Tonification including:

i. Yang tonification to strengthen Yang Qi, a precursor to Wei Qi, immune function. This will encourage the body to release toxic fluids from body tissue, muscles, and joints, lymphatic and circulatory systems, through the stool, urine, skin, and sexual fluid by promoting movement through metabolic stimulation.

ii. Mild Yin tonification to create “Decompensation”, This will encourage the body to release toxic fluids from body tissue, muscles, and joints, lymphatic and circulatory systems through the stool, urine, skin, and sexual fluid because the introduction of Yin will trigger the body to cease producing pathological fluids and to release the accumulations of fluids it has pathologically manufactured during the course of illness. The physiological explanation for this is that the tonification will positively affect the lining of the small intestine thereby reducing inflammation and the translocation of antigens. Yin tonics are not strongly recommended however; indirectly tonifying the Yin through the tonification of the Blood is more often advised.

iii. Blood (and Qi) tonification for body fluids and therefore Gu Qi, the nutritive function of the Stomach, one precursor of immune function, and Ying Qi, the inner aspect of Wei Qi. This will encourage the body to release toxic fluids from body tissue, muscles, and joints, lymphatic and circulatory systems through the stool, urine, skin, and sexual fluid through Decompensatory responses. Like ii. above, this occurs through the positive affect the tonification has on the lining of the intestine that in turn reduces the translocation of antigens. The application of Blood tonics is, in this author’s experience within the treatment of IC, more effective because they are lighter and less sweet than Yin tonics that will encourage the reparation of tissue and reduction of inflammation without encouraging the growth of the indigenous flora that must be reduced. In this author’s experience the use of Blood tonics appears to affect all of the mucosa associated lymphatic tissue (MALT) through their affect on the intestine.

And/Or:

B) The use of sedating herbs such as bitter cold herbs to drain pathologies such as Yin Fire, Damp-Heat, and/or the Fu organs and Bowels; in Western understanding to reduce the presence of pathogenic organisms.

The varying combinations of using herbs to positively affect the MALT with tonification, and to simultaneously reduce overgrown and possibly translocated indigenous microbes or other antigens with sedation, provides a balanced treatment that will slowly reverse the mechanism creating the illness.

The following tests may be helpful:

1. Broth analysis of female urine and seminal analysis of the male sexual partner.

2. Broth analysis of the male semen and urine and the urine analysis of the female sexual partner.

3. Urethral swabs from the patient and their sexual partner.

4. Comprehensive stool analysis to determine flora imbalances, IgA markers, and other markers indicative of gastrointestinal hyperpermeability such as lactulose/mannitol testing may be useful.

5. Serum antibody testing for Candida.

If acute health conditions arise, although the treatment of them will temporarily worsen symptoms, IC treatment must be diverted to the acute situation that has arisen.

The understanding behind developing these protocols rather than the duplication of them that is important. This author uses herbs within her experience and style, but other herbs may also be very effective if used within the philosophy of this work.

 

This Dissertation was finished and published in 2007, and so information contained in this excerpt reflects the first decade of my work. The second decade continued along the same lines with a lot of refinement of course and now going into the third with even more movement forward. I also don't agree completely with a few of the things I thought then.

 

I thought this reading would be good for the new readers who are unfamiliar with our work. I hope giving this exerpt helps give insight.

 

Dr. M