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American Urology Association (AUA) - San Francisco 8-13 May 2004

IICPN booth

The International IC Patient Network was once again represented at the annual American Urological Association (AUA) conference. Thanks to the AUA, we had a complimentary booth in an excellent location along the walkway between the two main exhibition halls, attracting a lot of callers.
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Toby & Jane Meijlink and Florentina Ferreyra on the IICPN booth
As expected, the conference in San Francisco was attended by large numbers of urologists from South America and it became clear to us that there is a great need for information on IC and associated disorders at all levels throughout South America. And this is by no means the only part of the world in need of help. Doctors came to our booth from many countries including China, Turkey, India, former Yugoslavia, Israel, Philippines, Qatar, Australia, to name but a few. They all need information for urologists (and gynaecologists) as well as information for patients and all took our basic IC leaflet to translate into their own language and own culture. And it is this cultural aspect that plays such an important role in many countries where bladder problems have traditionally been a taboo subject. Reaching these patients is not an easy matter. In the west, we tend to take internet with its vast information resources for granted. But most patients around the world still have no access to computers. This means that undiagnosed patients mainly need to be reached via doctors. A booth at a urology or gynaecology congress is a basic method of achieving this outreach. And the AUA conference is the world's biggest urology conference.

New studies

As might be expected of a congress and organisation on this scale, a wide variety of new research was presented. A few of the many studies have been selected below.


Ciprofloxacin and tamsulosin


Perhaps the surprise of the conference was the presentation of the results of the randomized, placebo controlled multicenter trial carried out by the NIH Chronic Prostatitis Collaborative Research Network to assess the effectiveness of ciprofloxacin and tamsulosin, the standard antimicrobial remedies prescribed for patients with chronic prostatitis and chronic pelvic pain. The results of the study were presented by Dr Richard Alexander from Baltimore who informed the understandably confused delegates that “Neither ciprofloxacin nor tamsulosin reduced symptoms of the disease after six weeks of therapy in men with moderate to severe symptoms of long duration and with many previous treatments”. According to Dr Alexander, the data do not support the use of these agents as empiric therapy for these patients. However, it should be emphasised that this trial was limited to 196 men with severe CP/CPPS who had already received extensive pre-treatment to which they had not responded. Bearing in mind that many millions of men probably suffer from this problem, perhaps this relatively small trial should not lead us jump to over-hasty conclusions since so much can depend on patient selection.

A RANDOMIZED TRIAL OF CIPROFLOXACIN AND TAMSULOSIN IN MEN WITH CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME – Alexander et al, AUA abstract 232


Serenoa repens

A study from 2 centres in Austria into Serenoa repens (Permixon) also known as Saw Palmetto suggested that this herbal remedy may lead to an improvement in patients with category IIIA/B chronic prostatitis/chronic pelvic pain syndrome.

PROSPECTIVE PLACEBO-CONTROLLED MULTICENTER TRIAL ON SAFETY AND EFFICACY OF PHYTOTHERAPY IN THE TREATMENT OF CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME – Reissigl et al, AUA abstract 233


Anti-proliferative factor (APF)


One of the most exciting pieces of information to be presented at the AUA in relation to interstitial cystitis was the study on the anti-proliferative factor by Dr Susan Keay and her group from the University of Maryland. This now offers us the opportunity of potentially being able to identify a biological marker for IC. The anti-proliferative factor (APF), which is now known to be secreted only by the bladder epithelium and was discovered in the urine of IC patients, appears to play a critical role in the pathogenesis of IC. The molecular structure has now been determined and this protein has been synthesized (a 9 amino acid peptide). It inhibits the epithelial cell cycle, contributing to the deterioration of the surface of the bladder. It causes an arrest of the G2 phase of the replication/proliferation. In more basic terms, APF profoundly inhibits the growth of cells lining the bladder wall. Dr Keay believes that it may cause the epithelial thinning or the ulceration seen in IC. This is an ongoing study which could eventually lead to the development of specific and more effective therapies for IC, and it could prove to be a biomarker for the disease and an indicator of disease activity useful for early diagnosis of IC. A further interesting aspect is that APF may also be useful for inhibition of bladder cancer cell prohibition. We look forward to hearing more in the not too distant future.

COMPLETE CHARACTERISATION OF AN ANTIPROLIFERATIVE FACTOR FROM BLADDER EPITHELIAL CELLS OF INTERSTITIAL CYSTITIS PATIENTS – Susan Keay et al, AUA abstract 359


Amitriptyline

Although amitriptyline, a tricyclic antidepressant, is one of the commoner types of medication used to treat interstitial cystitis, it has never been adequately studied until now. Dr A. van Ophoven from Germany carried out a randomised clinical trial with 48 patients to study the safety and efficacy of this agent, escalating the dose of amitriptyline from 25 to 100 mg a day depending on how the patient tolerated it. Dr Van Ophoven was able to find a significant improvement in symptom scores at 4 months. A major drawback of this drug is its anticholinergic side-effects.

A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF AMITRIPTYLiNE FOR TREATMENT OF INTERSTITIAL CYSTITIS – Arndt van Ophoven et al, AUA abstract 354


Evaluation of urinary pH

Nguan from Vancouver instilled alkaline and acid solutions intravesically in patients with interstitial cystitis but could not detect any pain differences. They concluded that further work is required to define the role, if any, of urinary pH in the pathophysiology of IC.

A PROSPECTIVE, DOUBLE BLIND, RANDOMIZED CROSSOVER STUDY EVALUATING URINARY PH ALTERATION FOR THE RELIEF OF SYMPTOMS OF INTERSTITIAL CYSTITIS – Christopher Nguan et al, AUA abstract 356


Electromotive Drug Administration (EMDA) and distention


Since there has never been a study carrying out a direct comparison of EMDA distention in the office with a standard distention under general anaesthesia, Amy Neuder and Dr C. Payne, Stanford performed a study with EMDA using lidocaine and hydrodistention. Using this technique in the office, they reached 102% of the same volume as under general anaesthesia. Their results suggest that EMDA is a very promising technique that may move hydrodistention out of the operating theatre and into the office.

OFFICE BLADDER DISTENTION WITH ELECTROMOTIVE DRUG ADMINISTRATION – EMDA – IS EQUIVALENT TO DISTENTION UNDER GENERAL ANAESTHESIA – Amy Neuder, Christopher Payne, AUA abstract 368.


Sacral neuromodulation


In a prospective clinical study, Dr Craig Comiter from Arizona evaluated the efficacy of sacral neuromodulation for the treatment of symptoms in patients with refractory interstitial cystitis. Of 19 patients who qualified for permanent implantation and were followed over a period of 26 months, 79% sustained reduction in pain scores by the last post-operative check-up. The conclusion is that sacral neuromodulation is a safe and effective treatment for the voiding problems and pelvic pain in selected patients with IC who fail to respond to other forms of treatment.

SACRAL NEUROMODULATION FOR THE TREATMENT OF INTERSTITIAL CYSTITIS – Craig Comiter, AUA abstract 361.


Decreased adrenocortical reserve


Bruce Woodworth and Tony Buffington (famous for his cat studies and seen sporting a cat emblem on his lapel at the AUA poster session) carried out an interesting study into decreased adrenocortical reserve in women with interstitial cystitis. The purpose was to further investigate adrenocortical function in women with IC. The results suggest that women with IC may have decreased adrenocortical reserve to respond to stressors such as a flare, as previously identified in cats with feline IC. A fascinating and potentially promising line of research that we will follow with interest.

DECREASED ADRENOCORTICAL RESERVE IN WOMEN WITH INTERSTITIAL CYSTITIS – Bruce Woodworth, Anthony Buffington, AUA abstract 362.


Potassium sensitivity test


In a study into the intravesical potassium sensitivity test (PST) by Joe Philip and Paul Irwin from the United Kingdom, the PST was incorporated into a formal urodynamic study to determine its usefulness in diagnosing IC. In their conclusions, they suggest that the PST may not act on the urothelial sensory mechanism but rather on the detrusor muscle.

CAN THE POTASSIUM SENSITIVITY TEST BE EXPLAINED BY AN EFFECT ON DETRUSOR ACTIVITY ? -
A PROSPECTIVE DOUBLE-BLINDED STUDY - Joe Philip, Paul Irwin, AUA abstract 355


Bladder cancer misdiagnosed as IC


In a retrospective review of 600 patients at Beaumont IC centre from 1998-2002 who had been diagnosed by minimally invasive means (potassium sensitivity test and PUF questionnaire) as is currently the trend in the United States, William Tissot and colleagues discovered that six of the patients had transitional cell carcinoma and had been wrongly diagnosed with interstitial cystitis. This indicates that patients suspected of having IC should receive a thorough workup including cystoscopy, cytology and upper urinary tract imaging. The researchers suggest that the number of misdiagnosed cancer patients may increase if the criteria for the diagnosis of IC are oversimplified.

A REFERRAL CENTER'S EXPERIENCE OF TRANSITIONAL CELL CARCONOMA MISDIAGNOSED AS INTERSTITIAL CYSTITIS – Tissot et al, AUA abstract 373.

Comment
Following on the above study, the IICPN has detected an increasing difference in investigation test trends between the United States and Europe. The USA has tended to opt for simpler, less invasive investigations, while Europe prefers more invasive but on the other hand more thorough methods of diagnostic investigation, aimed at excluding all other possible causes of the symptoms and leaving nothing to chance.


AUA Courses


You had to be up with the lark to attend the course presented by Philip Hanno MD on Interstitial Cystitis and related pain syndromes: definition, pathogenesis and management, held at the unsociable hour of 5.45 in the morning. Nevertheless, an amazingly large number of delegates caught the first shuttle buses at 5 am to attend this valuable course. Dr Hanno took us through the history of IC and criteria, bringing us to the problems faced today, starting with how to define IC and what the criteria should be. He then led us through the pros and cons of various diagnostic investigations and different approaches to treatment. This was a practical course and will hopefully have clarified basic aspects of diagnosis and treatment for attendees.

Comment
One major problem these days is that many changes have taken place in the diagnosis of IC but these have not been published sufficiently widely or sufficiently clearly for all doctors around the world to be aware of them. In recent years, new insights have been published in a piecemeal fashion and there has been a lack of any coordinated overview. There is also a widening gap between the approaches of the United States and Europe in the field of diagnostic tests. This course underlined the fact that different centres, factions and physicians all have their own concepts of IC, how to diagnose it and how to treat it and we are still a long, long way from reaching any kind of international consensus on any aspect.

A second course: Interstitial Cystitis: Chronic Pelvic Pain: Female Urinary Incontinence Work Up and Treatment, was presented by Deborah Erickson MD and Christopher Payne MD. Part of this course dealt with IC/painful bladder syndrome and part with incontinence issues. Christopher Payne began Evaluation of Pelvic Pain by reviewing the problematic issue of criteria. He summed up his own viewpoint as follows: “For the general urologist, there is no question but that a broad definition of IC/PBS is appropriate. While one may debate the optimum criteria for research, there can be no justification for denying treatment to a large segment of the population on the basis of arbitrary and unreasonable criteria.”

Deborah Erickson then discussed Treatment of Female Pelvic Pain and Interstitial Cystitis, including non-urologic pelvic pain and also touching on vulvodynia. On the subject of intravesical treatment, she suggested that discomfort could be minimised by using small catheters and lidocaine jelly. This is certainly an important aspect because catheters that are too large cause post-treatment pain and discomfort which the patient tends to link with the drug rather than the catheterisation. Some useful recipes for cocktails were given with inexpensive ingredients that could be used in most countries. This was a very patient-friendly approach with Dr Erickson emphasising that “A busy urologist may not have time for all the necessary patient support, so knowledgeable and sympathetic staff are crucial”. But that outcome could be improved by letting the patient tell her story, conveying that you care about her and providing an explanation of the symptoms that makes sense to her. In addition, decrease her feeling of threat by providing: an increased sense of control over IC, prompt help if she has problems, reassurance that IC does not usually progress. And that really seems to sum up the ideal physician!

Webcasts, provided by Prous Science, are available on the AUA 2004 site: www.aua2004.org, click on webcast. For information on IC, go to Highlights: Highlights of infection and inflammation. There is incidentally a wonderful lecture and slide show under State of the Art Lectures: the presidential address by Martin Resnick deals with the earthquake in San Francisco in 1906. Fascinating!

Jane Meijlink

   
updated 09.02.2006 13:09 © 2006-2018 International Painful Bladder Foundation (IPBF). All rights reserved.