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American Urology Association (AUA) - San Antonio 21-26 May 2005

IICPN Foundation booth – Many presentations and posters on PBS/IC – Excellent course by Philip Hanno MD and David Burks MD


San Antonio may be situated in the United States but it has a definite Hispanic flavour about it and is steeped in the history of the early Spanish settlers and missionaries and their constant struggle with recurrent flooding of the river. Following another major flood in 1921, much of San Antonio was reconstructed aimed at flood control of the river, nevertheless still retaining San Antonio’s historic links and characteristic style. Delegates at the AUA conference greatly enjoyed the river walks, river taxis and excursion boats in temperatures soaring to 100°F/38°C.


The IICPN Foundation once again organised a PBS/IC information booth at this conference, manned by Jane Meijlink and Florentina Ferreyra. With delegates from all around the world attending this conference, it was clearly very worthwhile having an international booth giving a specifically international approach to painful bladder syndrome/interstitial cystitis. With its emphasis on diagnosis and treatment with the latest treatment algorithms, information on PBS/IC and associated disorders and leaflets in a number of languages including Chinese and Hebrew, the booth had many satisfied customers, as demonstrated by the letters of appreciation received after the conference.

As might have been expected from the conference location not far from the Mexican border, the AUA annual conference was attended by many doctors from Central and South America. Awareness of painful bladder syndrome/interstitial cystitis in Latin America is rapidly increasing. It is now essential for the Latin American doctors working in the same languages (Spanish and Portuguese) to coordinate and collaborate with each other and perhaps consider a Latin American Painful Bladder Syndrome symposium, addressing issues of specific relevance to this part of the world. The patients in Latin America are already starting to work together with activities focused around the support group in Mexico, headed by Florentina Ferryra. With vast numbers of Spanish-speakers throughout the United States, the ICA is also creating more and more patient information in Spanish. The Spanish-speaking patients form a major challenge.


Excellent course on PBS/IC

For the IC world, the highlight of the AUA conference was undoubtedly the excellent AUA course on painful bladder syndrome/interstitial cystitis given by Professor Philip Hanno and Dr David Burks. This was an up-to-date and very realistic presentation of the current situation, with Professor Hanno reminding delegates that little is still known in concrete terms about this complex bladder syndrome and much remain hypothetical. We still do not know the cause, there is no definitive way of diagnosing it and treatment is trial and error and highly individual.


Prevalence

True prevalence is also an unknown factor since epidemiological studies around the world have produced hugely varying figures. Accurate epidemiological studies will only possible with e.g. a validated diagnostic marker; an evidence-based, symptom-specific definition that is sufficiently accurate for epidemiological studies and an ability to differentiate PBS/IC in men from a myriad of other causes of voiding dysfunction and “bladder” pain, according to Professor Hanno.


Name: Painful Bladder Syndrome including Interstitial Cystitis ( PBS/IC)

In his review of international consultations held since 2003, Professor Hanno stated that the name now to be used is Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC), possibly with a view to using only Painful Bladder Syndrome in the future or until further research identifies different entities within this category. The International Continence Society (ICS) uses the term “Painful Bladder Syndrome including Interstitial Cystitis” and defines Painful Bladder Syndrome as “suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and nighttime frequency in the absence of infection or other pathology”. Although the ICS reserves the term IC for painful bladder syndrome with “typical cystoscopic and histological features”, there is as yet no international consensus as to what these “typical” features in fact are.

According to Professor Hanno, it is not yet known whether the term IC will be synonymous with PBS or whether it will ultimately form a specific type of PBS. It is hoped that research in the coming years will shed further light on this.


Diagnosis

Due to the lack of any currently valid diagnostic criteria, diagnosis at the present time has to be based on the symptoms of pain, urgency and frequency along with the exclusion of all other possible known causes of these symptoms. Dr David Burks listed some of these which include common urologic disorders such as overactive bladder, bacterial cystitis/urethritis, uteral or bladder calculi and bladder carcinoma. Gynaecological disorders include urogenital atrophy, vulvar vestibulitis, endometriosis and pelvic neoplasms. Gastroenterological disorders mimicking PBS/IC include irritable bowel syndrome, inflammatory bowel disease, hernias, neoplasms and many more besides. However, he emphasised that doctors should be aware that PBS/IC patients may have one or more of these conditions concurrently with PBS/IC and that their presence therefore does not automatically exclude PBS/IC. Men are more difficult to diagnose because of prostate factors. Chronic prostatitis appears to be a different entity, despite the fact that glomerulations may be seen in these patients. This is a further indication that glomerulations are not specific to PBS/IC.


How many voids equal frequency ?

It is difficult to say how many voids a day can be considered normal. Whether a patient’s level of frequency is normal or not may greatly depend on the patient’s drinking habits and level of perspiration. The patient’s own perception of the frequency may be a more accurate indication than the actual number of voids. Many of the delegates were shocked to hear Dr Burks say that he has patients voiding so frequently (80x a day) that they are actually sleeping on the toilet. With regard to drinking habits, he explained that some patients will reduce drinking when they know they have to go out, while others drink more to reduce the concentration of the urine and thereby reduce the pain. This can distort the daily voiding picture. An interesting point, according to Dr Burks, is that history-taking may reveal that frequency dates back much earlier than the pain.


Urgency

The concept of urgency in PBS/IC still needs much further investigation but is possibly caused by discomfort, pressure or pain, according to Professor Hanno.


Pain

Professor Hanno explained that pain, and particularly pain as the bladder fills, is the feature that specifically distinguishes PBS/IC from overactive bladder. However, the source of pain may be difficult to determine and some patients may have minimal pain or do not perceive it as pain.

With so many variables, Dr Burks told the delegates that urologists therefore have to use their own judgement when making an assessment and that the biggest challenge is the atypical patient.


Diagnostic procedures

Diagnostic procedures begin with a detailed history and a focused physical examination, followed by urinalysis and urine culture. Dr Burks emphasised that the patient should be infection-free for at least one month to make a clear diagnosis. Professor Hanno included a frequency/volume chart at this stage.

According to Dr Burks, urodynamic studies offer little information relevant to the diagnosis of PBS/IC, but can help rule out neurogenic bladder and bladder outlet obstruction in men.

Both doctors emphasised that questionnaires should not be used for diagnostic purposes, but may be useful to assess the severity of the symptoms as perceived by the patient, the impact on the patient’s quality of life and to follow the patient’s response to treatment.

It was underlined that the controversial potassium sensitivity test (PST) is not sufficiently reliable to be used for diagnostic purposes.

In the past glomerulations in the bladder wall on cystoscopy were considered to be the hallmark of interstitial cystitis, however it is now known that not only do glomerulations occur in other disorders and in patients with no symptoms, but also that some patients with severe symptoms many display no glomerulations at all.

Both urologists hoped that the ongoing research into the antiproliferative factor (APF) would eventually produce a reliable non-invasive test. Diagnostic approaches vary around the world with Europe tending to perform cystoscopy and biopsy as standard procedures, with the USA seeing these as optional, bearing in mind that the findings are currently no longer seen as specific for IC. Cystoscopy and biopsy are now principally used to exclude other possible conditions such as carcinoma. However, Dr Burks emphasised that a Hunner’s ulcer should always be biopsied. Following biopsy, Hunner’s ulcers can be fulgerated or resected.


Clinical management

In his review of treatment, Professor Hanno explained that different treatments were aimed at treating different hypothetical causes. His list of treatments included pentosan polysulphate sodium, heparin and hyaluronic acid to temporarily replenish the bladder lining, different approaches to pain such as tricyclic antipressants and neurontin, antihistamines, immunological approaches, neuromodulation… The list was long and many treatments that initially seemed promising, such as resiniferatoxin, have been shown in further studies to be ineffective.


Multi-disciplinary approach for some patients

In his practical presentation on clinical management, Dr Burks stated that straightforward patients are simpler to diagnose and treat than patients with a multitude of associated medical disorders who may need a multi-disciplinary approach.

Based on his treatment algorithm, Dr Burks recommended delegates to start with education about the disorder and diet modification. In the mildest cases, a change of diet may be all the patient needs. The first line treatment he usually opts for is amitriptyline, starting at a low basic dose and increasing to what is best for an individual patient. If this fails or is not tolerated, other oral drugs such as PPS, antihistamines, analgesics and/or antispasmodics can be tried. The next stage may be intravesical instillations. Some patients benefit from hydrodistension, although the actual mechanism is still not fully understood. The refractory patient may benefit from neuromodulation, research protocols and pain clinics for opioid treatment. However, for the end stage patient cystectomy and urinary diversion may be the only option. Unfortunately in some patients phantom pain may continue after cystectomy and a continent diversion may lead to pouch pain problems. However, selected patients who undergo a cystectomy often experience a dramatic increase in their quality of life.

Dr Burks ended by emphasising that the patient support groups can play an important role in providing the patients with information about their condition and how to cope with it.

The AUA is to be congratulated on this very useful course.


Other presentations on PBS/IC at the AUA

Other presentations at the AUA conference on PBS/IC included a panel session with IC experts Deborah Erickson MD, Susan Keay MD, Christopher Payne MD, Daniel Shoskes MD, moderated by David Foster MD who heads the NIDDK’s Interstitial Cystitis Clinical Research Network. This panel session gave the delegates hope that new treatments might be available in the not too distant future, as emphasised by Dr Deborah Erickson, and that biomarkers may ultimately provide an answer to the current problem of diagnosis. Dr Susan Keay, well-known for her research into the antiproliferative factor, updated delegates on the ongoing research into this promising future marker test. Dr Payne, speaking on the difficult topic of pain management, emphasised that opioids play an important role in treatment for all pain conditions and that doctors treating IC patients should not be afraid to use them. Dr Shoskes discussed the similarities and differences between IC and chronic prostatitis in men.

Many delegates attended a course on Female Urology: Evaluation and Treatment of Incontinence and Interstitial Cystitis presented by Deborah Erickson MD and Christopher Payne MD which focused on outpatient evaluation and non-surgical management of women with urinary incontinence or interstitial cystitis.

A press briefing was held on IC by Dr Kristene Whitmore in the Press Centre at which she focused discussion on IC, answered questions on the disease and commented on an abstract presented on IC: Sacral versus Pudendal Nerve Stimulation for the Treatment of Interstitial Cystitis: A Prospective, Single-blinded, Randomized, Crossover Trial (293).

A substantial number of research posters were presented on different aspects of PBS/IC, further studies on treatment currently being trialled and studies on potential treatments were presented during the conference.


Webcasts

Webcasts of some presentations at the AUA can be found at either: www.aua2005.org/webcasts or www.prous.com/AUA2005.

Although these do not include presentations on PBS/IC, the armchair delegate will nevertheless find many presentations of great interest, including for example the Use of Botox in Urology, New Concepts in Molecular Pathogenesis of UTI, Myths and Facts about the Use of Bowel in Urology and Overactive Bladder: Risk Factors & Pathophysiology/Implications for Future Treatment, as well as the Highlights. And the advantage of webcasts is that if you miss a bit, or doze off for a second, you can always replay them!

The IICPN Foundation would like to thank Bioniche Life Sciences for their greatly appreciated contribution towards sponsorship of the IICPN Foundation booth. Also thanks to the AUA for providing complimentary booth space.


Jane Meijlink
   
updated 14.02.2006 15:59 © 2006-2018 International Painful Bladder Foundation (IPBF). All rights reserved.