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XXth Annual Congress of the European Association of Urology (EAU), 16-19 March 2005, Istanbul, Turkey

Former seat of the Byzantine and Ottoman empires, once home to the fabulously wealthy sultans, the city of Istanbul is divided into European Istanbul and Asian Istanbul by the Bosphorus that has formed an important trading route since the dawn of history and is today a massively busy shipping strait. This sprawling city of some 17 million inhabitants has a skyline dominated by domes and minarets and an historic centre dating back to the earliest civilisations. Istanbul formed the backdrop to this year’s annual congress of the European Association of Urology attended by some 6,000 urologists from around the world.

The IICPN Foundation once again had an information booth providing info on diagnosis and treatment of IC and on various associated disorders. This year useful items on the IICPN booth included our summary of the latest diagnosis and evaluation guidelines which is also available on this website.


The annual congress of the European Association of Urology in Istanbul in March 2005 was the 6th consecutive year that there has been an IC information booth at this international congress. During this period, huge changes have been seen in the field of IC: changes in awareness, in attitude, in knowledge and above all in the willingness of urology associations to include PBS/IC in their scientific programmes. At the time of the first IC booth in 2000, IC was regarded with great scepticism in Europe and beyond. It was still considered by many to affect only middle-aged women of Northern European origin and by others to be "all in the mind". Today, we know that it affects people of all races and all nationalities, it features on most scientific programmes and many doctors are deeply concerned about how to give their IC patients the best possible treatment and support. Nevertheless, there are many countries around the world where there is still little or no awareness and many countries where treatment is either unavailable or unaffordable.

This year the EAU Congress press pack included a press release on IC which had this year achieved the status of "hot item" ! In addition, a state of the art lecture on IC was given by Professor J. Nordling of Herlev Hospital, Copenhagen, Denmark and a number of interesting posters/abstracts were presented.


State of the art lecture on IC


Professor J. Nordling from Copenhagen, who is also chairman of the European Society for the Study of Interstitial Cystitis (www.essicoffice.org), presented an overview of the main historic developments and the situation prevailing today. He described IC as “a painful, potentially disabling inflammatory disease of the urinary bladder of unknown etiology”.

In 1870 Lawson Tait described two cases of young females with a perforating bladder ulcer.
However, it was a little later in 1887 that this bladder disease was first described as interstitial cystitis by A.J.C. Skene who stated that “when the disease has destroyed the mucus membrane partly or wholly and extended to the muscular parietes, we have what is known as interstitial cystitis” [1].

In 1915 and 1918, G.L. Hunner described seeing what he believed to be an ulcer in the bladder of some of these patients. What he in fact saw were red bleeding areas high on the bladder wall. Due to the inadequate equipment at that time, he misinterpreted these areas as ulcers. Since then, this has been known as Hunner’s ulcer, although it is now believed to be a vulnus and not a true ulcer [2].

It was in 1949 that the first comprehensive review of IC was published by J.R. Hand in the Journal of Urology. This included 223 cases [3].


NIDDK 1987

The first step towards drawing up diagnostic criteria was taken at a workshop in 1987 organised by the American NIDDK and published in 1988 [4]. In the following year these criteria were revised, but unfortunately these revised criteria were never published in a scientific journal. [5]. Consequently many doctors were unaware of the revised version, leading to considerable confusion. However, it gradually became clear that these criteria – which were intended for research purposes and never for clinical diagnosis – probably excluded a substantial number of patients with the symptoms of IC.
In 1999, Philip Hanno et al carried out a study to examine whether patients actually fitted into these criteria and came to the conclusion that strict application of NIDDK criteria would have led to a misdiagnosis in more than 60 % of patients [6]. It became increasingly clear that the NIDDK criteria were too restrictive for clinical diagnosis and that new diagnostic criteria and a new definition were needed.

A number of international consultations on criteria have been held in recent years. The ICICJ held in Kyoto in March, 2003, which was the first meeting to bring international IC doctors around one table, revealed clear differences between the American and European viewpoints. In Europe diagnosis is conservative and tends to be based on the findings of a cystoscopy with hydrodistension and biopsy, while in the USA diagnosis may be based on the symptoms of urgency and frequency with the possibility of pain.

A meeting of European doctors held in Copenhagen in May 2003 was aimed at standardising procedures of evaluation for patients with IC or chronic pelvic pain covering: History, physical examination, laboratory tests, urodynamics, cystoscopy and morphology. This led to the publication of guidelines for standard diagnostic procedures in 2004 in European Urology [7]. These were further discussed and refined in Copenhagen in 2004. [An interesting ongoing discussion on criteria and a definition of IC with a wealth of reference material can be found on the ESSIC website: www.essicoffice.org then click on IC criteria]. Professor Nordling emphasised that glomerulations, once considered a hallmark of IC, are not specific to IC. It is possible, however, that Hunner’s ulcer may be specific, but the problem then arises as to what Hunner’s ulcer is exactly and no two doctors can as yet agree about that.


In the conclusions of the NIDDK Subcommittee on the Diagnosis of Interstitial Cystitis and Painful Bladder Syndrome following the Basic and Clinical Science Symposium 30 October-1 November 2003, it was decided that in the 15 years since publication of the original NIDDK guidelines there had been no high quality evidence to support the routine use of any diagnostic test in defining IC. Conclusions included the following:
Involuntary detrusor contractions (IVDC) should not be used to exclude a diagnosis of IC/PBS.
At this time there is no biomarker that can be used to diagnose IC.
Antiproliferative factor (APF) is a very promising potential marker.
The potassium sensitivity test (PTS) cannot be recommended for general use as a diagnostic tool for IC at this time as neither a high sensitivity or specificity has been established.
Cystoscopy is only required if other disease processes are suspected.
Bladder biopsy is indicated for abnormal cystoscopy or urine cytology.
Bladder distension has some value in diagnosis, prognosis and treatment but neither the sensitivity nor specificity has been established such that this test can be used to routinely establish or refute the diagnosis of IC.
There is no evidence that any questionnaire can be used to diagnose IC although any of the three published instruments might be used as screening tools.

Monaco 2004

At the 3rd International Consultation on Incontinence in June 2004 in Monaco, the committee on Painful Bladder Syndrome reached no conclusions but produced 9 recommendations for future research:
Investigate the cause and development of IC/PBS.
Conduct epidemiologic research.
Develop a simple, non-invasive diagnostic test for IC/PBS.
Investigate IC/PBS and co-morbid conditions such as vulvodynia, IBS, fibromyalgia, inflammatory bowel disease, chronic fatigue syndrome and other autoimmune diseases such as SLE and Sjögren’s syndrome.
Pathogenesis and treatment of pain in IC/PBS patients.
Conduct clinical trials of novel therapies, including pain medications.
Develop new, uniform diagnostic criteria for IC/PBS.
Encourage standardisation of biopsy techniques.
Resolve nomenclature of IC/PBS and its various subtypes [8].
 
Treatment

On the subject of treatment, Professor Nordling showed the following algorithm with a recommended approach to treatment:
c


He emphasised that most treatment for PBS/IC is empiric.

Oral remedies discussed and evaluated during the presentation included: Pentosan polysulfate sodium, Hydroxyzine, L-Arginine, Aercitin, Amytriptyline, IPD-115IT, Quercetin, Antibiotics, Methotrexate, Montelukast, Nifedipine, Misoprostol, Cyclosporine and Analgesics. Amytriptyline was recommended as a good starting therapy.

The intravesical therapies mentioned included: Resiniferatoxin, Hyaluronic acid, Heparin, Chondroitin sulphate, Lidocaine, Doxorubicin, Clorpactin WCS 90, Lidocaine electromotive plus steroid, Capsaicin, BCG, DMSO, Oxybutynin, PPS, Silver nitrate.

Sacral Nerve Modulation is a promising surgical treatment for IC/PBS but is still investigational.

Peripheral/sympathetic/parasympathetic denervation is NOT indicated for IC/PBS.

Bladder augmentation may consist of: cystoplasty, cystoplasty with supratrigonal resection or cystoplasty with subtrigonal cystectomy.

Total cystectomy and urethrectomy may ultimately be the only solution for some patients. Professor Nordling’s advice was that urinary diversion should not be delayed too long in patients with severe refractory IC. Urinary diversion may be performed with or without cystectomy and orthotopic continent bladder. While continent diversion may have a better cosmetic and lifestyle outcome, recurrence of IC in the pouch is a real possibility.

Surgical options should be a last resort when all other treatment options have failed. Patients should be informed of all aspects of surgery and understand the consequences and potential side effects of surgery.


Recommendations for patient evaluation
Professor Nordling concluded with recommendations for patient evaluation:
History
Focused physical examination
Urine culture
Cystoscopy with hydrodistension
Biopsies for morphological investigation (if you have an interested pathologist with knowledge of IC).
In 2005 there is still no consensus on a definition of IC and no internationally accepted diagnostic criteria. The result of this lack of international consensus is that every doctor has his own perception of what IC is and that this perception differs greatly from doctor to doctor. Consequently many patients remain either undiagnosed or misdiagnosed.


EAU Posters/Abstracts

Below is a selection of EAU posters/abstracts of particular interest to IC.


Abstract 353

Quality of life assessment post implantation of an electro stimulator for the treatment of interstitial cystitis

This study investigated the impact of pelvic floor electro stimulation on quality of life for determining the success of the miniaturo™- I implantable system in patients with interstitial cystitis. Conclusions were that evaluation of quality of life may be an additional useful tool for assessing the clinical outcome of pelvic floor stimulation for IC and that based on these results and correlation to IC symptoms, electro stimulation brings relief to IC patients.

Abstract 533
Interstitial cystitis: immune histochemical proof of human papilloma viruses (HPV) in bladder biopsies

This particularly interesting study investigated whether human papilloma virus mediates mast cell activity in our study population. HPV activity was found in 70% of the study population. The conclusion reached was that HPV (type 11, 6, 18) seems to be present in the mast cells of IC. The next step is a molecular biological test aimed at defining the role of HPV as a potential trigger.

Abstract 534
Comparative assessment of maximal bladder capacity, 0.9% NACL vs 0.2 M KCL before and after therapy for interstitial cystitis

In this study, comparative assessment of maximal bladder capacity was performed before and after GAG substitution therapy to assess post therapeutic changes in potassium sensitivity. Study data indicated that GAG substitution responders also show improvement of bladder function, suggesting correction of increased urothelial permeability in these cases.

Abstract 535
The therapeutic effect of intravesical heparin and peripheral neuromodulation on interstitial cystitis

This study on the effect of the combined use of intravesical heparin and peripheral neuromodulation led to the conclusion that this combination could be an alternative for patients with IC who have been unresponsive to other therapy.


EAU Guidelines Pocket Edition 4

This booklet in the EAU Pocket Guidelines Series includes Chronic Pelvic Pain with a section on Painful Bladder Syndrome and an overview of treatment.


Thanks to sponsor

The IICPN Foundation would like to thank the Medtronic Foundation for generously sponsoring its participation in this international event.

Jane Meijlink

 

References
1 Skene AJC. Diseases of the bladder and urethra. William Wood Publishing Company, New York 1887.
2 Hunner GL. Boston Med Surg J 1915172:660. Am J Obstet. 1918.78:374.
3 Hand JR. J Urol 1949;61:291.
4 Gillenwater J, Wein A. J Urol 1988; 1409:203 (workshop summary).
5 Wein A et al in Hanno P et al: Interstitial Cystitis-Springer Verlag. 1990, 3-15.
6 Hanno PM, Landis JR, Matthews-Cook Y, Kusek J, Nyberg L. The diagnosis of interstitial cystitis revisited: lessons learned from the National Institutes of Health Interstitial Cystitis Database study. J Urol. 1999 Feb;161(2):553-7
7 Nordling J et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). European Urology 45 (2004) 662-669.
8 Proceedings of the 3rd International Consultation on Incontinence, June 26-29 2004. Editors: Abrams P, Cardozo L, Khoury S, Wein A 2005.
   
       
updated 14.02.2006 15:59 © 2006-2018 International Painful Bladder Foundation (IPBF). All rights reserved.