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4th Warsaw Seminar on Neurourology    
 
3 December, 2005, Sofitel Victoria Hotel, Warsaw, Poland
 
The scene of the greatest devastation in the Second World War, the Polish capital of Warsaw straddling the river Vistula is literally a phoenix risen from the ashes. Little but rubble was left of the original city by the end of the war and virtually the whole city had to be rebuilt. A small area of the city, Stare Miasto or old town founded in the 13th century, was rebuilt immediately after the war as a faithful copy of the original, thereby giving the people of Warsaw at least a replica to remind them of their long, sometimes chequered, sometimes illustrious history. Poland, now a member of the European Union, today has its eyes focused firmly on the future.

stad

The rebuilt old town in Warsaw is no problem for patients. Clearly signposted toilets are to be found everywhere as the photographs show!

 
A wintry December day formed the backdrop to the highly successful 4th Warsaw Seminar on Neurourology, organised by Professor Andrzej Borkowski and Dr Piotr Radziszewski of Warsaw University and attended by some 370 Polish urologists, gynaecologists and neurologists. The title of the seminar was “Nocturia, overactivity and pain – symptoms or syndrome?” The International Painful Bladder Foundation (IPBF) distributed background information to delegates.
 
The speakers in the morning programme, all international experts in their field, provided a state-of-the-art picture of nocturia, overactive bladder and painful bladder syndrome within a neurourological context. Neurourology is an area that grows increasingly complex as researchers delve deeper and deeper, but as we learn more about its complexities the pieces of the puzzle concerning pelvic and bladder pain and urinary tract dysfunction slowly begin to fit together.
 
Michael Craggs (neurophysiologist, United Kingdom) provided delegates with a truly excellent overview of the pathophysiology of the lower urinary tract from the brain to the bladder and this gave delegates a clear basis for the presentations that followed and a deeper understanding of how and where treatment options have an effect at different points along the neurological pathways. He explained that “many of the signs and symptoms associated with problems of the lower urinary tract, for example those of nocturia, overactivity and pain, probably have their origins in sensory dysfunction.Such dysfunction can lead to overactive sacral reflexes, uncoordinated function of the bladder and sphincters by the pontine micturition centre and aberrant perceptual processes of the brain. The pathology associated with sensory dysfunction of the bladder, for example in conditions such as interstitial cystitis, urinary tract infection, obstruction or neuropathic conditions, is likely to result in disruption to normal urothelial function and abnormal responses of the sensory receptors lying in the sub-urothelial tissues. Hence bladder filling and urine composition could have exaggerated effects on the signals being sent to the central nervous system possibly resulting in changes to renal function via the hypothalamus, circulation and hormones (eg antidiuretic hormones), as well as causing the bladder-sphincter dysfunctions and symptoms described above. The thesis is that we should be considering functions of the whole urinary tract in these pathologies and not just those affecting the lower urinary tract.”
 
Christopher Chapple (consultant urologist, United Kingdom), speaking on principles of lower urinary tract pharmacotherapy, explained that the sensory system is important in overactive bladder, but whether this is due to an overlap between OAB and PBS/IC still remains to be seen. There are still many gaps in our knowledge concerning these inter-relationships. He emphasised that antimuscarinics are effective for the treatment of overactive bladder, despite their well-known side-effects. There are differences between different drugs in terms of how well they are tolerated and dose titration is particularly important. In terms of new treatment, botulinum toxin looks particularly interesting for OAB. In future we are likely to see new drugs being developed to control the bladder by acting on the neurological system. Current treatment options for OAB were then reviewed in detail by David Castro (urologist, Tenerife).
 
Jean-Jacques Wyndaele (urologist, Belgium) spoke on the complex problem of diagnosing and treating painful bladder syndrome/interstitial cystitis. He pointed out that PBS/IC is still mainly a diagnosis of exclusion due to the lack of international agreement on diagnostic criteria, adding that in this context the abbreviation I.C. could be said to stand for International Confusion! Careful exclusion of other causes is vital since there is a long list of other possible identifiable causes (so-called “confusables”) of a painful bladder. Diagnosis can sometimes be backed up by cystoscopic and biopsy findings, but not always. Glomerulations were once held to be the hallmark of interstitial cystitis, but this is no longer the case. Treatment is generally multimodal with different drugs for the different symptoms. He stressed that urologists should be alert to the possibility of concomitant disorders including allergies, irritable bowel syndrome, inflammatory bowel disease, chronic fatigue, fibromyalgia, systemic lupus erythematosus and Sjögren’s syndrome He emphasised that patients with PBS/IC need a great deal of support and counselling and that the patient support groups can play an important role here with patient-to-patient counselling. Patients themselves can do a lot in the form of self-care: reducing stress as far as possible and adjusting their diet where necessary in order to cut out food and drink that seems to be irritating the symptoms. Reassessment is worthwhile after a few years to check whether the original diagnosis was correct or whether other causes of the symptoms can be found. During this seminar, it was generally emphasised that PBS/IC is an oversensitive bladder rather than an overactive bladder, although some patients may have both.
 
Christopher Chapple described nocturia (frequent urination at night) as a very common and troublesome condition which is a major cause of morbidity, illness and even mortality due to the increased risk of falls and fractures in the elderly during nocturnal trips to the bathroom. It has a major impact on the patient’s general health due to its detrimental effect on the quality of sleep. Furthermore there is an increased likelihood of depression. Nighttime frequency can have many other possible causes in addition to PBS/IC, OAB and urgency urinary incontinence and nocturia should therefore be considered in terms of pathophysiological causes generally in the body as well as specific bladder-related dysfunction.
 
Neuromodulation for OAB patients was discussed by Emmanuel Chartier-Kastler (urologist, France) and for PBS/IC patients by Jerzy Gajewski (neuro-urologist, Canada) Although not a first-line treatment, it nevertheless has a place in the treatment of refractory chronic voiding disorders. The PNE test is considered to be a good method of selecting patients who may benefit from this type of treatment. A disadvantage, however, is that it is an expensive treatment option which is not going to be either affordable or obtainable in many countries. Jerzy Gajewski emphasised that this treatment is still experimental for PBS/IC patients but that some positive results have been seen, particularly in relation to urgency/frequency symptoms.
 
panel
 
The afternoon session comprised a round table discussion with an eminent panel of international and Polish experts on a variety of issues, including the questions: Are OAB, pain and nocturia symptoms of a wider syndrome? Are hormonal levels responsible for the symptoms of OAB? Do sex hormones affect the functioning of the urinary tract? Is neuropathology a new diagnostic tool for establishing targeted treatment? There were many different views but few conclusions were reached other than the fact that much more research is necessary in these areas.
 
The success of this bi-lingual seminar in Poland underlined the importance of providing up-to-date practical information on treatment on the one hand and stimulating new ideas by means of brainstorming on the other. Polish delegates went home armed not only with practical knowledge but also with many new concepts to think about in relation to the treatment and support of their patients. This type of 1-day seminar provides doctors who may be unable to attend international conferences with the latest information from the experts in a form that they can immediately use in clinical practice.
 
International Painful Bladder Foundation info table

An information table on PBS/IC, OAB and associated disorders provided by the International Painful Bladder Foundation (former IICPN Foundation) was likewise a success with all the material disappearing within the first 2 hours. Once again an affirmation of the need for information and particularly information that is easily understandable by non-native speakers of English. Many thanks to Professor Borkowski and Dr Radziszewski for giving the IPBF the opportunity to do this for the first time under its new name.
 
Jane Meijlink
       
updated 14.02.2006 16:01 © 2006-2018 International Painful Bladder Foundation (IPBF). All rights reserved.