Hyaluronan treatment of interstitial cystitis/painful bladder syndrome. Riedl CR, Engelhardt PF, Daha KL, et al. Int Urogynecol J Pelvic Floor Dysfunct 2007 Dec 21 [Epub ahead of print] • this study evaluated the efficacy of intravesical hyaluronan therapy in 126 patients with IC/PBS and mean disease duration of 6.1 years; to be eligible for hyaluronan treatment, a positive modified potassium test was requested as a sign of a urine-tissue barrier disorder • patients were treated with weekly instillations of a 50 ml phosphate-buffered saline solution containing 40 mg sodium hyaluronate
• data were obtained by a visual analogue scale (VAS) questionnaire rating from 0 to 10 that asked for global bladder symptoms before and after therapy; additional questions evaluated the therapeutic impact on quality of life
• 85% of the patients reported symptom improvement (2 or more VAS units); the mean initial VAS score of 8.5 decreased to 3.5 after therapy (p<0.0001); 55% remained with no or minimal bladder symptoms after therapy (VAS 0-2); 84% reported significant improvement of their quality of life
• intravesical therapy had to be initiated again with good success in 43 patients (34.5%) as symptoms recurred after discontinuation of treatment, while the rest stayed free of symptoms for up to 5 years
• in general, hyaluronan therapy was well tolerated and, with the exception of mild irritative symptoms, no adverse reactions were reported for a total of 1,521 instillations
• the authors conclude that timely hyaluronan instillation therapy may lead to complete symptom remission or even cure in part of the IC/PBS patients, while some responders need continuous intravesical therapy
• the present results suggest that selection of patients for hyaluronan therapy by potassium testing improves the outcome of intravesical therapy with a response rate of >80%
management review
Pharmacologic management of painful bladder syndrome/interstitial cystitis: a systematic review. Dimitrakov J, Kroenke K, Steer WD, et al. Arch Intern Med 2007;167:1922-9 • over 180 different therapies have been tried for PBS/IC, yet evidence from trials remains inconclusive
• this study concludes that PPS may be modestly beneficial for PBS/IC
• there is insufficient evidence for other pharmacologic treatment
• a consensus on standardized outcome measures is urgently needed
Neural mechanisms of pelvic organ cross-sensitization. Malykhina AP. Neuroscience 2007;149:660-72
• Pelvic organ cross-sensitization is considered one of the factors contributing to chronic pelvic pain of unidentified origin (including IBS and IC)
• This review summarizes existing hypotheses about neural mechanisms underlying cross-sensitization in the pelvis.
intravesical treatment
Intravesical treatments for painful bladder syndrome/ interstitial cystitis. Dawson T, Jamison J. Cochrane Database Syst Rev 2007 Oct 17;(4):CD006113
• Cochrane report on intravesical treatment for PBS/IC
• Evidence base for intravesical treatment is limited
• Quality of trial reports mixed
• BCG and oxybutynin reasonably well-tolerated; RTX showed no evidence of effect for most outcomes
• Little evidence for other treatments included in this review
• Randomised controlled trials and standardisation are still needed
Effect of Comestibles on Symptoms of Interstitial Cystitis.
Shorter B, Lesser M, Moldwin RM, Kushner L. J Urol 2007;178:145-52 • patients with painful bladder syndrome/interstitial cystitis 90.2% indicated that the consumption of certain foods or beverages caused symptom exacerbation • there was no correlation between allergies and the effect of comestibles on symptoms
• the most frequently reported and most bothersome comestibles were coffee, tea, soda, alcoholic beverages, citrus fruits and juices, artificial sweeteners and hot pepper
fibromyalgia bladder index
The Fibromyalgia Bladder Index. Brand K, Littlejohn G, Kristjanson L, et al. Clin Rheumatol 2007;26:2097-103 • the aim of this study was to determine whether the Interstitial Cystitis Symptom and Problem Index (ICSI/ICPI), is a valid, reliable, and clinically relevant instrument to assess the sensory urinary symptoms in women with fibromyalgia syndrome (FM)
• factor analysis displayed two separate components of symptom and problem combinations as distinct from the original ICSI/ICPI developed for the interstitial cystitis population
• the eight items of the index configured differently and formed two subscales of a newly developed Fibromyalgia Bladder Index
• the two subscales of this index include the Bladder Urgency and Pain Subscale and the Bladder Frequency and Nocturia Subscale.
ketamine
Ketamine-Associated Ulcerative Cystitis: A New Clinical Entity. Shahani R, Streutker C, Dickson B, Stewart RJ. Urology 2007;69:810-2 • ketamine is an anesthetic agent that is increasingly being used as a recreational drug
• the authors describe a series of 9 patients, all of whom were daily ketamine users, who presented with severe dysuria, frequency, urgency, and gross hematuria; the urine cultures were sterile in all cases
• CT revealed marked thickening of the bladder wall, a small capacity, and perivesicular stranding, consistent with severe inflammation; at cystoscopy, all patients had severe ulcerative cystitis.
• biopsies in 4 patients revealed epithelial denudation and inflammation with a mild eosinophilic infiltrate
• cessation of ketamine use, with the addition of pentosan polysulfate, appeared to provide some symptomatic relief
Interstitial cystitis and female sexual dysfunction. Ottem DP, Carr LK, Perks AE, et al. Urology 2007;69:608-10
• the authors conclude that female patients with IC have sexual dysfunction, including pain, more commonly than do controls
Diagnosis of interstitial cystitis/ painful bladder syndrome in patients with overactive bladder symptoms. Macdiarmid SA, Sand PK. Rev Urol 2007;9:9-16 • overactive bladder (OAB) and interstitial cystitis (IC) have similar symptoms, including urinary urgency/frequency and nocturia, making them difficult to differentiate on the basis of clinical presentation alone
• the authors propose a diagnostic framework that may be useful for differentiating IC from OAB and for facilitating appropriate treatment
Update on the diagnosis and treatment of bladder endometriosis. Pastor-Navarro H, Gimenez-Bachs JM, Donate-Moreno MJ, et al. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:949-54 • common clinical manifestations of bladder endometriosis include menouria and urethral and pelvic pain syndrome occurring cyclically
• cystoscopy is the most useful diagnostic test with confirmation by histologic study
painful bladder symptoms
Prevalence of painful bladder symptoms and effect on quality of life in black, hispanic and white men and women. Clemens JQ, Link CL, Eggers PW, et al. J Urol 2007;177:1390-4 • a population based cross-sectional survey of 5506 individuals was done in the Boston area for symptoms of painful bladder symptoms (PBS, based on consensus statements, research definitions and published articles) • the prevalence of PBS symptoms was 0.83-2.71% in women and 0.25-1.22% in men depending on the definition used; the presence of symptoms was associated with a significant adverse impact on quality of life • the findings indicate no racial/ethnic disparity and limited gender disparity in the prevalence of PBS symptoms
Bilateral s3 stimulator in patients with interstitial cystitis. Steinberg AC, Oyama IA, Whitmore KE. Urology 2007;69:441-3
• this retrospective study demonstrated that 15 patients diagnosed with interstitial cystitis with the symptoms of frequency, urgency, and pain had a significant decrease in frequency and nocturia with bilateral stimulator placement
Assessing urgency in interstitial cystitis/painful bladder syndrome.
Diggs C, Meyer WA, Langenberg P, et al. Urology 2007;69:210-4 • the O'Leary-Sant Symptom Index appeared to underreport urgency
• asking about urgency "with little or no warning" underestimated the prevalence and degree of urinary urgency
• the authors conclude with the question that may have pathophysiological importance: "why do patients with IC/PBS have urgency ?"
RANTES mediates TNF-dependent lamina propria mast cell accumulation and barrier dysfunction in neurogenic cystitis. Chen MC, Keshavan P, Gregory GD, Klumpp D. Am J Physiol Renal Physiol 2007;292:F1372-9
• this study shows that RANTES plays a key role in the pathogenesis of neurogenic cystitis and suggest that chemokines may represent novel therapeutic targets for IC patients with mast cell-associated disease
(webmaster's comment: RANTES, an acronym for Regulated on Activation - Normal T Expressed and Secreted, is a cytokine that attracts a particular subset of T-lymphocytes and monocytes)
prevalence
Prevalence and correlates for interstitial cystitis symptoms in women participating in a health screening project. Temml C, Wehrberger C, Riedl C, et al. Eur Urol 2007;51:803-9
• the prevalence of IC in an urban female population was 306/100,000 women
• bowel disorders and psychological stress were correlated to the probability of IC
• the authors conclude that the prevalence of IC symptoms is higher than previously estimated and substantially affects quality of life and sexuality
symptoms
Symptoms of interstitial cystitis, painful bladder syndrome and similar diseases in women: a systematic review. Bogart LM, Berry SH, Clemens JQ. J Urol 2007;177:450-6 • for the purpose of development of a case definition for IC in women, the authors performed a systemic literature review of symptoms of IC, PBS, vulvodynia, pelvic floor dysfunction, overactive bladder, urethral syndrome, various presentations of urinary infections, incontinence (not stress) and various presentations of endometriosis
• the authors conclude that in terms of symptoms:
-
IC and PBS may be the same entity; recurrent urinary tract infections may be distinguished from IC and PBS via a combination of self-report and urine culture information
- IC and PBS may be distinguished from OAB, vulvodynia and endometriosis, although
identifying IC and PBS in women with more than 1 of these diseases may be difficult
duloxetine
The dual serotonin and noradrenaline reuptake inhibitor duloxetine for the treatment of interstitial cystitis: results of an observatinal study. van Ophoven A, Hertle L.J Urol 2007;177:552-5
• in this observational study, duloxetine was given for two months to 48 women with IC according to the NIDDK criteria
• 5 patients (10.4%) responded and 17 (35.4%) dropped out due to nausea
• patients who responded reported onset of improvement but not until they had reached the target dose of 2x 40 mg per day
• the authors conclude that
duloxetine did not result in significant improvement of symptoms in patients with IC
Multiple intravesical instillations of low-dose resiniferatoxin in the treatment of refractory interstitial cystitis. Peng CH, Kuo HC. Urol Int 2007;78: 78-81.
• this study from Taiwan shows that RTX seems to be back in the picture again as a potential treatment for interstitial cystitis
• this small study of 12 patients suggests that multiple intravesical instillations of RTX at the concentration of 10 nM are effective in relieving lower urinary tract symptoms in patients with refractory IC