Animal models of overactive bladder: cyclophosphamide (CYP)-induced cystitis in rats

Cyclophosphamide (CYP) treatment induces chemical cystitis leading to bladder overactivity (OAB) in animals and humans. There is a great number of OAB models evaluations, which consider the bladder histology, as well as alterations in neurochemical, electrophysiological properties of bladder afferent neurons and reflex arcs activity in the spinal cord. However there are no data differentiating cystometrically acute and chronic models of OAB induced by CYP under urethane anaesthesia. The aim of this study was to investigate the influence of acute and chronic models of CYP-induced cystitis on urinary bladder motor activity in rats.

[A case of eosinophilic cystitis presenting with urinary retention]

A 56-year-old woman was referred to our hospital presenting with urinary retention. Ultrasonography revealed bilateral hydronephrosis and magnetic resonance imaging of the pelvis showed diffuse thickening of the bladder wall. The hydronephrosis was improved by urethral balloon catheter. A cystoscopic examination revealed papillary lesions, polypoid yellow lesions and gross mucosal edema in the whole bladder. Pathological examination of transurethral punch biopsy showed no malignancy but inflammatory infiltration in the submucosa of bladder wall with many eosinophils. She performed clean intermittent self-catheterization and was treated with corticosteroids and antihistaminics. Three months after diagnosis, conservative treatment resulted in an excellent relief of symptoms, decrement of residual urine and remission of the bladder lesions in cystoscopy. In women with urinary retention, eosinophilic cystitis (EC) must be considered in the differential diagnosis. To our knowledge, this is the first case of EC presenting with urinary retention reported in the Japanese literature.

Large Cystitis Glandularis: A Very Rare cause of Severe Obstructive Urinary Symptoms in an Adult

Cystitis glandularis is a very rare proliferative disorder of the mucus-producing glands within the mucosa and submucosa of urinary bladder epithelium. We report such a case of glandular cystitis with intestinal metaplasia masquerading as a bladder tumor in a young male patient who presented with severe obstructive urinary symptoms. Cystoscopy revealed a tumor well circumscribed, measuring 5 x 4 cm on the trigone. Transurethral resection of the mass was carried out and the histopathology suggested cystitis glandularis. The literature regarding this entity has been reviewed and the differential diagnosis was discussed. Short-term follow-up of the patient with sonography and cystoscopy showed no recurrence.

Escherichia coli isolates associated with uncomplicated and complicated cystitis and asymptomatic bacteriuria possess similar phylogenies, virulence genes, and O-serogroup profiles

The genetic and serological characteristics of Escherichia coli isolates from patients with uncomplicated cystitis (UC), complicated cystitis (CC), and complicated asymptomatic bacteriuria (CASB) were determined. Phylogenetic group B2 was predominant in all categories. The prevalences of 14 out of 18 virulence factor genes were similar among the three categories, while pap, iha, ompT, and PAI were more frequently seen in isolates associated with UC than CC or CASB.

[Bilateral pyelonephritis and emphysematous cystitis: an exceptional association]

The authors report the case of a patient hospitalized for bilateral pyelonephritis and emphysematous cystitis requiring bilateral nephrostomy. This rare disease occurs in diabetic patients and is essentially due to Escherichia coli and Klebsiella pneumoniae. Treatment consists of antibiotics and renal drainage or nephrectomy. The prognosis is poor with a mortality rate greater than 50%.

Clinical evaluation of multimodal environmental modification (MEMO) in the management of cats with idiopathic cystitis

This prospective observational study evaluated client-reported recurrence of lower urinary tract signs (LUTS) and other signs of abnormalities in cats with idiopathic cystitis after institution of multimodal environmental modification (MEMO). Forty-six client-owned indoor-housed cats with idiopathic cystitis, diagnosed based on a history of recurrent LUTS and evidence of absence of urolithiasis or bacterial urinary tract infection were studied. In addition to their usual care, clients were offered recommendations for MEMO based on a detailed environmental history. Cases were followed for 10 months by client contact to determine the effect of MEMO on LUTS and other signs. Significant (P<0.05) reductions in LUTS, fearfulness, nervousness, signs referable to the respiratory tract, and a trend (P<0.1) toward reduced aggressive behavior and signs referable to the lower intestinal tract were identified. These results suggest that MEMO is a promising adjunctive therapy for indoor-housed cats with LUTS, and should be followed up with prospective controlled clinical trials.

Neonatal Urinary Bladder Inflammation Produces Adult Bladder Hypersensitivity

Inflammatory events experienced during early development may permanently alter sensory processing. Because urinary tract infections frequently occur during early development in females and painful bladder disorders have a high female prevalence, the present studies were undertaken to determine whether inflammation of the bladder in female rats could lead to altered sensory processing later in life. Female rat pups were anesthetized and treated as neonates (14th-16th days of life) or as adolescents (28th-30th days of life) with either intravesical zymosan (yeast cell wall component that produces robust inflammation), intravesical normal saline, or only with anesthesia. As adults, rats that had their bladders inflamed as neonates exhibited increased spontaneous micturition frequency and, after reinflammation of the bladder, increased cardiovascular and abdominal muscle contractile responses to urinary bladder distension when compared with controls. Similar effects were not observed in rats which did not experience inflammation of the bladder until adolescence. Evan's blue extravasation, a measure of the magnitude of inflammatory changes, was also greater in rats treated as neonates with intravesical zymosan. Thermal and mechanical hindpaw sensitivity was not altered by bladder inflammation. Altogether, this suggests that neonatal bladder inflammation increases bladder sensitivity and may be a cause of the hypersensitivity of painful bladder syndromes.

PERSPECTIVE

The present study observed that bladder inflammation experienced in a neonatal rat led to accentuated responses to urinary bladder distension when tested as adults. This suggests that events experienced during development may permanently sensitize visceral sensory systems and so represent one of the causes of painful bladder disorders.

Lower urinary tract symptoms in female patients with rheumatoid arthritis

OBJECTIVE

Patients with autoimmune diseases such as systemic lupus erythematosus (SLE) and Sjögren's syndrome (SS) are associated with an increased severity of lower urinary tract symptoms (LUTS). Recent surveys also reveal that rheumatoid arthritis (RA) is prevalent in patients with interstitial cystitis (IC). Therefore, we have investigated LUTS in patients with RA.

METHODS

A total of 198 female patients with RA, aged 40 years or older, from the rheumatology outpatient clinic completed this prospective study. The American Urological Association Symptom Index (AUASI) score was used to assess the severity of LUTS and the O'Leary-Sant Symptom Index (ICSI) was used to evaluate IC-like urinary symptoms in these patients, which were compared to those of 679 age-matched controls. The possible associations of clinical parameters with LUTS were also explored.

RESULTS

The Mean AUASI score and the percentage of individuals reporting severe LUTS (AUASI score > or = 20) or IC-like urinary symptoms (ICSI score > or = 12) showed no significant differences between the RA and control groups. However, in the RA group multivariate regression analyses identified patients with secondary SS (n = 21) to be associated with a significantly higher AUASI score (p = 0.007) and a higher percentage of severe LUTS (p = 0.02); these were also significantly higher than those of the control group (p = 0.02 and p = 0.01, respectively).

CONCLUSION

Patients with RA have similar urinary complaints when compared to controls. However, those with secondary SS have a greater severity of LUTS, a finding similar to that observed in patients with primary SS.

Unique BK virus non-coding control region (NCCR) variants in hematopoietic stem cell transplant recipients with and without hemorrhagic cystitis

Hematopoietic stem cell transplant recipients frequently develop BK virus (BKV)-associated hemorrhagic cystitis, which coincides with BK viruria. However, the precise role of BKV in the etiology of hemorrhagic cystitis in hematopoietic stem cell transplant recipients remains unclear, since approximately 50% of all such adult transplant recipients excrete BKV, yet do not develop this clinical condition. In the present study, BKV were analyzed to determine if mutations in the non-coding control region (NCCR), and specific BKV sub-types defined by sequence analysis of major capsid protein VP1, were associated with development of hemorrhagic cystitis in hematopoietic stem cell transplant recipients. The regions encoding VP1 and NCCRs of BKV in urine samples collected from 15 hematopoietic stem cell transplant recipients with hemorrhagic cystitis and 20 without this illness were amplified and sequenced. Sequence variations in the NCCRs of BKV were identified in urine samples from those with and without hemorrhagic cystitis. Furthermore, five unique sequence variations within transcription factor binding sites in the canonical NCCR, O-P-Q-R-S, were identified, representing new BKV variants from a population of cloned quasi-species obtained from patients with and without hemorrhagic cystitis. Thirty-five BKV VP1 sequences were analyzed by phylogenetic analysis but no specific BKV sub-type was associated with hemorrhagic cystitis. Five previously unrecognized naturally occurring variants of the BKV are described which involve amplifications, deletions, and rearrangements of the archetypal BKV NCCRs in individuals with and without hemorrhagic cystitis. Architectural rearrangements in the NCCRs of BKV did not appear to be a prerequisite for development of hemorrhagic cystitis in hematopoietic stem cell transplant recipients.

Eosinophilic cystitis causing spontaneous rupture of the urinary bladder in a child

We report a unique case of eosinophilic cystitis causing intraperitoneal bladder perforation in a child diagnosed by chance with no signs or history of trauma. To our knowledge, this is the first case of eosinophilic cystitis complicated by bladder rupture in children. The patient was successfully treated with primary repair. For children with non-traumatic bladder perforation, eosinophilic cystitis must be considered in the differential diagnosis.

Epinephrine promotes hemostasis in rats with cyclophosphamide-induced hemorrhagic cystitis

OBJECTIVES

To evaluate the hypothesis that intravesical instillation of epinephrine would attenuate bladder hemorrhage in a rat model of cyclophosphamide (CYP)-induced hemorrhagic cystitis.

METHODS

Female Sprague-Dawley rats were divided into seven treatment groups: positive control (CYP, 150 mg/kg), negative control (epinephrine, 10 microg/mL), intravesical instillation of normal saline (vehicle) and epinephrine (2.5, 5, and 10 microg/mL), and intraperitoneal administration of mesna (50 mg/kg). Rats were killed on days 1, 2, and 3, and the urinary bladders were removed, weighed, and evaluated by gross and histologic analysis. Vesical vascular permeability was determined by wet bladder weight and Evan's blue dye absorbance.

RESULTS

Cyclophosphamide administration induced severe hemorrhagic cystitis with marked edema, hemorrhage, and inflammation. All three epinephrine-treated groups had marked attenuation of hemorrhagic cystitis compared with the positive and negative control and mesna-treated groups. Epinephrine was also associated with significant inhibition of tissue edema, indicating decreased vesical vascular permeability.

CONCLUSIONS

In this rat model of CYP-induced hemorrhagic cystitis, intravesical instillation of epinephrine inhibited edema, hemorrhage, and inflammation.

Controversies in the diagnosis and management of urinary tract infections in children

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.

Eosinophilic cystitis: successful long-term treatment with montelukast sodium

We report a rare case of eosinophilic cystitis in a 6-year-old boy who presented with irritative voiding symptoms, peripheral eosinophilia, and a bladder mass initially visualized on ultrasonography. Cystoscopy and transurethral biopsy confirmed the diagnosis. Complete resolution of his symptoms occurred within 1 week of corticosteroid use and the x-ray findings improved within 6 weeks. At 6 months of follow-up, the patient continued to require a leukotriene receptor antagonist (montelukast sodium) despite several attempts to discontinue its use. We propose that eosinophilic cystitis in children who present with peripheral eosinophilia will often require long-term treatment.

Inflammation and enhanced nociceptive responses to bladder distension produced by intravesical zymosan in the rat

Background

Mycotic infections of the bladder produce pain and inflammatory changes. The present study examined the inflammatory and nociceptive effects of the yeast cell wall component, zymosan, when admininstered into the urinary bladder in order to characterize this form of bladder sensitization.

Methods

Parametric analyses of the time-course (0–48 hr) and concentration (0–2% solutions) variables associated with intravesical zymosan-induced bladder inflammation were performed in female rats. Plasma extravasation of Evan's Blue dye was used as a measure of tissue inflammation. Cardiovascular and visceromotor responses to urinary bladder distension were used as measures of nociception.

Results

Zymosan-induced bladder inflammation, as indexed by plasma extravasation of Evan's Blue, was significantly greater in rats treated with either 1 or 2% solutions as compared to either 0.1 or 0.5% zymosan solutions. In time-course studies (1 – 48 hr post-treatment), 1% zymosan-induced inflammation progressively increased with time following administration, was greatest at 24 hr and began to normalize by 48 hr. In the studies of inflammation-induced changes in nociception, arterial blood pressure (ABP) and visceromotor responses to graded distension of the urinary bladder were significantly increased relative to controls 24 hr after zymosan administration.

Conclusion

These studies provide important time-course and solution concentration parameters for studies of zymosan-induced inflammation of the bladder and suggest utility of this model for the study of bladder-related pain.

L6-S1 spinal nerve stimulation reduces micturition frequency in anaesthetized rats with cyclophosphamide-induced cystitis

OBJECTIVE

To further investigate the rationale for using spinal nerve stimulation (SNS) for treating bladder overactivity associated with cystitis in a rat model of cyclophosphamide-induced cystitis, as several studies suggested that symptoms associated with chronic cystitis could be treated using stimulation of sacral spinal nerves, but the mechanisms by which it works are unknown.

MATERIALS AND METHODS

Cystitis was induced by i.p. injection of cyclophosphamide 48 h before the experiments in anaesthetized male rats. Neurograms were taken by placing a recording electrode onto the pelvic nerve and a stimulating electrode on either the L6 or S1 ipsilateral spinal nerves. Two selected intensities were then evaluated for SNS in control and cyclophosphamide-treated rats during cystometry.

RESULTS

Cyclophosphamide resulted in significant bladder overactivity. There was no apparent difference in the neurograms generated in response to SNS of the S1 and L6 spinal nerves, and between cyclophosphamide and control rats. Intensities of 200 microA (Adelta-fibre-specific) and 2 mA (Adelta+ C-fibres) were chosen for SNS. Continuous SNS at 200 microA significantly reduced the frequency of voiding and non-voiding contractions in cyclophosphamide-treated rats. SNS at 2 mA resulted in the abolition of voiding contractions, accompanied by continuous leakage of urine.

CONCLUSION

SNS recruiting only Adelta-fibre produced fewer voiding contractions in cyclophosphamide-treated rats, to a level similar to that from the control rats. These results support the ability of SNS to decrease bladder overactivity in a pathophysiological model of chemical irritation of the bladder.

Uropathogenic Escherichia coli flagella aid in efficient urinary tract colonization

In the murine model of urinary tract infections (UTI), cystitis by uropathogenic Escherichia coli (UPEC) occurs through an intimate relationship with the bladder superficial umbrella cell entailing cycles of adherence, invasion, intracellular bacterial community (IBC) formation, and dispersal (fluxing) from the intracellular environment. IBC dispersal is a key step that results in the spread of bacteria over the epithelial surface to initiate additional rounds of IBC formation. We investigated the role of flagella in mediating adherence and motility during UTI, hypothesizing that the dispersion of the IBC would be incomplete in the absence of motility, thus interrupting the IBC pathway and attenuating the infection. Using gfp reporter fusions, the expression of the flagellar class I flhDC and class III fliC genes was monitored to track key points of regulation throughout the pathogenic cascade. In vitro, growth under conditions promoting motility resulted in the robust expression of both fusions. In contrast, only the class I fusion produced significant expression throughout early stages of IBC development including the dispersion stage. Thus, unlike in vitro modeling of motility, the regulatory cascade appeared incomplete in vivo. Throughout IBC formation, nonmotile DeltafliC mutants achieved the same number of IBCs as the wild-type (wt) strain, demonstrating that flagella are neither essential nor required for first- or second-generation IBC formation. However, in competition experiments between wt and DeltafliC strains, the wt was shown to have a fitness advantage in persisting throughout the urinary tract for 2 weeks, demonstrating a subtle but measurable role for flagella in virulence.

[Encrusted cystitis]

Encrusted cystitis is a chronic inflammation of the bladder mucosa associated with calcified deposits induced by numerous bacteria in an alkaline medium. Corynebacterium urealyticum or group D2 is most frequently incriminated. Encrusted cystitis is a rare disease with non-specific clinical features. The diagnosis may be suspected on imaging, but is often only established later on histological findings. Treatment of this disease is based on appropriate antibiotics with acidification of the urine. The authors report a new case of encrusted cystitis in a 78-year-old woman and review the literature on encrusted lesions of the urinary tract.

Three-day vs longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis

PURPOSE

We performed a meta-analysis to ascertain the efficacy and safety of the currently practiced 3-day antibiotic therapy for cystitis versus prolonged therapy (5 days or longer) to relieve symptoms and to achieve bacteriological cure.

METHODS

The Cochrane Library, the Cochrane Renal Group's Register of trials, EMBASE and MEDLINE were searched to identify all randomized controlled trials comparing 3-day oral antibiotic therapy with prolonged therapy (5 days and longer) for uncomplicated cystitis in adult non-pregnant women. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. Relative risks (RR) with their 95% confidence intervals (CI) were estimated; a fixed effect model was used. An intention-to-treat analysis was performed whenever possible.

RESULTS

Thirty-two trials and 9605 patients met inclusion criteria. For symptomatic failure rates no difference between 3-day and prolonged antibiotic regimens was found at short term (RR 1.16, 95% CI: 0.96-1.41) and long-term follow-up (RR 1.17, 95% CI: 0.99-1.38). Three-day treatment was less effective than prolonged therapy in preventing bacteriological failure, relative risk 1.37 (95% CI: 1.07-1.74) for short-term follow-up, and 1.47 (95% CI: 1.22-1.77) for long-term follow-up. Adverse effects were more common in the prolonged therapy group (RR 0.83, 95% CI: 0.79-0.91). The results were consistent for subgroup and sensitivity analyses.

CONCLUSION

Antibiotic therapy for 3 days is similar to prolonged therapy in achieving symptomatic cure for cystitis, while the prolonged treatment is more effective in obtaining bacteriological cure.

Application of fibrin glue to damaged bladder mucosa in a case of BK viral hemorrhagic cystitis

BK virus is a common cause of severe hemorrhagic cystitis refractory to standard treatment. We describe a technique to achieve hemostasis after failed conservative therapy using fibrin glue applied suprapubically while visualizing and insufflating the bladder through a cystoscope. Long-term hemostasis was achieved using this novel procedure.