Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal

Sexually dimorphic effects of early life stress in rat pups on urinary bladder detrusor muscle contractility in adulthood

Background

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a chronic disorder that is commonly seen in women who report a history of adversity in early life. Here, we test the hypothesis that early life stress (ELS) induces sexually dimorphic abnormalities in urinary bladder smooth muscle function in adulthood.

Methods

Male and female rat pups were conditioned on postnatal (PN) days 8–12 with either a “predictable or “unpredictable” odor-shock, or odor only control treatment. In adulthood, urinary bladder function was assessed in vivo via urine spot analysis and in vitro via contractile responses to electrical field stimulation (EFS) and membrane depolarization with potassium chloride (KCl).

Results

In adulthood, we found that female rats exposed to unpredictable ELS showed a significant (p < 0.05) increase in urine voiding volume compared to predictable ELS or controls. We also found that detrusor muscle contractile responses to EFS were significantly (p < 0.001) decreased following unpredictable ELS in adult female rats compared to the predictable ELS or controls. In male rats exposed to ELS, there was no difference in voiding volume or EFS-induced contractility between groups. In adulthood, the myogenic smooth muscle response to KCl was not significantly different between groups. Histological analysis from adult female and male rats revealed no differences in the appearance of the urinary bladder in rats exposed to ELS.

Conclusions

In summary, our findings provide evidence to support abnormalities in the nerve-mediated contractile responses of the detrusor smooth muscle in adult female rats following ELS. We speculate that these sexually dimorphic alterations in urinary bladder function may account, at least in part, for the female predominance of PBS/IC.

Complementary therapies for bladder pain syndrome: a systematic review

Introduction and hypothesis

Bladder pain syndrome is a difficult condition to treat. The purpose of this systematic review is to assess the effectiveness of various complementary therapies available for treatment.

Methods

This review was conducted in adherence with Preferred Reporting Items for Systematic Reviews. Citations were retrieved using a comprehensive database search (from inception to July 2014: CINAHL, Cochrane, EMBASE, Medline and SIGEL and grey literature). Studies that fulfilled the inclusion criteria were selected. Eligibility consisted of women with bladder pain syndrome, an intervention of alternative/complementary therapies and an outcome of improvement of symptoms. Information regarding study characteristics and primary outcomes was collated. The Cochrane risk of bias scale was used to evaluate the quality of the studies included.

Results

A total of 1,454 citations were identified, 11 studies fulfilled the inclusion criteria (4 randomised control trials [RCTs] and 7 prospective studies). The key interventions studied were acupuncture, relaxation therapy, physical therapy, hydrogen-rich therapy, diet and nitric oxide synthetase.

Conclusion

Therapies with the potential for benefit in patients with bladder pain syndrome are dietary management, acupuncture and physical therapy. These findings were obtained from small studies and hence caution is advised. Robustly designed multicentre RCTs on these complementary therapies are needed to guide patients and clinicians.

Hunner-Type (Classic) Interstitial Cystitis: A Distinct Inflammatory Disorder Characterized by Pancystitis, with Frequent Expansion of Clonal B-Cells and Epithelial Denudation

Interstitial cystitis (IC) is a chronic bladder disease with urinary frequency, bladder discomfort or bladder pain of unknown etiology. Based on cystoscopic findings, patients with IC are classified as either Hunner-type/classic IC (HIC), presenting with a specific Hunner lesion, or non-Hunner-type IC (NHIC), presenting with no Hunner lesion, but post-hydrodistension mucosal bleeding. Inflammatory cell infiltration, composed predominantly of lymphocytes, plasma cells and epithelial denudation, has in the past been documented as a major pathological IC finding. However, the significance of the pathological evaluation of IC, especially with regard to the difference between HIC and NHIC, has been downplayed in recent years. In this study, we performed immunohistochemical quantification of infiltrating T-lymphocytes, B-lymphocytes and plasma cells, and measured the amount of residual epithelium in urinary bladder biopsy specimens taken from patients with HIC and NHIC, and those with no IC, using image analysis software. In addition, in situ hybridization of the light chains was performed to examine clonal B-cell expansion. Lymphoplasmacytic infiltration was significantly more severe in HIC specimens than in NHIC specimens (P <0.0001). Substantial lymphoplasmacytic inflammation (≥200 cells/mm²) was observed in 93% of HIC specimens, whereas only 8% of NHIC specimens were inflamed. Plasmacytic infiltration was more prominent in HIC specimens compared with NHIC and non-IC cystitis specimens (P <0.005). Furthermore, expansion of light-chain-restricted B-cells was observed in 31% of cases of HIC. The amount of residual epithelium was decreased in HIC specimens compared with NHIC specimens and non-IC cystitis specimens (P <0.0001). These results suggest that NHIC and HIC are distinct pathological entities, with the latter characterized by pancystitis, frequent clonal B-cell expansion and epithelial denudation. An abnormality in the B-cell population may be involved in the pathogenesis of HIC.

Recommendations to the primary care practitioners and the patients for managing pelvic pain, especially in painful bladder syndrome for early and better prognosis

Painful bladder syndrome (PBS) is a common disease presenting with chronic pelvic pain and discomfort with at least one urinary symptom with no identifiable cause. The etiology is still unknown, and the medication has limited effects on pelvic pain or other urinary symptoms. This article presents advanced insight regarding the approach to PBS, particularly pelvic pain for primary care practitioners and patients. We suggest six tips for medical staff and suspected patients for easy diagnosis and proper treatment of pelvic pain. These six tips cover: Self-awareness of the disease; immediate urine culture test; specifying the location of pain urinary incontinence; frequency, or urgency without functional disorder of an overactive bladder helpful dietary control; complementary, and alternative medicine, and finding an expert. These tips might be helpful in advancing the schematic approach and in achieving better prognosis of PBS. Further study should be conducted to achieve better treatment for this disease, including development of a definitive test and diagnosis.

An assessment of clinicians' and patients' experiences in the management of bladder pain syndrome

Current management of bladder pain syndrome (BPS) was evaluated through a prospective electronic questionnaire posted on three patient support groups and sent to all members on the British Society of Urogynaecology (BSUG) database. Methods of diagnosis and treatment were assessed. 133 patients and 69 clinicians participated in the survey. Patients reported their main symptom to be pain when their bladder was full in 80% (n = 107) and the most bothersome symptom was pelvic pain (22%, n = 29). 93% (n = 64) of clinicians made their diagnosis by history and cystoscopy. 78% (n = 54) of clinicians treated patients with amitriptyline and 75% (n = 52) by dietary modification while 77% (n = 102) of patients reported using simple analgesia, 74% (n = 98) dietary modification and 62% (n = 83) low-dose long-term antibiotics. There is wide variation in diagnostic methods and treatments of BPS used by clinicians and experienced by patients with no obvious consensus. National guidance is needed to help standardise care.

Patient-centred standardization in interstitial cystitis/bladder pain syndrome-a PLEA

Standardization has an impact on all links in the healthcare chain and directly affects patients with regard to diagnosis, treatment, eligibility for reimbursement, social benefits and care. Furthermore, patients are also affected if research goes down inappropriate pathways due to inaccurate terminology and definitions. Complex healthcare coding and electronic medical record systems and global reliance on the internet and search machines mean that new terminology or changes now need in some way to be designed to last or to be updated in a way that will cause least disruption, while still allowing for evolution, since changes have far more ramifications today than they ever did in the past. Official recognition of a condition is vital, so coding must be correct and uniform across all authorities. Potential problems must be anticipated at an early stage in the process. In order to achieve global consensus, stakeholders from all parts of the world need to communicate and collaborate with all viewpoints taken into consideration. Patients and their advocacy groups should be involved in standardization processes to ensure that all aspects of a condition are covered, that no patients or symptoms are excluded and that there is no adverse impact on the patient in practical terms following implementation. The trend today is for patients to be more involved in healthcare and decision-making. We must ensure that standardisation and guidelines do not get left behind in this process of development either now or in the future. However, it is necessary to find some way of training patient representatives to enable them to participate fully in standardization and guidelines and also to encourage them to do so.

Recommendations for the Diagnosis and Management of Bladder Pain Syndrome. Spanish Urological Association Consensus Document

INTRODUCTION

Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) and other bladder pathologies share common manifestations, such as the presence of mictional symptoms and a negative impact on the patient's quality of life. To be properly diagnosed and clinically managed, it is important to distinguish between its clinical modalities and diagnostic criteria for adequate exclusion.

OBJECTIVE

The purpose of this study was to standardize criteria for making decisions in BPS management, for its diagnosis, initial treatment and follow-up.

MATERIAL AND METHOD

A nominal group methodology was employed, using scientific evidence on BPS taken from a systematic (non-exhaustive) literature review for developing recommendations along with specialist expert opinions.

RESULTS

The diagnosis of BPS should be made based on the patient's clinical history, with emphasis on pain and mictional symptoms as well as excluding other pathologies with similar symptomatology. BPS treatment should be directed towards restoring normal bladder function, preventing symptom relapse and improving patients' quality of life. It is therefore advisable to start with conservative treatment and to adopt less conservative treatments as the level of clinical severity increases. It is also recommended to abandon ineffective treatments and reconsider other therapeutic options.

CONCLUSIONS

Quickly identifying the pathology is important when trying to positively influence morbidity and care quality for these patients.

Hydrodistension with or without fulguration of hunner lesions for interstitial cystitis: Long-term outcomes and prognostic predictors

AIMS

Hydrodistension of the bladder, with optional fulguration of Hunner lesions, is one of the recommended therapies for interstitial cystitis (IC). The aims of this study are to evaluate long-term outcomes of hydrodistension and identify outcome predictors.

METHODS

The study cohort was 191 newly diagnosed IC patients (155 women and 36 men) who underwent hydrodistension with fulguration of Hunner lesions if detected between 2007 and 2013 at our institution. The primary outcome was therapeutic failure, which was defined as repeat hydrodistension, bladder instillation therapy, or narcotic use for pain control. Clinical features, including comorbidities and endoscopic findings, were analyzed along with the outcome.

RESULTS

The cohort comprised 126 patients of Hunner type IC and 65 patients of non-Hunner type IC. The mean time to therapeutic failure was 28.5 months in Hunner type IC and 25.2 months in non-Hunner type IC. The therapeutic failure rate was higher in non-Hunner type IC at 17.3 months; however, the long-term outcomes reversed thereafter. The mean time to therapeutic failure was shorter in patients with lumbar spinal stenosis (LSS) or irritable bowel syndrome (IBS). Multivariate analysis identified LSS as a predictor for failure in Hunner type IC and non-Hunner type IC (HR = 18.8, P = 0.001; HR = 3.8, P = 0.028, respectively) and IBS in non-Hunner type IC (HR = 18.0, P = 0.008).

CONCLUSIONS

Bladder hydrodistension, with fulguration of the Hunner lesions, improved IC symptoms. The outcome was worse in non-Hunner type IC shortly after hydrodistension but eventually comparable across the two types. Concomitant LSS and IBS were predictors for poor outcome. Neurourol. Urodynam. 35:965-969, 2016. © 2015 Wiley Periodicals, Inc.

From bladder to systemic syndrome: concept and treatment evolution of interstitial cystitis

Interstitial cystitis, presently known as bladder pain syndrome, has been recognized for over a century but is still far from being understood. Its etiology is unknown and the syndrome probably harbors different diseases. Autoimmune dysfunction, urothelial leakage, infection, central and peripheral nervous system dysfunction, genetic disease, childhood trauma/abuse, and subsequent stress response system dysregulation might be implicated. Management is slowly evolving from a solo act by the end-organ specialist to a team approach based on new typing and phenotyping of the disease. However, oral and invasive treatments are still largely aimed at the bladder and are based on currently proposed pathophysiologic mechanisms. Future research will better define the disease, permitting individualization of treatment.

Novel Treatment of Chronic Bladder Pain Syndrome and Other Pelvic Pain Disorders by OnabotulinumtoxinA Injection

Chronic pelvic pain (CPP) is defined as pain in the pelvic organs and related structures of at least 6 months' duration. The pathophysiology of CPP is uncertain, and its treatment presents challenges. Botulinum toxin A (BoNT-A), known for its antinociceptive, anti-inflammatory, and muscle relaxant activity, has been used recently to treat refractory CPP with promising results. In patients with interstitial cystitis/bladder pain syndrome, most studies suggest intravesical BoNT-A injection reduces bladder pain and increases bladder capacity. Repeated BoNT-A injection is also effective and reduces inflammation in the bladder. Intraprostatic BoNT-A injection could significantly improve prostate pain and urinary frequency in the patients with chronic prostatitis/chronic pelvic pain syndrome. Animal studies also suggest BoNT-A injection in the prostate decreases inflammation in the prostate. Patients with CPP due to pelvic muscle pain and spasm also benefit from localized BoNT-A injections. BoNT-A injection in the pelvic floor muscle improves dyspareunia and decreases pelvic floor pressure. Preliminary studies show intravesical BoNT-A injection is useful in inflammatory bladder diseases such as chemical cystitis, radiation cystitis, and ketamine related cystitis. Dysuria is the most common adverse effect after BoNT-A injection. Very few patients develop acute urinary retention after treatment.

Interstitial cystitis and the painful bladder: a brief history of nomenclature, definitions and criteria

"Practically every author writing on this subject has suggested a new name which only adds to the confusion and multiplication" (Kretschmer H, 1922). Despite multiple names and many definitions and classifications over the past two centuries, the medical world is no closer to discovering the cause or causes of this enigmatic bladder disorder, currently known as interstitial cystitis, bladder pain syndrome or painful bladder syndrome and hypersensitive bladder. International consensus on nomenclature, definitions and diagnosis is now essential to ensure that studies are carried out on the same basis, thereby generating meaningful data that can be relied on for further use. In our electronic age, multiple names and definitions cause confusion for researchers, clinicians and patients, even leading to the patient's diagnosis being unrecognized by authorities, resulting in refusal to reimburse treatment or provide social benefits. As the key to the puzzle lies in the patients, with all their symptoms and comorbidities, and as patients are directly affected by changes in nomenclature and definitions, patient organization representatives should be given every opportunity to participate in discussions on guidelines, taxonomy, definitions and terminology.

Bladder afferent hyperexcitability in bladder pain syndrome/interstitial cystitis

Bladder pain syndrome/interstitial cystitis is a disease with lower urinary tract symptoms, such as bladder pain and urinary frequency, which results in seriously impaired quality of life of patients. The extreme pain and urinary frequency are often difficult to treat. Although the etiology of bladder pain syndrome/interstitial cystitis is still not known, there is increasing evidence showing that afferent hyperexcitability as a result of neurogenic bladder inflammation and urothelial dysfunction is important to the pathophysiological basis of symptom development. Further investigation of the pathophysiology will lead to the effective treatment of patients with bladder pain syndrome/interstitial cystitis.

Hypersensitive bladder: a solution to confused terminology and ignorance concerning interstitial cystitis

Taxonomy or nomenclature concerning interstitial cystitis and its related symptom syndromes is in a state of confusion. After analyzing the reasons for confusion in regard to three components (disease name, symptoms, Hunner's lesion), I would like to propose a new term, "hypersensitive bladder", taking after overactive bladder, as a solution. Hypersensitive bladder symptoms are defined as "increased bladder sensation, usually associated with urinary frequency and nocturia, with or without bladder pain." The proposal of hypersensitive bladder is based on: (i) it does not appear a symptom syndrome, but a disease by ending with an organ name, "bladder"; (ii) it does not contain confusable symptom terms (pain and urgency), but indicates irritative symptoms including pain and urgency; and (iii) it suggests pathophysiological hyperactivity of sensory nerves. Interstitial cystitis is defined by three requirements: (i) hypersensitive bladder symptoms; (ii) bladder pathology; and (iii) no other diseases, where bladder pathology should be clearly stated either as Hunner's lesion or glomerulations after hydrodistention. Hypersensitive bladder can be used for the condition with hypersensitive bladder symptoms, but no obvious disease explaining hypersensitive bladder symptoms identified. Interstitial cystitis is a representative disease causing hypersensitive bladder symptoms, most typically with pain, but might be painless and indistinguishable from overactive bladder. Introducing hypersensitive bladder as a counter concept of overactive bladder into bladder dysfunction taxonomy will facilitate clinical practice and research progress, and attract considerable attention from the medical world.

Inflammation characteristics in bladder pain syndrome ESSIC type 3C/classic interstitial cystitis

OBJECTIVES

Interstitial cystitis is regarded as a heterogenous syndrome with two distinguishable forms: the non-ulcer and the classic form of interstitial cystitis, the latter with Hunner's lesions; or bladder pain syndrome type 3C and non-Hunner bladder pain syndrome, respectively.

METHODS

A cohort of 379 patients diagnosed with interstitial cystitis was studied. Nitric oxide release from the bladder was measured using a chemiluminescence nitric oxide analyzer. Bladder biopsies from the patients and healthy controls were analyzed by routine histopathological examination. Biopsies from a subset of patients and controls were also analyzed by immunohistochemistry and cytokine gene expression by real-time polymerase chain reaction.

RESULTS

Patients with bladder pain syndrome type 3C/classic interstitial cystitis had considerably higher levels of nitric oxide as compared with non-Hunner bladder pain syndrome/non-ulcer interstitial cystitis patients and healthy individuals, and showed histologically a chronic inflammation in the bladder mucosa, with abundant mast cell infiltration in all layers of the bladder wall. No inflammation was noted in non-Hunner bladder pain syndrome/non-ulcer interstitial cystitis patients. The isoenzymes inducible nitric oxide synthase, the catalyst in the nitric oxide production, was strongly expressed in the inflammatory cells in the bladder mucosa of bladder pain syndrome type 3C/classic interstitial cystitis patients. In addition, the expression of the pro-inflammatory cytokines interleukin-6 and interleukin-17A messenger ribonucleic acid, and of anti-inflammatory interleukin-10 messenger ribonucleic acid showed significantly increased levels in bladder pain syndrome type 3C/classic interstitial cystitis compared with healthy controls.

CONCLUSION

Bladder pain syndrome type 3C/classic interstitial cystitis is a distinct inflammatory disease and in many aspects shares features of inflammatory autoimmune diseases. These findings could open up novel research avenues with expectations for new targets for pharmacological treatment.

Potential urine and serum biomarkers for patients with bladder pain syndrome/interstitial cystitis

There is a lack of consensus on the pathophysiology of bladder pain syndrome/interstitial cystitis. The chronic pain symptoms of bladder pain syndrome/interstitial cystitis refractory to local treatment could be a result of central nervous system sensitization and persisting abnormalities in the bladder wall, which activate the afferent sensory system. Evidence also shows that bladder pain syndrome/interstitial cystitis is a heterogeneous syndrome and that the two subtypes, the ulcerative (classic) and non-ulcerative types, represent different disease entities. There is a need for non-invasive markers for the differential diagnoses of the subtypes of bladder pain syndrome/interstitial cystitis, and between bladder pain syndrome/interstitial cystitis and bladder sensory disorders, such as hypersensitive bladder syndrome or overactive bladder. Bladder pain syndrome/interstitial cystitis, but not overactive bladder, involves an aberrant differentiation program in the bladder urothelium that leads to altered synthesis of several proteoglycans, cell adhesion and tight junction proteins, and bacterial defense molecules. These findings have led to the rationale for identifying urinary biomarkers to detect bladder pain syndrome/interstitial cystitis in patients with frequency urgency syndrome. Recently, the markers that have been the focus of the most research are antiproliferative factor, epidermal growth factor, heparin-binding epidermal growth factor, glycosaminoglycans and bladder nitric oxide. In addition, inflammatory proteins in the urine and serum play important roles in the pathogenesis of bladder pain syndrome/interstitial cystitis. The urinary proteome is an easily accessible source of biomarkers for differentiation between inflammatory bladder disorders. Analysis of multiple urinary proteins and serum cytokines could provide a diagnostic basis for bladder pain syndrome/interstitial cystitis, and could be a tool for the differential diagnosis of bladder pain syndrome/interstitial cystitis and other sensory bladder disorders.

Mesenchymal Stem Cell Therapy Alleviates Interstitial Cystitis by Activating Wnt Signaling Pathway

Interstitial cystitis (IC) is a syndrome characterized by urinary urgency, frequency, pelvic pain, and nocturia in the absence of bacterial infection or identifiable pathology. IC is a devastating disease that certainly decreases quality of life. However, the causes of IC remain unknown and no effective treatments or cures have been developed. This study evaluated the therapeutic potency of using human umbilical cord-blood-derived mesenchymal stem cells (UCB-MSCs) to treat IC in a rat model and to investigate its responsible molecular mechanism. IC was induced in 10-week-old female Sprague-Dawley rats via the instillation of 0.1 M HCl or phosphate-buffered saline (PBS; sham). After 1 week, human UCB-MSC (IC+MSC) or PBS (IC) was directly injected into the submucosal layer of the bladder. A single injection of human UCB-MSCs significantly attenuated the irregular and decreased voiding interval in the IC group. Accordingly, denudation of the epithelium and increased inflammatory responses, mast cell infiltration, neurofilament production, and angiogenesis observed in the IC bladders were prevented in the IC+MSC group. The injected UCB-MSCs successfully engrafted to the stromal and epithelial tissues and activated Wnt signaling cascade. Interference with Wnt and epidermal growth factor receptor activity by small molecules abrogated the benefits of MSC therapy. This is the first report that provides an experimental evidence of the therapeutic effects and molecular mechanisms of MSC therapy to IC using an orthodox rat animal model. Our findings not only provide the basis for clinical trials of MSC therapy to IC but also advance our understanding of IC pathophysiology.

Are mast cells still good biomarkers for bladder pain syndrome/interstitial cystitis?

PURPOSE

ESSIC identifies mast cell infiltrates of detrusor muscle as a diagnostic criterion for bladder pain syndrome/interstitial cystitis. However, an increased mast cell count is also characteristic of overactive bladder syndrome. The lack of uniformity in mast cell detection methods hampers data comparison. Using state-of-the-art techniques we investigated whether mast cells differ among bladder conditions.

MATERIALS AND METHODS

We analyzed bladder biopsies from 56 patients, including 31 with bladder pain syndrome/interstitial cystitis with (12) or without (19) Hunner lesions, 13 with overactive bladder syndrome and 12 without bladder symptoms to determine the quantity, location, distribution and activation of mast cells using immunohistochemistry with anti-mast cell tryptase. Patients were allocated to study groups by key bladder symptoms commonly used to define conditions (pain and major urgency).

RESULTS

Subepithelial mast cell localization (p <0.001) and an increased detrusor mast cell count (p = 0.029) were characteristic of bladder pain syndrome/interstitial cystitis with Hunner lesions. The optimal cutoff of 32 detrusor mast cells per mm(2) achieved only 68% accuracy with 38% positive predictive value. No difference was observed between bladder pain syndrome/interstitial cystitis without Hunner lesions and overactive bladder syndrome. Patient groups differed in lymphocyte infiltration (p = 0.001), nodular lymphocyte aggregates (p <0.001) and urothelium integrity (p <0.001).

CONCLUSIONS

Subepithelial mast cell distribution was characteristic of bladder pain syndrome/interstitial cystitis with Hunner lesions. Detrusor mastocytosis had poor predictive value for bladder pain syndrome/interstitial cystitis. Mast cell assessment did not distinguish bladder pain syndrome/interstitial cystitis without Hunner lesions from overactive bladder syndrome.

Evaluation of prostaglandin E2 and E-series prostaglandin receptor in patients with interstitial cystitis

PURPOSE

We evaluated PGE2 and EP receptor in patients with interstitial cystitis.

MATERIALS AND METHODS

Enrolled in the study were 20 female patients with interstitial cystitis (11 with and 9 without Hunner lesions), 9 female controls with another urological disease who needed a cystoscopic procedure and 10 normal volunteers. In all participants we determined O'Leary-Sant symptom and problem scores, and obtained voluntary urine specimens for PGE2 analysis. Using anesthesia the bladder was distended by saline in stepwise fashion from 100 ml to maximum capacity in patients with interstitial cystitis. Each time the infused saline was retrieved for PGE2 analysis. We also measured PGE2 and the expression of EP receptor mRNA in bladder biopsy tissue in patients with interstitial cystitis.

RESULTS

Symptom and problem indexes in patients with interstitial cystitis and Hunner lesions were significantly higher than in patients with interstitial cystitis without Hunner lesions. Urinary PGE2 in patients with interstitial cystitis and Hunner lesions was significantly higher than in patients with interstitial cystitis without lesions, controls and normal volunteers. PGE2 in retrieved saline in patients with interstitial cystitis and Hunner lesions increased depending on infusion volume but not in patients with interstitial cystitis without lesions. PGE2 content in bladder biopsy tissue was significantly higher in patients with interstitial cystitis and Hunner lesions than in controls. In patients with interstitial cystitis and Hunner lesions the expression of EP1 and EP2 mRNA was significantly higher than in controls.

CONCLUSIONS

Our study showed increased PGE2 production and mRNA expression of EP1 and EP2 receptors in the bladder in patients with interstitial cystitis and Hunner lesions. Further studies are warranted to explore the pathophysiological and therapeutic implications.

Activation of cannabinoid receptor 1 inhibits increased bladder activity induced by nerve growth factor

Nerve growth factor (NGF) is an important mediator of inflammatory pain, in part by sensitizing afferent nerve fibers, and expression of NGF is increased during bladder inflammation. We investigated whether intravesical instillation of the selective cannabinoid receptor 1 (CB1) agonist arachidonyl-2'-chloroethylamide (ACEA) affects NGF-induced increased bladder activity in female C57BL/6J wild-type (WT) mice. We also examined the effects of intravesical NGF in female fatty acid amide hydrolase knock-out (FAAH KO) mice. We found that CB1 and tyrosine kinase A (trkA, the high-affinity NGF receptor) were present in L6 dorsal root ganglion (DRG) afferent neurons and in bladders of both genotypes. Intravesical NGF increased bladder activity that was inhibited by intravesical ACEA in WT mice. The inhibitory effects of ACEA were reversed by the selective CB1 antagonist AM 251. Intravesical NGF failed to affect bladder activity in FAAH KO mice, and treatment with AM251, restored the stimulatory effects of NGF on the bladder in FAAH KO mice. These results indicate that activation of CB1 inhibits increased bladder activity induced by NGF.

Prevalence of lower urinary tract symptoms and level of quality of life in men and women with chronic pelvic pain

OBJECTIVES

The aim of this study was to evaluate the prevalence of lower urinary tract symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

The McGill Pain Questionnaire, Dutch Leiden/Leuven Version (MPQ-DLV), Pain Disability Index (PDI), National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Interstitial Cystitis Symptom Index (ICSI) and Pelvic Pain and Urinary/Frequency Symptom Scale (PUF) were used, based on their specific properties, to assess the symptoms and impact on the quality of life. Total scores and domains were compared for gender.

RESULTS

The studied group (N = 35; 18 male, 17 female) showed a good distribution in gender for age [Mann-Whitney U test (MW-U) p = 0.4] and body mass index (MW-U p = 0.2). The MPQ-DLV showed significantly higher scores for pain in women for Pain Rating Index - Affective (MW-U p = 0.030) and Total (MW-U p = 0.031), and Visual Analogue Scale for Pain - Most (MW-U p = 0.005). Women were less sexually active (PUF-SA) (chi-squared test p = 0.021) and had a significantly higher disability (PDI-T) (MW-U p = 0.005) and MPQ - Quality of Life (MW-U p = 0.003). The urinary symptoms showed similar results for gender (chi-squared test p > 0.05).

CONCLUSIONS

A wide variety of symptoms and a negative impact on quality of life were shown. No differences in lower urinary tract symptoms were found between genders. Women were less sexually active than men. Chronic pelvic pain had a significantly higher negative impact on the level of quality of life in women than in men.

Attenuation of cystitis and pain sensation in mice lacking fatty acid amide hydrolase

Endocannabinoids, such as N-arachidonoylethanolamine (AEA, also called anandamide), exert potent analgesic and anti-inflammatory effects. Fatty acid amide hydrolase (FAAH) is primarily responsible for degradation of AEA, and deletion of FAAH increases AEA content in various tissues. Since FAAH has been shown to be present in the bladder of various species, we compared bladder function, severity of experimental cystitis, and cystitis-associated referred hyperalgesia in male wild-type (WT) and FAAH knock-out (KO) mice. Basal concentrations of AEA were greater, and the severity of cyclophosphamide (CYP)-induced cystitis was reduced in bladders from FAAH KO compared to WT mice. Cystitis-associated increased peripheral sensitivity to mechanical stimuli and enhanced bladder activity (as reflected by increased voiding frequency) were attenuated in FAAH KO compared to WT mice. Further, abundances of mRNA for several pro-inflammatory compounds were increased in the bladder mucosa after CYP treatment of WT mice, and this increase was inhibited in FAAH KO mice. These data indicate that endogenous substrates of FAAH, including the cannabinoid AEA, play an inhibitory role in bladder inflammation and subsequent changes in pain perception. Therefore, FAAH could be a therapeutic target to treat clinical symptoms of painful inflammatory bladder diseases.

Urothelial dysfunction and increased suburothelial inflammation of urinary bladder are involved in patients with upper urinary tract urolithiasis--clinical and immunohistochemistry study

Objectives

To investigate the urothelial dysfunction and inflammation of urinary bladder in patients with upper urinary tract (UUT) urolithiasis through the results of cystoscopic hydrodistension and immunohistochemistry study.

Methods

Ninety-one patients with UUT urolithiasis underwent cystoscopic hydrodistension before the stone surgery. Immunofluorescence staining of E-cadherin, zonula occludens-1 (ZO-1), tryptase (mast cell activation), and TUNEL (urothelial apoptosis) were performed in 42 patients with glomerulations after hydrodistension, 10 without glomerulations, and 10 controls.

Results

Of the 91 patients, 62 (68.2%) developed glomerulations after hydrodistension. Lower urinary tract symptoms (LUTS) were present in 53.8% patients, in whom significantly smaller maximal anesthetic bladder capacity (MBC) was noted. Patients with middle or lower 1/3 ureteral stones had a significantly higher glomerulation rate (88.6% vs. 55.4%, p<0.01) and lower MBC (618.4±167.6 vs. 701.2±158.4 ml, p = 0.027) than those with upper 1/3 ureteral or renal stones. Patients with UUT urolithiasis had significantly lower expression of E-cadherin (26.2±14.8 vs. 42.4±16.7) and ZO-1 (5.16±4.02 vs. 11.02±5.66); and higher suburothelial mast cell (13.3±6.8 vs. 1.3±1.2) and apoptotic cell (2.6±2.5 vs. 0.1±0.3) numbers than in controls (all p<0.01).

Conclusions

Urothelial dysfunction and increased suburothelial inflammation and apoptosis are highly prevalent in the bladders of UUT urolithiasis patients, indicating inflammation cross-talk between UUT and urinary bladder. Patients with UUT urolithiaisis concomitant with LUTS had a smaller MBC, which may explain the presence of irritative bladder symptoms.

Clinical comparision of intravesical hyaluronic acid and hyaluronic acid-chondroitin sulphate therapy for patients with bladder pain syndrome/interstitital cystitis

INTRODUCTION

Patients with a history of bladder pain syndrome/interstitial cystitis (BPS/IC) and who responded poorly or unsatisfactorily with previous treatment were compared taking intravesical hyaluronic acid (HA) or hyaluronic acid-chondroitin sulphate (HA-CS).

METHODS

Patients were treated with intravesical instillation with 50 mL sterile sodium hyalurinic acid (Hyacyst, Syner-Med, Surrey, UK) (n = 32) and sodium hyaluronate 1.6% sodium chondroitin sulphate 2% (Ialuril, Aspire Pharma, UK) (n = 33). Intravesical instillations were performed weekly in first month, every 15 days in the second month and monthly in third and fourth months, for a total of 8 doses. Patients were evaluated using a visual analog pain scale (VAS), interstitial cystitis symptom index (ICSI), interstitial cystitis problem index (ICPI), voiding diary for frequency/nocturia, cystometric bladder capacity and voided volume at the beginning and at 6 months. All patients had a potassium sensitivity test (PST) initially. Wilcoxon and Mann-Whitney U tests were used for statistical analysis.

RESULTS

In total, 53 patients met the study criteria. There were 30 patients in the HA-CS group (mean age: 48.47) and 23 patients in the HA group (mean age: 49.61) (p > 0.05). The initial PST was positive in 71.7% patients (38/53) overall with no difference between groups (p > 0.05). Responses for VAS, ICCS, ICPS, 24-hour frequency/nocturia statistically improved in both groups at 6 months. There was no significant difference in symptomatic improvement (p > 0.05). Eight patients had mild adverse events.

CONCLUSION

HA and HA/CS instillation can be effective in BPS/IC patients who do not respond to conservative treatment. An important limitation of our study is that the HA dosage of the 2 treatment arms were different. It would be more appropriate with same HA dosage in both groups; however, there was no commercially available glycosaminoglycan (GAG) substance with same HA dosage for single and combination therapy. Large, long-term randomized studies are required to determine if there is a difference between these treatments.

The MAPP research network: design, patient characterization and operations

Background

The “Multidisciplinary Approach to the Study of Chronic Pelvic Pain” (MAPP) Research Network was established by the NIDDK to better understand the pathophysiology of urologic chronic pelvic pain syndromes (UCPPS), to inform future clinical trials and improve clinical care. The evolution, organization, and scientific scope of the MAPP Research Network, and the unique approach of the network’s central study and common data elements are described.

Methods

The primary scientific protocol for the Trans-MAPP Epidemiology/Phenotyping (EP) Study comprises a multi-site, longitudinal observational study, including bi-weekly internet-based symptom assessments, following a comprehensive in-clinic deep-phenotyping array of urological symptoms, non-urological symptoms and psychosocial factors to evaluate men and women with UCPPS. Healthy controls, matched on sex and age, as well as “positive” controls meeting the non-urologic associated syndromes (NUAS) criteria for one or more of the target conditions of Fibromyalgia (FM), Chronic Fatigue Syndrome (CFS) or Irritable Bowel Syndrome (IBS), were also evaluated. Additional, complementary studies addressing diverse hypotheses are integrated into the Trans-MAPP EP Study to provide a systemic characterization of study participants, including biomarker discovery studies of infectious agents, quantitative sensory testing, and structural and resting state neuroimaging and functional neurobiology studies. A highly novel effort to develop and assess clinically relevant animal models of UCPPS was also undertaken to allow improved translation between clinical and mechanistic studies. Recruitment into the central study occurred at six Discovery Sites in the United States, resulting in a total of 1,039 enrolled participants, exceeding the original targets. The biospecimen collection rate at baseline visits reached nearly 100%, and 279 participants underwent common neuroimaging through a standardized protocol. An extended follow-up study for 161 of the UCPPS participants is ongoing.

Discussion

The MAPP Research Network represents a novel, comprehensive approach to the study of UCPPS, as well as other concomitant NUAS. Findings are expected to provide significant advances in understanding UCPPS pathophysiology that will ultimately inform future clinical trials and lead to improvements in patient care. Furthermore, the structure and methodologies developed by the MAPP Network provide the foundation upon which future studies of other urologic or non-urologic disorders can be based.

Trial registration

ClinicalTrials.gov identifier: NCT01098279 “Chronic Pelvic Pain Study of Individuals with Diagnoses or Symptoms of Interstitial Cystitis and/or Chronic Prostatitis (MAPP-EP)”. http://clinicaltrials.gov/show/NCT01098279

Use of vanilloids in urologic disorders

The bladder is an organ rich in vanilloid targets: dense unmyelinated c-fibers partially responsible for bladder sensation and response to noxious stimuli. Drugs such as capsaicin and resiniferatoxin (RTX) interact with the VR1 vanilloid receptor subtype to initially excite then subsequently desensitize the c-fibers. This chapter examines the literature describing the use of vanilloid receptor agonists in the treatment of the following urological disorders: neurogenic bladder (NGB), overactive bladder (OAB), and interstitial cystitis/painful bladder syndrome (IC/PBS). Review of the literature was performed using Pubmed and the following key words "capsaicin," "resiniferatoxin (RTX)," and "neurogenic bladder," "overactive bladder (OAB)," and "interstitial cystitis," "painful bladder syndrome." Articles focusing on randomized trials comparing intravesical administration of a vanilloid receptor agonist to placebo and those in English were reviewed. We conclude that capsaicin and RTX do appear to provide some acceptable treatment results in patients with neurogenic bladder, though larger studies are needed to confirm this. Although efficacy has been shown in some studies, currently the use of vanilloids cannot be recommended for routine use in patients with OAB as the need for catheterization may cause the risk to outweigh the benefit of treatment. Similarly, for the treatment of BPS, vanilloid receptor agonists lack strong evidence for efficacy or tolerability; larger studies are needed to define their role. Understanding how vanilloids are able to impact these disorders, however, may help further elucidate their underlying pathophysiological processes.

The pain of painful bladder

Bladder pain can have a number of different etiologies. This brief summary provides an overview of bladder pain syndrome, including current evidence-based recommendations for diagnosis and management.

Ulcerative and nonulcerative forms of bladder pain syndrome/interstitial cystitis do not differ in symptom intensity or response to onabotulinum toxin A

OBJECTIVE

To determine whether intratrigonal Onabotulinum toxin A (OnabotA) injection produces a different symptomatic outcome and duration of effect on ulcerative (Ulc) and nonulcerative (NUlc) bladder pain syndrome/interstitial cystitis (BPS/IC) patients and to compare the urinary levels of neurotrophines (NGF, BDNF, and GDNF) in response to OnabotA.

METHODS

Ten Ulc and 14 NUlc bladder pain syndrome/interstitial cystitis patients were included in this study. OnabotA (100 U) was injected in 10 trigonal sites, each receiving 10 U in 1 mL of saline. Outcome measures included pain visual analog scale (0-10), a 3-day voiding chart, O'Leary-Sant Score (OSS), and quality of life (QoL) from International Prostate Symptoms Score assessed before treatment, 1 month after injection, and every 3 months afterwards. Urinary NGF, BDNF, and GDNF were accessed using ELISA, at same time points. Treatment duration was determined at the time patients requested another injection.

RESULTS

Patients had a mean age of 40 ± 12 years in the Ulc and 47 ± 13 years in the NUlc group (ns). Mean values at baseline of pain intensity, frequency, nocturia, OSS, QoL, and urinary NGF, BDNF, GDNF were identical in the 2 groups. Patients with the Ulc phenotype had a longer duration of symptoms (28.8 ± 11 vs 19.2 ± 8 months, P = .018). Both groups responded equally to OnabotA, with significant improvements in pain intensity, frequency, nocturia, OSS, QoL, and urinary NGF, BDNF, GDNF. The effect lasted for 9 ± 2.8 (Ulc) and 10.5 ± 2 (NUlc) months.

CONCLUSION

In this cohort, Ulc and NUlc patients had similar symptoms at baseline and comparable clinical response to intratrigonal OnabotA. These findings suggest that pain may not be directly related with ulcers themselves.

Polyomavirus BK--a potential new therapeutic target for painful bladder syndrome/interstitial cystitis?

AIMS

To investigate the role of urinary BK polyoma virus (BKPyV) in the pathophysiology and prognosis of patients with painful bladder syndrome/interstitial cystitis (PBS/IC).

METHODS

Urine samples were collected from 15 patients with PBS/IC and 8 control patients (with urolithiasis, overactive bladder and benign prostatic hyperplasia). BKPyV titres were quantitatively determined using real time PCR. Fisher's exact test was used to compare virus titre levels between the two groups. The PBS/IC patients subsequently underwent cystoscopy, hydrodistension and bladder biopsy. Finally, a chart review was performed in order to correlate PBS/IC subtype and treatment outcomes with BKPyV status.

RESULTS

Positive BKPyV titres were found in 11 out of 15 PBS/IC patients but none of the controls. Cystoscopy was performed in 13 of the 15 PBS/IC patients (in 2 BKPyV positive patients, cystoscopy was not performed). Bladder ulceration and glomerulations were observed in all 9 BKPyV positive PBS/IC patients but only 1 out of 4 BKPyV negative patients. None of the non-ulcerative PBS/IC patients had BKPyV positive urine. Viral titres were not predictive of the clinical course however, 3 patients with the highest viral titres eventually underwent cystectomy.

CONCLUSIONS

We identified BKPyV in the urine of virtually all our patients with ulcerative PBS/IC. This finding suggests there may be a pathophysiological association between the virus and the haemorrhagic manifestations of PBS/IC. Classifying PBS/IC patients into BKPyV positive or negative groups may prove useful in future research on markers of disease prognosis and the subtypes of PBS/IC. We believe that BKPyV may therefore have a role as a potential therapeutic target in PBS/IC.

The overlap and distinction of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder: a questionnaire based analysis

PURPOSE

We compared symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder based on patient self-reported symptoms on validated questionnaires.

MATERIALS AND METHODS

We prospectively recruited 26 patients diagnosed with interstitial cystitis/bladder pain syndrome, 53 diagnosed with overactive bladder and 30 healthy controls to participate in a questionnaire based study that inquired about lower urinary tract symptoms. The questionnaires used were GUPI, ICSI, ICPI, ICIQ-OAB, ICIQ-UI, IUSS, numerical rating scales of the severity of bladder pain, pressure or discomfort, and numerical rating scale of the severity of urgency and frequency symptoms.

RESULTS

On univariate analysis patients with interstitial cystitis/bladder pain syndrome reported significantly more severe pain symptoms than those with overactive bladder. Patients with overactive bladder reported significantly more severe urinary incontinence symptoms than those with interstitial cystitis/bladder pain syndrome. There was no difference in frequency and urgency severity between the groups. Surprisingly, 33% of patients with overactive bladder reported pain or discomfort when the bladder filled and 46% with interstitial cystitis/bladder pain syndrome reported urgency incontinence. On multivariate analysis ICIQ-UI total scores (p = 0.01) and bladder pain severity on the numerical rating scale (p <0.01) distinguished the 2 conditions with 90.6% sensitivity and 96.1% specificity. Overactive bladder had higher ICIQ-UI and lower numerical rating scale pain scores.

CONCLUSIONS

There is considerable overlap of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder. This overlap raises the possibility that the 2 conditions represent a continuum of a bladder hypersensitivity syndrome.

Urinary nerve growth factor correlates with the severity of urgency and pain

INTRODUCTION AND HYPOTHESIS

Urinary nerve-growth-factor (NGF) level reflected the severity of urgency in patients with lower urinary tract symptoms (LUTS) and pain in patients with Bladder pain syndrome/interstitial cystitis (BPS/IC). The aim of this study was to investigate the levels of biomarkers, nerve growth factor (NGF), and prostaglandin E2 (PGE2) among disease groups sharing similar urinary symptoms and to elucidate which symptoms are related to individual biomarker levels.

METHODS

We studied 83 patients with LUTS who visited our outpatient clinic from May 2011 to December 2012. On the basis of clinical symptoms and a 3-day voiding diary, patients were classified into three groups: those with frequency (n = 13), overactive bladder (OAB) (n = 35), and BPS/IC (n = 35). Patients with stress urinary incontinence (SUI) or microscopic hematuria served as controls (n = 24). Storage symptoms were evaluated based on OAB symptom score (OAB-SS).

RESULTS

Mean patient age was 62.08 ± 11.47 (range, 23-84). Urinary NGF and creatinine-normalized NGF levels were significantly increased in those with OAB (201.90 and 4.08, respectively) and BPS/IC (173.71 and 2.72) compared with controls (77.77 and 1.29) and those with frequency (67.76 and 1.23). Neither value significantly differed between OAB and BPS/IC patients or between controls and frequency patients. Urinary PGE2 and creatinine-normalized PGE2 levels were not significantly different among groups. On linear regression analysis, urinary NGF levels were significantly correlated with urgency severity overall (R = 0.222) and also pain in BPS/IC patients (R = 0.409).

CONCLUSIONS

The levels of urinary NGF were elevated in patients with OAB and BPS/IC but not those with frequency and reflected the severity of urgency. In BPS/IC patients, urinary NGF increased with pain severity.

Chemical cystitis developed in experimental animals model: Topical effect of intravesical ozone application to bladder

Aims:

To demonstrate the effects of intravesical ozone treatment on inflammation and epithelial cell damage in chemical cystitis animal model.

Materials and Methods:

A total of 30 New Zealand rabbits were divided into six groups. Cystitis was conducted with transurethral intravesical hydrochloric acid instillation on the subjects in Groups IA, IB, IIA, and IIB. Then, Group IA-IB subjects were transurethrally administered intravesical ozone therapy twice a week, while Group IIA-IIB subjects were only given intravesical isotonic NaCl instillation. Group IIIA-IIIB subjects were administered intravesical isotonic NaCl instillation without conducting chemical cystitis in order to create the same stress. Treatment schemes of all groups were arranged in the same manner. Following a 3-week (early period) and 6-week (late period) therapy, the rabbits were sacrificed and histopathologic investigations were carried out in order to demonstrate changes in the urinary bladder.

Results:

In our study, we observed that the basal membrane and mucosal integrity were maintained, inflammatory cells were suppressed in Group IA-IB (Early and late period), which received ozone therapy. However, it was also observed that mucosal integrity was spoiled, numerous inflammatory cells were accumulated in Group IIA-IIB, which was administered isotonic NaCl.

Conclusion:

Due to its low cost and minimal side effects; ozone therapy could be a new therapeutic approach in the treatment of interstitial cystitis.

Efficacy of daily low-dose sildenafil for treating interstitial cystitis: results of a randomized, double-blind, placebo-controlled trial--treatment of interstitial cystitis/painful bladder syndrome with low-dose sildenafil

OBJECTIVE

To evaluate the efficacy of daily low-dose sildenafil for the treatment of nonulcer interstitial cystitis (IC) in women.

PATIENTS AND METHODS

Forty-eight women with a clinical diagnosis of IC from 3 medical centers were randomly assigned to treatment with daily low-dose sildenafil (25 mg, n=24) or placebo (n=24) for 3 months. The O'Leary-Sant IC symptom and problem indices, visual analog scale scores, and a micturition diary with the interval of micturition, the frequency of nocturia, and urgency episodes were recorded before treatment, every 2 weeks after the treatment until 3 months. Patient Overall Rating of Improvement in Symptoms was assessed and regarded as effective when the value was above 50%.

RESULTS

The IC symptom and problem indices scores and urodynamic index were significantly improved in sildenafil treatment group as compared with placebo group and baselines at week 4, 6, 8, 10, and 12, as well as 3 months after treatment (P<.05). Urodynamic index including first desire to void, strong desire to void, and maximum cystometric capacity was significantly improved in sildenafil treatment group at week 12 and at 3 months after treatment (P<.05). The efficiency of treatment reached 62.5%. However, no significant change of the visual analog scale values was observed between 2 groups except at week 12 in the sildenafil treatment group (P<.05). All adverse events were mild to moderate and transient.

CONCLUSION

Daily low-dose sildenafil is an easy, well-tolerated, and effective treatment for IC in women.