Intravesical treatments for painful bladder syndrome/ interstitial cystitis

Bladder pain syndrome and sexual function: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS)/interstitial cystitis can adversely affect physical, mental, and sexual health. The aim of the systematic review is to compare sexual function between patients with BPS and healthy controls and to examine whether or not treatment of BPS improves sexual function.

METHODS

A literature search was conducted on Embase, Medline, and other databases. Studies comparing sexual function in BPS patients with healthy controls and before/after treatment were included. Where appropriate, data were pooled in a meta-analysis, using a random effects model and the standardised mean difference (SMD) was used for comparison.

RESULTS

Out of 384 studies initially identified, 26 studies met the inclusion criteria for the systematic review and 11 for the meta-analysis. Six studies compared sexual function in BPS cases with healthy controls. All studies found that the Female Sexual Function Index (FSFI) was worse in BPS cases than in controls. Pooled data from 5 studies showed that the SMD was -1.02 (CI -1.64, -0.4) in total FSFI scores between the cases and controls, p=0.001. Further analysis showed better sexual function in all FSFI subdomains in healthy controls. Five studies compared sexual function in BPS patients before treatment with after treatment. Pooled data from 3 studies showed an overall improvement in total FSFI score after intravesical treatment: SMD=0.69 (CI 0.23, 1.14), p=0.003. Further analysis showed improvement in all subdomains.

CONCLUSION

Our review suggests that sexual function might be worse in BPS patients than in the general population, but it seems to improve with intravesical BPS treatment.

Efficacy and safety comparison of pharmacotherapies for interstitial cystitis and bladder pain syndrome: a systematic review and Bayesian network meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to compare the clinical efficacy and safety of pharmacological interventions for interstitial cystitis and bladder pain syndrome (IC/BPS) with direct and indirect evidence from randomized trials.

METHODS

We searched PubMed, the Cochrane library, and EMBASE for randomized controlled trials (RCTs) that assessed the pharmacological therapies for IC/BPS. Primary efficacy outcomes included ICSI (O'Leary Sant Interstitial Cystitis Symptom Index), ICPI (O'Leary Sant Interstitial Cystitis Problem Index), 24-h micturition frequency, visual analog scale (VAS), and Likert score for pain. Safety outcomes are total adverse events (AEs, intravesical instillation, and others), gastrointestinal symptoms, headache, pain, and urinary symptoms. A systematic review and Bayesian network meta-analysis were performed.

RESULTS

A total of 23 RCTs with 1,871 participants were identified. The ICSI was significantly reduced in the amitriptyline group (MD = -4.9, 95% CI: -9.0 to -0.76), the cyclosporine A group (MD = -7.9, 95% CI: -13.0 to -3.0) and the certolizumab pegol group (MD = -3.6, 95% CI:-6.5 to -0.63) compared with placebo group. Moreover, for ICPI, cyclosporine A showed superior benefit compared to placebo (MD = -7.6, 95% CI: -13 to -2.3). VAS score improved significantly in cyclosporine A group than pentosan polysulfate sodium (MD = 3.09, 95% CI: 0.13 to 6.07). None of the agents revealed a significant alleviation of 24-h micturition frequency. In terms of safety outcomes, the incidence rate on urinary symptoms for botulinum toxin A was the only variate higher than chondroitin sulfate (MD = -2.02, 95% CI: -4.99 to 0.66) and placebo (MD = -1.60, 95% CI:-3.83 to 0.17). No significant difference was found among the other treatments.

CONCLUSIONS

Cyclosporine A might be superior to other pharmacological treatments in efficacy. Amitriptyline and certolizumab pegol were capable of lowering the ICSI as well.

Efficacy and safety of intravesical instillation of KRP-116D (50% dimethyl sulfoxide solution) for interstitial cystitis/bladder pain syndrome in Japanese patients: A multicenter, randomized, double-blind, placebo-controlled, clinical study

Objective

To evaluate the efficacy and safety of intravesical KRP‐116D, 50% dimethyl sulfoxide solution compared with placebo, in interstitial cystitis/bladder pain syndrome patients.

Methods

Japanese interstitial cystitis/bladder pain syndrome patients with an O’Leary‐Sant Interstitial Cystitis Symptom Index score of ≥9, who exhibited the bladder‐centric phenotype of interstitial cystitis/bladder pain syndrome diagnosed by cystoscopy and bladder‐derived pain, were enrolled. Patients were allocated to receive either KRP‐116D (n = 49) or placebo (n = 47). The study drug was intravesically administered every 2 weeks for 12 weeks.

Results

For the primary endpoint, the change in the mean O’Leary‐Sant Interstitial Cystitis Symptom Index score from baseline to week 12 was −5.2 in the KRP‐116D group and −3.4 in the placebo group. The estimated difference between the KRP‐116D and placebo groups was −1.8 (95% confidence interval −3.3, −0.3; P = 0.0188). Statistically significant improvements for KRP‐116D were also observed in the secondary endpoints including O’Leary‐Sant Interstitial Cystitis Problem Index score, micturition episodes/24 h, voided volume/micturition, maximum voided volume/micturition, numerical rating scale score for bladder pain, and global response assessment score. The adverse drug reactions were mild to moderate, and manageable.

Conclusions

This first randomized, double‐blind, placebo‐controlled trial shows that KRP‐116D improves symptoms, voiding parameters, and global response assessment, compared with placebo, and has a well‐tolerated safety profile in interstitial cystitis/bladder pain syndrome patients with the bladder‐centric phenotype.

Treatment of Interstitial Cystitis/Bladder Pain Syndrome: A Contemporary Review

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating condition affecting approximately 3% of the female population. IC/BPS is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable cause. This condition is known to have a profound negative impact on quality of life. There are few well-studied treatment options and no cure for this condition, which is therefore challenging to treat. The purpose of this narrative review is to summarise the contemporary literature, including the Canadian Urological Association (CUA) and American Urological Association (AUA) guidelines, on various treatment options that exist for IC/BPS, including conservative therapies, oral therapies, intravesical therapies, and more invasive surgical options. Most importantly, this review highlights the need for an individualised, multimodal approach to the treatment of IC/BPS.

Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis

BACKGROUND

Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide-ranging treatment options, used alone or in combination, with limited evidence. A network meta-analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS.

OBJECTIVES

To conduct a network meta-analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS).

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random-effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta-analysis of head-to-head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories.

MAIN RESULTS

We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low-certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD -1.27, 95% CrI -3.25 to 0.71; low-certainty evidence), daytime frequency (MD -2.41, 95% CrI -6.85 to 2.05; very low-certainty evidence) or nocturia (MD 0.01, 95% CrI -2.53 to 2.50; very low-certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low-certainty evidence) or reduced pain (MD 0.42, 95% CrI -1.04 to 1.91; low-certainty evidence), frequency (MD -0.37, 95% CrI -5.00 to 3.44; very low-certainty evidence) or nocturia (MD -1.20, 95% CrI -3.62 to 1.28; very low-certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD -0.33, 95% CrI -1.71 to 1.03), frequency (MD -0.91, 95% CrI -3.24, 1.29) or nocturia (MD -0.04, 95% CrI -1.35 to 1.27). The certainty of this evidence was always very low.

AUTHORS' CONCLUSIONS

We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base.

Cross-over data supporting long-term antibiotic treatment in patients with painful lower urinary tract symptoms, pyuria and negative urinalysis

Purpose

To measure the effects of an unplanned, sudden cessation of treatment in an unselected group of patients with chronic painful LUTS managed with protracted antimicrobial treatment and to report these observational data collected from a cross-over process.

Materials and methods

The imposition of a guideline resulted in the immediate cessation of antibiotic treatment in a cohort of patients with chronic painful LUTS and microscopic pyuria. Patients were assessed before treatment withdrawal, whilst off treatment, and following reinstatement. Outcome measures included a validated symptom score, microscopic enumeration of urinary white cells and uroepithelial cells, and routine urine culture.

Results

These patients had reported treatment-resistant, painful LUTS for a mean of 6.5 years before treatment at this centre. Treatment was stopped in 221 patients (female = 210; male = 11; mean age = 56 years; SD = 17.81). Sixty-six per cent of women were post-menopausal. After unplanned treatment cessation, 199 patients (90%; female = 188; male = 9) reported deterioration. Eleven patients required hospital care in association with disease recurrence, including acute urinary tract infection (UTI) and urosepsis. Symptom scores increased after cessation and recovered on reinitiating treatment (F = 33; df = 2; p < 0.001). Urinary leucocyte (F = 3.7; df = 2; p = 0.026) and urothelial cells counts mirrored symptomatic changes (F = 6.0; df = 2; p = 0.003). Routine urine culture results did not reflect changes in disease status.

Conclusion

These data support the hypothesis that treating painful LUTS associated with pyuria with long-term antimicrobial courses, despite negative urine culture, is effective. The microscopy of fresh unspun, unstained urine to count white cells and epithelial cells offers a valid method of monitoring disease. An unplanned cessation of antibiotic therapy produced a resurgence of symptoms and lower urinary tract inflammation in patients with chronic LUTS, supporting an infective aetiology below the level of routine detection.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Molecular pathogenesis of interstitial cystitis based on microRNA expression signature: miR-320 family-regulated molecular pathways and targets

Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic inflammatory disease that affects the bladder. The symptoms of IC vary, including feeling an urgent need for immediate urination and of needing to urinate often, as well as bladder or pelvic pain. Despite its high incidence, no molecular diagnostic methods are available for IC, and the molecular pathogenesis is unknown. microRNAs (miRNA) can regulate expression of RNA transcripts in cells and aberrant expression of miRNAs is associated with several human diseases. Here, we investigated the molecular pathogenesis of IC based on miRNA expression signatures. RNA sequencing of miRNA levels in IC tissues and comparison with levels in normal bladder tissue and bladder cancer revealed dysregulated expression of 366 miRNAs (203 and 163 down- and upregulated miRNAs, respectively). In particular, miR-320 family miRNAs(miR-320a, miR-320b, miR-320c, miR-320d and miR-320e) had downregulated expression in IC tissues. Genome-wide gene expression analyses and in silico database analyses showed that three transcription factors, E2F-1, E2F-2 and TUB, are regulated by miR-320 family miRNAs. Immunostaining of IC tissues confirmed that these transcription factors are overexpressed in IC tissues. Novel approaches that identify aberrantly expressed miRNA regulatory networks in IC could provide new prognostic markers and therapeutic targets for this disease.

A prospective randomized controlled multicentre trial comparing intravesical DMSO and chondroïtin sulphate 2% for painful bladder syndrome/interstitial cystitis

Objective

To compare effectiveness of intravesical chondroïtin sulphate (CS) 2% and dimethyl sulphoxide (DMSO) 50% in patients with painful bladder syndrome/interstitial cystitis (PBS/IC).

Materials and methods

Patients were randomized to receive either 6 weekly instillations of CS 2% or 50% DMSO. Primary endpoint was difference in proportion of patients achieving score 6 (moderately improved) or 7 (markedly improved) in both groups using the Global Response Assessment (GRA) scale. Secondary parameters were mean 24-hours frequency and nocturia on a 3-day micturition dairy, changes from baseline in O’Leary-Sant questionnaire score and visual analog scale (VAS) for suprapubic pain.

Results

Thirty-six patients were the intention to treat population (22 in CS and 14 in DMSO group). In DMSO group, 57% withdrew consent and only 6 concluded the trial. Major reasons were pain during and after instillation, intolerable garlic odor and lack of efficacy. In CS group, 27% withdrew consent. Compared with DMSO group, more patients in CS group (72.7% vs. 14%) reported moderate or marked improvement (P=0.002, 95% CI 0.05-0.72) and achieved a reduction in VAS scores (20% vs. 8.3%). CS group performed significantly better in pain reduction (-1.2 vs. -0.6) and nocturia (-2.4 vs. -0.7) and better in total O’Leary reduction (-9.8 vs. -7.2). CS was better tolerated. The trial was stopped due to high number of drop-outs with DMSO.

Conclusions

Intravesical CS 2% is viable treatment for PBS/IC with minimal side effects. DMSO should be used with caution and with active monitoring of side effects. More randomized controlled studies on intravesical treatments are needed.

Intravesical treatment for interstitial cystitis/painful bladder syndrome: a network meta-analysis

INTRODUCTION AND HYPOTHESIS

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic inflammatory condition of the submucosal and muscular layers of the bladder. So far, there is no effective and targeted treatment strategy for IC/PBS. This study aimed to assess the efficacy and safety of intravesical instillation treatment in IC/PBS patients.

METHODS

We searched various databases up to October 2015. A network meta-analysis was performed to compare global response assessment (GRA) for different treatment strategies, including botulinum toxin A (BoNTA), bacillus Calmette-Guerin (BCG), resiniferatoxin (RTX), lidocaine, chondroitin sulfate (CS), oxybutynin, and pentosan polysulfate (PPS). A traditional meta-analysis was also performed.

RESULTS

Sixteen trials evaluating 905 patients were included. Network meta-analysis indicated that BoNTA had the highest probability of being the best treatment course according to GRA assessment results (probability 81.7 %). BCG or BoNTA therapy yielded significant improvement in GRA incidence according to traditional meta-analysis. Patients who received PPS showed higher urinary frequency results compared with the placebo groups. BCG- and PPS-treated patients had elevated urinary urgency treatment effects compared with placebo groups. Bladder capacity restoration results also showed significant improvements in patients who received BoNTA compared with placebo-treated individuals.

CONCLUSIONS

These findings indicate that BoNTA therapy has the highest probability of being the best therapy according to GRA, and significantly improves bladder capacity in IC/PBS patients. BCG treatment also significantly increases the incidence of GRA and improves the symptoms of urinary urgency. PPS can significantly improve urinary frequency and urgency symptoms in IC/PBS patients.

The enigma of men with interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common and frequently misdiagnosed disorder in men. Hallmark symptoms are the presence of chronic discomfort attributed to the urinary bladder associated with bladder filling and relieved with bladder emptying, often associated with irritative voiding symptoms, in the absence of any other identifiable cause. It is often grouped with another common clinical entity, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Men with IC/BPS often suffer from a delay in diagnosis and subsequent treatment, often being categorized as having prostatitis, benign prostatic hyperplasia, or epididymitis before the correct diagnosis is reached. The etiology of IC/BPS is poorly understood, and its pathogenesis may involve multiple pathways leading to a common clinical entity. Diagnostic criteria continue to evolve over time as the understanding of IC/BPS improves, and a clinical diagnosis with properly performed history and physical exam is suitable for diagnosis after other processes such as infection, radiation, or pharmaceutical exposure are appropriately excluded. No set pathological findings, biomarkers, or phenotypic descriptions have been universally accepted as a result of conflicting studies. Guidelines for diagnostic and treatment options are limited by available data, and few studies incorporate substantial numbers of male patients. Reported outcomes for common therapies are mixed or have not yet been subjected to study in rigorous placebo-controlled clinical trials in men. Lessons learned from the treatment of CP/CPPS can be applied to IC/BPS, by favoring a phenotypically directed, multimodal approach rather than a stepwise algorithm as advocated by current practice guidelines.

Chronic pelvic pain

Chronic pelvic pain is pain lasting longer than 6 months and is estimated to occur in 15% of women. Causes of pelvic pain include disorders of gynecologic, urologic, gastroenterologic, and musculoskeletal systems. The multidisciplinary nature of chronic pelvic pain may complicate diagnosis and treatment. Treatments vary by cause but may include medicinal, neuroablative, and surgical treatments.

Validation of voiding diary for stratification of bladder pain syndrome according to the presence/absence of cystoscopic abnormalities: a two-centre prospective study

OBJECTIVE

To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities.

PATIENTS AND METHODS

From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test.

RESULTS

Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039).

CONCLUSION

On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.

Management of chronic pelvic pain

Chronic pelvic pain is a complex condition that requires evaluation of the reproductive, gastrointestinal, urologic, musculoskeletal, psychological, and neurological systems. Usually, diagnosis and management entail identifying a network of disorders rather than a single cause of pain with a definitive cure. Only disorders that we commonly encounter in our practice will be discussed in this review.

Urologic chronic pelvic pain syndrome

Painful bladder syndrome or urologic chronic pelvic pain syndrome is a chronic condition that presents with lower urinary tract symptoms that include dysuria, urgency, frequent urination, and chronic pelvic pain. Diagnoses included in the painful bladder syndrome are interstitial cystitis and prostatodynia. The history, physical examination, and laboratory evaluation of patients with lower urinary tract symptoms are important in ruling out other diagnoses. Treatment options that are US Food and Drug Administration approved and evidence based are limited; however, many symptom-based treatment options can reduce symptoms and improve quality of life.

Minimum 6-year outcomes for interstitial cystitis treated with sacral neuromodulation

INTRODUCTION AND HYPOTHESIS

Interstitial cystitis is a multifaceted medical condition consisting of pelvic pain, urgency, and frequency. Can sacral neuromodulation be successfully utilized for the medium term of ≥ 6 years in interstitial cystitis patients for whom standard drug therapies have failed?

METHODS

In our observational, retrospective, case-controlled review (January 2002-March 2004), we sought to discern whether neuromodulation could be successfully implemented with acceptable morbidity rates in interstitial cystitis patients. Thirty-four female patients underwent stage 1 and 2 InterStim placements under a general anesthetic. Simple means and medians were analyzed.

RESULTS

Mean pre-op/post-op pelvic pain and urgency/frequency scores were 21.61 ± 8.6/9.22 ± 6.6 (p < 0.01), and mean pre-op/post-op visual analog pain scale (VAPS) were 6.5 ± 2.9/2.4 ± 1.1 (p < 0.01). Median age was 41 ± 14.8 years with a mean follow-up of 86 ± 9.8 months.

CONCLUSIONS

With a minimum 6-year follow-up we determined that sacral neuromodulation provides adequate improvement for the symptoms of recalcitrant interstitial cystitis.

Interstitial cystitis: an unsolved enigma

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a chronic disease of unknown etiology characterized by vague bladder pain and nonspecific urinary symptoms, such as urgency and frequency. Although it was initially considered to be a rare condition, its prevalence has significantly increased, possibly because of different definitions used and greater physician awareness. Because of the multiple diagnostic criteria used, there is significant variation in its prevalence. In addition, there is often a delay in the diagnosis of PBS/IC. It affects predominantly women of middle age, and it significantly decreases quality of life. Diagnosis of PBS/IC is mainly a diagnosis of exclusion; there are no characteristic symptoms or pathognomonic findings. Therefore, it is important to rule out diseases that have a similar clinical picture (i.e., urinary infections, bladder carcinoma) but definite therapies and worse prognosis if left untreated. PBS/IC management suffers from lack of evidence; many therapies are empiric or based on small studies and case series. Treatment includes supportive therapies (psychosocial, behavioral, physical), oral treatments, and intravesical treatments, whereas other more invasive treatments such as electric neuromodulation and reconstructive surgery are reserved for refractory cases. Physicians should always keep in mind the diagnosis of PBS/IC in patients presenting with chronic urinary symptoms after excluding other more common diseases.

Developmental influences on medically unexplained symptoms

BACKGROUND

Medically unexplained (or 'functional') symptoms (MUS) are physical symptoms that prompt the sufferer to seek healthcare but remain unexplained after an appropriate medical evaluation. Examples of MUS also occur in veterinary medicine. For example, domestic cats suffer a syndrome comparable to interstitial cystitis, a chronic pelvic pain syndrome of humans.

METHOD

Review of current evidence suggests the hypothesis that developmental factors may play a role in some cases of MUS. Maternal perception of a threatening environment may be transmitted to the fetus when hormones cross the placenta and affect fetal physiology, effectively 'programming' the fetal stress response system and associated behaviors toward enhanced vigilance. After birth, intense stress responses in the individual may result in similar vulnerability, which may be unmasked by subsequent stressors.

RESULTS

Epigenetic modulation of gene expression (EMGEX) appears to play a central role in creation of this 'survival phenotype'. The recent development of techniques to identify the presence of EMGEX provides new tools to investigate these questions, and drugs and other interventions that may reverse EMGEX are also under active investigation.

CONCLUSION

Viewing MUS from the perspective of underlying developmental influences involving EMGEX that affect function of a variety of organs based on familial (genetic and environmental) predispositions rather than from the traditional viewpoint of isolated organ-originating diseases has at least two important implications: it provides a parsimonious explanation for findings heretofore difficult to reconcile, and it opens whole new areas of investigation into causes and treatments for this class of disorders.

Paediatric painful bladder syndrome/interstitial cystitis: diagnosis and treatment

To describe the pathophysiology, diagnosis and controversies surrounding the diagnosis and pharmacological treatments of painful bladder syndrome/interstitial cystitis (PBS/IC) in children, we reviewed adult and paediatric literature pertaining to PBS/IC. Paediatric PBS/IC presents similarly to adult PBS/IC. The diagnosis is made by exclusion. Paediatric PBS/IC patients complain most commonly of urinary frequency, and abdominal pain occurs in up to 88% of affected children. Enuresis may also be a presenting complaint. Urinalysis and urine cultures are unremarkable. Management of paediatric PBS/IC is similar to that of adult PBS/IC, and non-surgical management includes dietary, lifestyle and pharmacological therapy. Pharmacological options include pentosan polysulfate, amitriptyline, hydroxyzine, cimetidine or intravesical therapies (dimethyl sulfoxide or 'therapeutic solution').