Challenges and current evidence on the management of bladder pain syndrome

Management of Bladder Pain Syndrome (BPS): A Practical Guide

Bladder pain syndrome (BPS) is a prevalent and pervasive disease. The physical and psychological sequelae can be very burdensome for the patient, and the condition represents a real challenge for the clinician as well. With no simple pathognomonic test, finding harmony in navigating patient care can be demanding. Diagnosis and management rely upon a multidisciplinary and holistic approach. Treatment options include conservative measures and pharmacotherapies as well as bladder instillation therapies. Ultimately, surgery may be offered but only in cases of refractory disease. This article offers a pragmatic guide for clinicians managing this challenging disease.

Association of Interstitial Cystitis/Bladder Pain Syndrome with Stress-Related Diseases: A Nationwide Population-Based Study

Background: Stress-related diseases (SRDs) are adjustment disorders triggered by stressful life changes. There is a growing body of evidence showing that stress plays an important role in the pathophysiology of IC/BPS. In the present study, we investigated the association between SRDs and a subsequent association of interstitial cystitis/bladder pain syndrome (IC/BPS). Methods: We performed a nested case-control study from the Longitudinal Health Insurance Database (LHID) of Taiwan. The two-year time-varying association between SRDs and IC/BPS was explored to distinguish the short- or long-term effects of these factors. We then conducted multiple conditional logistic regressions to evaluate the adjusted odds ratio (OR) of IC/BPS in patients with a history of SRDs. Results: A total of 1103 IC/BPS patients and 4412 non-IC/BPS patients were analyzed. For all SRDs, the significantly increased risks were obtained in 2 years before IC/BPS diagnosis, and the higher OR was observed within 3 months before the diagnosis of IC/BPS. Multiple conditional logistic regressions showed that patients who had prior medical care for urinary tract infection (OR = 10.95, 95% CI = 9.07 to 13.22), chronic obstructive pulmonary disease (OR = 1.48, 95% CI = 1.13 to 1.93), peptic ulcer (OR = 1.69, 95% CI = 1.37 to 2.09), inflammatory bowel syndrome (OR = 1.66, 95% CI = 1.21 to 2.29), autoimmune diseases (OR = 1.48, 95% CI = 1.11 to 1.97), depression (OR = 1.54, 95% CI = 1.24 to 1.91), sleep disorders (OR = 1.45, 95% CI = 1.19 to 1.78), and allergic rhinitis (OR = 1.29, 95% CI = 1.03 to 1.62) within 2 years had a significant risk of IC/BPS. Conclusions: Our study demonstrates that the health care for SRDs within the previous 2 years is associated with an increased risk of subsequent IC/BPS. The time-varying association provides an important insight that helps us to identify cases with IC/BPS, especially among patients with repeated UTI visits.

Onabotulinumtoxin a injection with or without hydrodistension for treatment of bladder pain syndrome

INTRODUCTION

Onabotulinumtoxin A (BoNT-A) injection has been used for bladder pain syndrome (BPS) treatment with good results. Our aim was to assess the efficacy and safety of BoNT-A injection with or without hydrodistension (HD).

METHODS

Retrospective analysis of patients treated with BoNT-A injection with or without HD because of BPS between 2008 and 2014 in our department. One hundred U of Botox® was injected in the trigone and 100 U in the bladder wall. Follow-up included a VAS of pain (0-10), a patient satisfaction scale (0-10) and a treatment benefit scale (1-2: response to treatment; 3-4: non-response to treatment). Complications were classified according to the Clavien-Dindo (CD) classification. BoNT-A retreatment was offered at the patient's request. Reasons for non-retreatment request were collected. Postoperative outcomes were compared between BoNT-A and BoNT-A + HD.

RESULTS

Forty-one patients were included (39 females, 2 males), median age: 73 years (69-78.5). Reduction in VAS, postoperative VAS = 0, satisfaction with surgery and responders to treatment were significantly higher after BoNT-A + HD (n = 26) than after BoNT-A (n = 15). Eleven (26.8%) complications (CD ≤ 2) were detected, with no differences between treatment groups. Mean follow-up was 153 (± 83) months. Twelve (46.2%) patients in the BoNT-A + HD group and seven (46.7%) patients in the BoNT-A group requested retreatment. Lack of severe pain was a common reason for treatment discontinuation.

CONCLUSION

BoNT-A injection could represent a safe and effective BPS treatment. BoNT-A + HD seems to be better than BoNT-A alone for pain relief, with no significant additional morbidity.

C-Phycocyanin Alleviates Bladder Inflammation and Dysfunction in Cyclophosphamide-Induced Cystitis in a Mouse Model by Inhibiting COX-2 and EP4

Objective

To explore the effect of C-phycocyanin (C-PC) on voiding behavior and histological changes in cyclophosphamide- (CYP-) induced cystitis in mice.

Methods

Sixty female mice were included. The mice in the C-PC group received C-PC (25 mg/kg, twice, i.p.) and then CYP (200 mg/kg, i.p.) two hours later, while the mice in the CYP group only received the equivalent CYP. Saline was injected in the mice in the control group. A voided stain on paper (VSOP) test was conducted to analyze the micturition. The bladders were harvested for histological evaluation and measurements of inflammatory factors.

Results

C-PC reduced the micturition frequency in the mice with CYP-induced cystitis. The bladder/body weight ratio and edema were remarkably higher in the CYP group compared to the C-PC group. C-PC suppressed the expressions of COX-2, PGE₂, and EP4 (prostaglandin E receptor 4) according to the ELISA assay. Immunohistochemical staining also indicated that C-PC reduced the expressions of COX-2 in urothelium and EP4 in smooth muscles.

Conclusions

C-PC relieved symptoms associated with CYP-induced cystitis in mice by inhibiting bladder inflammation through COX-2 and EP4 expression.

Biomarkers in the diagnosis and symptom assessment of patients with bladder pain syndrome: a systematic review

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS) is a disease of unknown etiology defined as an unpleasant sensation related to the bladder, associated with lower urinary tract symptoms of more than 6 weeks' duration, in the absence of any identifiable causes. Despite its impact on quality of life (QoL) and socioeconomic burden, there are no objective methods for the diagnosis or assessment of therapeutic response. We systematically reviewed biomarkers associated with BPS to update the current knowledge on this issue.

METHODS

A systematic review of the Cochrane Library, Embase, PubMed/MEDLINE, LILACS, SCOPUS, and ClinicalTrials.gov databases was conducted following the PRISMA statement. Original articles investigating biomarkers for the diagnosis or symptom assessment of patients with BPS were assessed; no language restrictions were applied. Animal or post-mortem studies were excluded.

RESULTS

Of the 478 records retrieved, 11 articles were included. MIF, NGF, Etio-S, APF, and a combined methylhistamine/Il-6 model were increased in BPS urine samples versus controls. Also increased were glyceraldehyde in stool, in addition to the expression of some genes (ARID1A, ARF, CHAT, eNOS, GLI-1, iNOS, MCP-1, NGF, WNT-8A, WNT-10A), nerve density, IL-16, VCAM-1, and ICAM-1 in bladder tissue specimens. In contrast, some fecal bacteria, expression of other genes (CHT, HB-EGF, OCT-1, SMRT-1, WNT11) in the bladder urothelium, and urinary DNA methylation in CpG-sites, MCP-3, G5P1, and HB-EGF were decreased in BPS. As none of the biomarkers was studied more than once, a Forest plot could not be constructed. Only 4 articles reported the relation of biomarkers to symptom scores.

CONCLUSIONS

Potential biomarkers for BPS in urine, stool, and bladder biopsy specimens are described. Further research is needed before their use in clinical practice.

Expression of programmed death ligand-1 on bladder tissues is detected in a clinically and histologically well-defined interstitial cystitis cohort

OBJECTIVE

To investigate the expression of programmed death ligand-1 (PD-L1) in interstitial cystitis (IC).

METHODS

We reviewed the data of IC patients underwent hydrodistension plus bladder biopsy. Follow-ups were performed. We assessed the degree of inflammation of the bladder wall on slides stained with hematoxylin and eosin (H&E). We performed immunohistochemistry for PD-L1 expression detection and for counting T lymphocytes and B lymphocytes.

RESULTS

The present study included eight men and 32 women. With H&E staining, we detected 13, 15, and 12 patients with mild, moderate, and severe inflammation. The degree of inflammation was negatively correlated with disease course (P = 0.018) and positively correlated with bladder pain (P < 0.001). Hydrodistension was found effective at postoperative 3-month for 19 patients. Overall, 17, 15, 7, and 1 subject had no, mild, moderate, and high PD-L1 expression, that correlated positively with the degree of inflammation. Compared with patients with no and mild PD-L1 expression, patients with moderate and high PD-L1 expression tended to have more effective hydrodistension outcomes (12 of 32 vs 7 of 8; P = 0.017). In the subset of 12 patients with severe inflammation, there were five of six patients (83.3%) with moderate or high PD-L1 expression and one of six patients (16.7%) with no and mild PD-L1 expression with an effective hydrodistension outcome.

CONCLUSIONS

Expression of PD-L1 on bladder is detected in a cohort of IC patients presented with diffuse global glomerulation or Hunner ulcer. PD-L1 expression is more common in IC patients with severe bladder inflammation.

Sponging off nature for new drug leads

Marine sponges have consistently been the richest source of new marine natural products with unprecedented chemical scaffolds and potent biological activities that have been reported in the chemical literature since the early 1970s. During the last 40years, chemists in the Andersen laboratory at UBC, in collaboration with biologists, have discovered many novel bioactive sponge natural products. Four experimental drug candidates for treatment of inflammation and cancer, that were inspired by members of this sponge natural product collection, have progressed to phase I/II/III clinical trials. This review recounts the scientific stories behind the discovery and development of these four drug candidates; IPL576,092, HTI-286 (Taltobulin), EPI-506 (Ralaniten acetate), and AQX-1125.

Dynamic Expression of Serotonin Receptor 5-HT3A in Developing Sensory Innervation of the Lower Urinary Tract

Sensory afferent signaling is required for normal function of the lower urinary tract (LUT). Despite the wide prevalence of bladder dysfunction and pelvic pain syndromes, few effective treatment options are available. Serotonin receptor 5-HT3A is a known mediator of visceral afferent signaling and has been implicated in bladder function. However, basic expression patterns for this gene and others among developing bladder sensory afferents that could be used to inform regenerative efforts aimed at treating deficiencies in pelvic innervation are lacking. To gain greater insight into the molecular characteristics of bladder sensory innervation, we conducted a thorough characterization of Htr3a expression in developing and adult bladder-projecting lumbosacral dorsal root ganglia (DRG) neurons. Using a transgenic Htr3a-EGFP reporter mouse line, we identified 5-HT3A expression at 10 days post coitus (dpc) in neural crest derivatives and in 12 dpc lumbosacral DRG. Using immunohistochemical co-localization we observed Htr3a-EGFP expression in developing lumbosacral DRG that partially coincides with neuropeptides CGRP and Substance P and capsaicin receptor TRPV1. A majority of Htr3a-EGFP+ DRG neurons also express a marker of myelinated Aδ neurons, NF200. There was no co-localization of 5-HT3A with the TRPV4 receptor. We employed retrograde tracing in adult Htr3a-EGFP mice to quantify the contribution of 5-HT3A+ DRG neurons to bladder afferent innervation. We found that 5-HT3A is expressed in a substantial proportion of retrograde traced DRG neurons in both rostral (L1, L2) and caudal (L6, S1) axial levels that supply bladder innervation. Most bladder-projecting Htr3a-EGFP+ neurons that co-express CGRP, Substance P, or TRPV1 are found in L1, L2 DRG, whereas Htr3a-EGFP+, NF200+ bladder-projecting neurons are from the L6, S1 axial levels. Our findings contribute much needed information regarding the development of LUT innervation and highlight the 5-HT3A serotonin receptor as a candidate for future studies of neurally mediated bladder control.

Pain relief after triamcinolone infiltration in patients with bladder pain syndrome with Hunner's ulcers

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS) is a chronic condition with severe implications in the patient's quality of life with no definitive treatment. Our objective was to assess pain relief after triamcinolone injection in patients with BPS with Hunner's ulcers (HU).

METHODS

Retrospective study of 20 consecutive patients with BPS treated at the Hospital Clinic of Barcelona with triamcinolone injection with flexible cystoscope between 2015 and 2016. Pain was assessed according to the visual analog scale (VAS) (0-10) before and after treatment. Outcomes were compared using Student's t test for paired samples.

RESULTS

Twenty-seven procedures were performed in 20 patients, who were followed up for a median of 7 months (range 1-15). Median age was 75 years (52-86), and median time from diagnosis to treatment was 4.5 years (1-7). Fifteen (75 %) patients had received treatment with corticoid injection for BPS before entering the study. Pre- and postreatment VAS was 8 and 2.5 (p < 0.001), respectively. Pre -and postreatment VAS in those with muscular pain was 8 and 5 (p = 0.012), respectively and in those without muscular pain was 8 and 2 (p < 0.001), respectively. Three (15 %) patients required retreatment due to nonresponse and 5 (25 %) patients for pain recurrence after 4 months (3.5-8). Four of them (50 %) were performed with triamcinolone injection again. Seven of ten patients (70 %) followed for ≥8 months required at least one retreatment.

CONCLUSION

Triamcinolone injection for HU in patients with BPS is associated with significant pain reduction. However, most patients will require retreatment.

Supraspinal Projection of Serotonergic and Noradrenergic Pathways Modulates Nociceptive Transmission in the Lower Urinary Tract of Rats

OBJECTIVES

To investigate the effect of descending serotonergic and noradrenergic pathways on nociception in the lower urinary tract (LUT).

METHODS

Female Sprague-Dawley rats were used. Following intraperitoneal administration of Vehicle or Milnacipran (30 mg/kg), which is one of serotonin-noradrenaline reuptake inhibitors (SNRI), 0.1% AA was infused into the bladder in normal (n = 4, each) and spinal cord injury (SCI) (n = 4, each) rats for 2 h on consciousness, and c-Fos, 5-HT and DβH were stained using immunohistochemistry at the L6 spinal cord as spinal areas associated with LUT.

RESULTS

In SCI rats, 5-HT or DβH-positive fibers were not observed at the L6 spinal cord, while there were many 5-HT and DβH-positive fibers in normal rats. The total number of c-Fos-positive cells was significantly increased in SCI rats compared to Normal rats (209.4 ± 7.1 in Normal, 336.4 ± 28.9 in SCI, P < 0.05), which indicated that interruption of supraspinal modulation enhances nocieptive transmission in the LUT. Regarding the effect of Milnacipran administration, the number of c-Fos-positive cells was significantly decreased at all region of the L6 spinal cord in normal rats (P < 0.05), while this reduction was not observed in SCI rats. This result demonstrated that administration of SNRI attenuates nocieptive transmission in the LUT, indicating that 5-HT and noradrenaline work as mediators of endogenous analgesic mechanisms through the supraspinal descending pain pathways.

CONCLUSIONS

Supraspinal projections of descending serotonergic and noradrenergic pathways to the lower lumbar spinal cord modulate nocieptive transmission in the LUT. Administration of SNRI attenuates nocieptive transmission in the LUT, which could result from enhancement of modulating descending serotonergic and noradrenergic pathways.

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.

O'Leary-Sant Symptom Index Predicts the Treatment Outcome for OnabotulinumtoxinA Injections for Refractory Interstitial Cystitis/Bladder Pain Syndrome

Although intravesical injection of onabotulinumtoxinA (BoNT-A) has been proved promising in treating patients with interstitial cystitis/bladder pain syndrome (IC/BPS), what kind of patients that may benefit from this treatment remains unclear. This study investigated the predictors for a successful treatment outcome. Patients with IC/BPS who failed conventional treatments were enrolled to receive intravesical injection of 100 U of BoNT-A immediately followed by hydrodistention. Variables such as O’Leary-Sant symptom and problem indexes (ICSI and ICPI), pain visual analogue scale (VAS), functional bladder capacity (FBC), voiding diary, and urodynamic parameters were measured at baseline and six months after treatment. A global response assessment (GRA) ≥ 2 at six months was defined as successful. There were101 patients enrolled. Significant improvements were observed in mean ICSI, ICPI, OSS (ICSI + ICPI), pain VAS, FBC, frequency, nocturia and GRA at six months after BoNT-A injections (all p < 0.05). The successful rate at six months was 46/101 (45.54%). Multivariate logistic regression revealed the baseline ICSI (odds ratio = 0.770, 95% confidence interval = 0.601–0.989) was the only predictor for a treatment outcome. ICSI ≥ 12 was the most predictive cutoff value for a treatment failure, with a ROC area of 0.70 (sensitivity = 69.1%, specificity = 60.9%).

Contrast enhanced magnetic resonance imaging as a diagnostic tool to assess bladder permeability and associated colon cross talk: preclinical studies in a rat model

PURPOSE

Interstitial cystitis/painful bladder syndrome is a devastating disease associated with multiple symptoms. It is usually diagnosed based on pain, urgency and frequency in the absence of other known causes. To our knowledge there is no diagnostic test to date.

MATERIALS AND METHODS

In a model of rats intravesically exposed to protamine sulfate we performed in vivo diagnostic contrast enhanced magnetic resonance imaging with intravesical administration of Gd-diethylenetriamine pentaacetic acid contrast medium via a catheter to visualize increased bladder urothelium permeability. Gd-diethylenetriamine pentaacetic acid was administered intravenously to visualize secondary tissue effects in the colon.

RESULTS

Bladder urothelium and colon mucosa were assessed 24 hours after bladder protamine sulfate exposure. Enhanced contrast magnetic resonance imaging established bladder urothelium leakage of Gd-diethylenetriamine pentaacetic acid according to the change in magnetic resonance imaging signal intensity in rats exposed to protamine sulfate vs controls (mean ± SD 399.7% ± 68.7% vs 39.2% ± 12.2%, p < 0.0001) as well as colon related uptake of contrast agent (mean 65.2% ± 17.1% vs 20.8% ± 9.8%, p < 0.01) after bladder protamine sulfate exposure. The kinetics of Gd-diethylenetriamine pentaacetic acid uptake and excretion were also assessed during 20 minutes of bladder and 30 minutes of colon exposure with increased signal intensity at 7 and 12 minutes, respectively.

CONCLUSIONS

These preliminary studies indicate that contrast enhanced magnetic resonance imaging can be used to monitor primary bladder urothelium loss of permeability and secondary enhanced contrast medium in the colon mucosa. It can be considered a potential clinical diagnostic method for interstitial cystitis/painful bladder syndrome that involves loss of the permeability barrier. It can also be used to assess visceral organ cross talk.