Clinical Efficacy of 1-Year Intensive Systematic Dietary Manipulation as Complementary and Alternative Medicine Therapies on Female Patients With Interstitial Cystitis/Bladder Pain Syndrome

Current updates relating to treatment for interstitial cystitis/bladder pain syndrome: systematic review and network meta-analysis

BACKGROUND

Despite the publication of several meta-analyses regarding the efficacy of certain therapies in helping individuals with interstitial cystitis (IC) / bladder pain syndrome (BPS), these have not provided a comprehensive review of therapeutic strategies. The study aimed to determine the efficacy of various therapies for IC/BPS and identify potential moderating factors using randomized controlled trials (RCTs).

METHODS

We queried the PubMed, Cochrane, and Embase databases to identify prospective RCTs using inclusion criteria: 1) patients diagnosed with IC, 2) interventions included relevant treatments, 3) comparisons were a specified control or placebo, 4) outcomes were mean differences for individual symptoms and structured questionnaires. The pairwise meta-analysis and network meta-analysis (NMA) were performed to compare the treatments used in IC/BPS. Hedges' g standardized mean differences (SMDs) were used for improvement in all outcomes using random-effects models. Efficacy outcomes included individual symptoms such as pain, frequency, urgency, and nocturia, as well as structured questionnaires measuring IC/BPS symptoms.

RESULTS

A comprehensive literature search was conducted which identified 70 RCTs with 3,651 patients. The analysis revealed that certain treatments, such as instillation and intravesical injection, showed statistically significant improvements in pain and urgency compared to control or placebo groups in traditional pairwise meta-analysis. However, no specific treatment demonstrated significant improvement in all outcomes measured in the NMA. The results of moderator analyses to explore influential variables indicated that increasing age was associated with increased nocturia, while longer follow-up periods were associated with decreased frequency.

CONCLUSION

This systematic review and meta-analysis provide insights into the efficacy of various treatments for IC. Current research suggests that a combination of therapies may have a positive clinical outcome for patients with IC, despite the fact that treatment for this condition is not straightforward.

TRIAL REGISTRATION

PROSPERO CRD42022384024.

Nutritional Considerations for Bladder Storage Conditions in Adult Females

BACKGROUND

Clinical guidelines developed by urologic, urogynecologic, and gynecologic associations around the globe include recommendations on nutrition-related lifestyle and behavioral change for bladder storage conditions. This study identified and compared clinical guidelines on three urological conditions (interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, and stress urinary incontinence) affecting adult women.

METHODS

A three-step process was employed to identify the guidelines. Next, a quality assessment of the guidelines was conducted employing the Appraisal of Guidelines Research and Evaluation (AGREE II) International tool. (3) Results: Twenty-two clinical guidelines, prepared by seventeen groups spanning four continents, met the inclusion criteria. The AGREE II analyses revealed that most of the guideline development processes complied with best practices. The most extensive nutrition recommendations were for women with IC/BPS. Dietary manipulation for the other two storage LUTS primarily focused on the restriction or limitation of specific beverages and/or optimal fluid intake. (4) Conclusion: Clinical guidelines for IC/BPS, overactive bladder, and stress urinary incontinence include nutrition recommendations; however, the extent of dietary manipulation varied by condition. The need to ensure that clinicians are informing patients of the limitations of the evidence supporting those recommendations emerged. Furthermore, given the need to treat nutrition-related comorbid conditions as a strategy to help mitigate these three urological disorders, the value of referral to a dietitian for medical nutrition therapy is apparent.

Centering Group Treatment for Women With Interstitial Cystitis/Bladder Pain Syndrome: A Prospective, Parallel-Group Cohort Study

IMPORTANCE

Women with interstitial cystitis/bladder pain syndrome (ICBPS) face isolation and treatment challenges. Group medical visits using Centering models have successfully treated other conditions but have not been explored in ICBPS.

OBJECTIVE

This study aimed to describe ICBPS pain and symptom control comparing standard treatment alone versus standard treatment augmented with Centering visits.

STUDY DESIGN

This prospective cohort study recruited women with ICBPS receiving standard care (control) or standard care augmented with group Centering. We administered validated questionnaires at baseline and monthly for 12 months. The primary outcome was change in the pain numerical rating scale, with Patient-Reported Outcomes Measurement Information System Pain Interference Scale and Bladder Pain/Interstitial Cystitis Symptom Score change as secondary measures.

RESULTS

We enrolled 45 women (20 Centering, 25 controls). Centering had significantly better numerical rating scale pain scores at 1 month (mean difference [diff], -3.45) and 2 months (mean diff, -3.58), better Patient-Reported Outcomes Measurement Information System Pain Interference Scale scores at 1 month (mean diff, -10.62) and 2 months (mean diff, -9.63), and better Bladder Pain/Interstitial Cystitis Symptom Score scores at 2 months (mean diff, -13.19), and 3 months (mean diff, -12.3) compared with controls. In modeling, treatment group (Centering or control) and educational levels were both associated with all the outcomes of interest. Beyond 6 months, there were too few participants for meaningful analyses.

CONCLUSIONS

Women with ICBPS participating in a Centering group have, in the short term, less pain, pain interference, and ICBPS-specific symptoms than patients with usual care alone. Larger studies with more follow-up are needed to determine if this treatment effect extends over time.

Anti-Inflammatory Diet for Women with Interstitial Cystitis/Bladder Pain Syndrome: The AID-IC Pilot Study

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by pelvic pain coupled with urinary frequency and urgency. The underlying cause of IC/BPS is unknown; there is no cure. Dietary components exacerbate symptoms. The Anti-Inflammatory Diet for Interstitial Cystitis (AID-IC) employs a randomized, crossover design to evaluate the effect of a plant-based, low saturated fat diet on the quality of life of women with IC/BPS. Insights on the implementation of the protocol and reflections on the facilitators and barriers experienced during the pilot study follow. The logistics of the protocol proved time-consuming; however, the barriers were surmountable. Quantitative and qualitative findings suggest that the AID-IC therapeutic diet may have lessened symptoms and improved the quality of life for many of the women in the study.

Current Challenges in the Management of Chronic Pelvic Pain in Women: From Bench to Bedside

Chronic pelvic pain (CPP) affects a significant proportion of women worldwide And has a negative impact on several aspects of these women’s lives including mental health, work, relationships and sexual function, among others. This set of factors ultimately reflects negatively on quality Of life. The physiopathology of CPP is complex and remains to be fully clarified; however, recent advances have increased understanding of the mechanisms involved in chronic pain in general, and more specifically, CPP. Nonetheless, even when a detailed clinical history is obtained, meticulous physical examination is performed and imaging resources are appropriately used, the organic cause of the pain may still fail to be identified in a substantial number of women with CPP. Management of CPP may therefore be challenging. This narrative review was aimed at adding to the available literature on the subject, presenting and discussing the principal characteristics of CPP in women. The paper highlights gaps in the literature while providing the most up-to-date evidence associated with the physiopathology and classification of pain, its diagnosis and treatment. In addition, current challenges in the management of women with CPP are discussed.

[Rehabilitation of patients with interstitial cystitis/bladder pain syndrome (IC/BPS)]

After unsuccessful outpatient conservative treatment or invasive inpatient treatment and after cystectomy in interstitial cystitis/bladder pain syndrome (IC/BPS), an inpatient discipline-specific urological rehabilitation (rehab) should be proposed according to the German guideline on IC/BPS. During rehab, diagnostic results will be completed. Multimodal therapy includes the optimisation of lifestyle and medication. Intensive psychotherapy may frequently improve the processing of the disease. Various forms of exercise therapy and physical therapy with water applications, thermotherapy, several forms of massage and electrical or magnetic therapies as well as nutritional advice frequently alleviate complaints in IC/BPS. The different therapies are modified during rehab, if necessary. Social medicine evaluation and advice, e.g. on grade of handicap or ability to work, are also important issues in rehab. Two-thirds of patients show an essential improvement after rehab, which lasts for a prolonged period in about 50% of patients.

Transcranial direct current electrical stimulation for the treatment of interstitial cystitis: A study protocol

BACKGROUND

Interstitial cystitis or painful bladder syndrome is a chronic disorder that presents an unknown etiology, with no generally accepted treatment. Although there is no gold standard treatment, transcranial direct current stimulation (tDCS) has shown efficacy in several chronic pain syndromes with decrease in pain, and improved functionality and mood. tDCS could be a safe, ease to use, and low-cost complementary intervention for patients with interstitial cystitis.

AIM

This study will investigate the effects of a tDCS protocol on pain, functionality, and mood in patients with interstitial cystitis.

METHODS

A randomized controlled clinical trial with two arms. Women will be randomized into two groups: active or sham. Anodal tDCS over the primary motor cortex will be performed for 5 consecutive days with an intensity of 2 mA for 20 min. Participants will be evaluated five times: 1 week before intervention; on the 5^th day of tDCS; and 1, 6, and 12 months after the last day of tDCS. The outcomes will be assessed using the numeric rating scale, McGill pain questionnaire, positive and negative affect scale, international consultation on incontinence questionnaire for female lower urinary tract symptoms, Hamilton anxiety scale, six-minute walk test, patient global impression of change, and voiding diary.

DISCUSSION

Only the active group will be expected to show decreased pain. The results of this trial will be the first step in the use of neuromodulation in interstitial cystitis and will provide additional data to support new studies with tDCS.

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.

How can we improve the diagnosis and management of bladder pain syndrome? Part 2:ICI-RS 2018

BACKGROUND

This paper summarises the discussion in a think tank at the International Consultation on Incontinence-Research Society (ICI-RS) 2018 about the treatment of bladder pain syndrome.

AIMS

To review the treatments of bladder pain syndrome from behavioural treatments to surgical interventions.

MATERIALS AND METHODS

Review the literature in the light of the think tank discussions.

RESULTS

All guidelines recommend different levels of treatment starting with conservative behavioral treatments then introducing oral treatments followed by intravesical instillations. If these treatments fail then more invasive treatments such as botulinum toxin injections, neuromodulation, or surgery could be suggested.

CONCLUSION

Unfortunately for all treatments, the numbers are limited and, therefore, the evidence base is not strong. Further suggestions for research are suggested.

Current best practice management of interstitial cystitis/bladder pain syndrome

Introduction

Over the last 100 years, the terminology and diagnosis criteria for interstitial cystitis have evolved. Many therapeutic options have changed, but others have endured. This article will review the idea of separating 'classic' Hunner lesion interstitial cystitis (HL IC) from non-Hunner lesion interstitial cystitis and bladder pain syndrome (N-HL IC/BPS) and their respective treatment algorithms.

Methods/Results

A literature search was performed to identify articles and research on HL IC and N-HL IC/BPS including definitions, etiological theories, and treatments. This article is an overview of the existing literature. We also offer insight into how HL IC and N-HL IC/BPS are approached at our tertiary referral center. Additionally, American Urological Association guidelines have been integrated and newer treatment modalities and research will be introduced at the conclusion.

Conclusion

The AUA guidelines have mapped out a stepwise fashion to treat IC/BPS; at our institution we separate patients with HL IC from those with N-HL IC/BPS prior to them entering a treatment pathway. We identify the rarer patient with HL as having classic 'IC'; this cystoscopic finding is critical in guiding treatment. We believe HL IC is a distinct disease from N-HL IC/BPS and therapy should focus on the bladder. The vast majority of patients with N-HL IC/BPS need management of their pelvic floor muscles as the primary therapy, complemented by bladder-directed therapies as needed as well as a multidisciplinary team to manage a variety of other regional/systemic symptoms. Ongoing research into IC/BPS will help us better understand the pathophysiology and phenotypes of this complex disease while exciting and novel research studies are developing promising treatments.