IMPROVEMENT OF INTERSTITIAL CYSTITIS SYMPTOMS AND PROBLEMS THAT DEVELOPED DURING TREATMENT WITH ORAL IPD-1151T

The Roles of T cells in Bladder Pathologies

T lymphocytes play important roles in the skin and mucosal surfaces such as the gut and lung. Until recently the contributions of T cells to mammalian bladder immunity were largely unknown. With newer techniques, including single-cell RNA sequencing and reporter mice, an understanding is emerging of T cell roles in bladder diseases (bacterial infections, bladder cancer, chronic inflammation). In these pathologies, many bladder T cell responses can be harmful to the host through suboptimal clearance of bacteria or cancer cells, or by modulating autoinflammation. Recent findings suggest that T cell behavior might be influenced by resident T cell interactions with the bladder microbiota and other immunostimulants. Thus, regulating bladder T cell functions could emerge as a putative immunotherapy to treat some bladder diseases.

Blocking α2δ-1 Subunit Reduces Bladder Hypersensitivity and Inflammation in a Cystitis Mouse Model by Decreasing NF-kB Pathway Activation

Bladder pain is frequently associated with bladder inflammation, as in conditions like interstitial cystitis (IC), for which current analgesic therapies have limited efficacy. The antinociceptive effect of alpha-2-delta (α₂δ) ligands on inflammation-associated visceral pain like that experienced in cystitis has been poorly investigated. To investigate the effect of pregabalin (PGB), an α₂δ ligand, we evaluated its impact on mechanical hyperalgesia in a mouse model of cystitis induced by cyclophosphamide (CYP). We further studied its effect on inflammation and NF-kB pathway activation. Acute cystitis was induced by intraperitoneal injection of 150 mg kg^-1 of CYP in C57Bl/6J male mice. PGB was subcutaneously injected (30 mg kg^-1) 3 h after CYP injection. The effect of PGB on CYP-induced mechanical referred hyperalgesia (abdominal Von Frey test), inflammation (organ weight, cytokine production, α₂δ subunit level, NF-kB pathway activation) were assessed 1 h after its injection. In parallel, its effect on cytokine production, α₂δ subunit level and NF-kB pathway activation was assessed in vitro on peritoneal exudate cells (PECs) stimulated with LPS. PGB treatment decreased mechanical referred hyperalgesia. Interestingly, it had an anti-inflammatory effect in the cystitis model by reducing pro-inflammatory cytokine production. PGB also inhibited NF-kB pathway activation in the cystitis model and in macrophages stimulated with LPS, in which it blocked the increase in intracellular calcium. This study shows the efficacy of PGB in hypersensitivity and inflammation associated with cystitis. It is therefore of great interest in assessing the benefit of α₂δ ligands in patients suffering from cystitis.

An evaluation of the pharmacotherapy for interstitial cystitis

INTRODUCTION

Interstitial cystitis (IC) and bladder pain syndrome (BPS) are chronic conditions that can be debilitating for patients. There is no consensus as to their etiology, and there are many proposed treatment algorithms. Oftentimes multimodal therapy, such as combining behavioral modification and physical therapy alongside pharmacotherapies, will be utilized. With the various treatment options available to patients and providers, there is an ever-growing need to implement evidence-based therapies.

AREAS COVERED

The authors explore the different pharmacotherapies as commonly recommended in the American Urological Association (AUA) and European Association of Urology (EAU) multitiered guidelines for IC/BPS treatment as well as other investigational therapies. Pharmacotherapies targeting bladder, pelvic, and/or systemic factors in the overall treatment of IC/BPS are discussed with a particular focus on evidence-based guideline therapies. This article also looks at emerging therapies of interest.

EXPERT OPINION

IC/BPS is a syndrome that requires a multimodal approach, including clinical phenotyping and directed therapy based on the patient's symptoms. The AUA and EAU provide guidelines for practitioners to follow, but adequate treatment requires the therapy to be targeted toward the patient's phenotypic domain.

Pharmacological management of interstitial cystitis /bladder pain syndrome and the role cyclosporine and other immunomodulating drugs play

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a symptomatic disorder characterized by pelvic pain and urinary frequency. Immunological responses are considered as one of the possible etiologies of IC/BPS. In this review, we focused on emerging targets, especially on those modulating immunological mechanisms for the treatments of IC/BPS. Area covered: This review was based on the literature search of PubMed/MEDLINE, for which key words following bladder pain syndrome, interstitial cystitis, and/or cyclosporine A (CyA) were used. We discussed current treatments and the drugs targeting the immune responses including CyA and other drugs with different mechanisms including NGF antibodies and P2X3 antagonists. Expert commentary: IC/BPS is often difficult to treat by current treatments. Immunosuppression agents, especially CyA are considered as effective treatments for IC/BPS with Hunner's lesion because these drugs suppress the inflammatory responses in the bladder underlying urinary symptoms of the disease. Base on the previous literatures, we should use CyA for the refractory IC/BPS, especially that with Hunner's lesion due to its side effects. New drugs targeting other mechanisms such as urothelial or afferent nerve dysfunction or new delivery systems such as sustained drug releasing devices or gene therapy techniques may be promising for the future treatments of IC/BPS.

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.

Methods and incentives for the early diagnosis of bladder pain syndrome/interstitial cystitis

INTRODUCTION

The concept of interstitial cystitis (IC) has changed dramatically during the last decades, eventually representing a symptom complex with varying contents. To include all patients with bladder pain, the umbrella term 'bladder pain syndrome' (BPS) has been suggested, incorporating the classic presentation of IC as a separate phenotype. This change of concepts has not been uncontroversial. Bladder pain syndrome often has a profound effect on the patients' quality of life. Generally, recognition of this problem complex is hampered by insufficient familiarity in the medical community. The correct diagnosis is often delayed by several years and may be preceded by multiple medical consultations and treatment attempts. There is no doubt that an early and correct diagnosis is of great significance for the patient.

AREAS COVERED

In this article, a critical review of methods and means to approach the diagnosis is presented including some notes of current controversies.

EXPERT OPINION

The key to an early diagnosis is symptom recognition. We are dealing with a heterogeneous concept including various phenotypes. The successful treatment requires understanding and expedient use of objective means, such as cystoscopy, biopsy and input from the multidisciplinary team. In the literature, limited evidence exists for the management of BPS/IC, due to heterogeneity in methodology and description of the syndrome(s). A more consequent use of available methods is desirable. For the immediate future, better understanding of the aetiology, pathogenesis and presentation of various BPS/IC phenotypes is indispensable.

Effect of herpes simplex virus vector-mediated interleukin-4 gene therapy on bladder overactivity and nociception

We investigated the effects of replication-defective herpes simplex virus (HSV) vector expression of interleukin-4 (IL-4) on bladder overactivity and nociception. HSV vector expressing murine interleukin-4 (S4IL4) or the control vector expressing β-galactosidase (SHZ) were injected to the rat bladder wall. At 1 week after viral injection, in cystometry performed under urethane anesthesia, the S4IL4-treated group did not show the intercontraction intervals reduction during intravesical administration of 10 nM resiniferatoxin (RTx). At 2 weeks after viral injection, behavioral studies were performed on vector-injected animals in an awakened state. Freezing behavior induced by 3 μM RTx, administered for 1 min into the bladder, was significantly suppressed in the S4IL4 group compared with the SHZ group. Murine IL-4 levels examined by ELISA were significantly increased in bladder and bladder afferent dorsal root ganglia at 2 weeks after viral injection. The expression of IL-1β and IL-2 and bladder inflammatory responses were significantly suppressed in the RTx-irritated bladder of S4IL4-injected rats. These results indicate that HSV vector-mediated interleukin-4 expression in the bladder and bladder afferent pathways reduces the inflammatory response, bladder overactivity and nociceptive behavior induced by bladder irritation in the rat model. Therefore, IL-4 gene therapy could be a new strategy for treating urinary frequency and/or bladder pain.

Contemporary management of the painful bladder: a systematic review

CONTEXT

Different types of behavioural, dietary, interventional, pharmacologic, and surgical therapies have been used to treat painful bladder syndrome/interstitial cystitis (PBS/IC). Because of the paucity of randomised placebo-controlled studies on different treatments, an evidence-based management approach has not yet been developed.

OBJECTIVE

To critically review and synthesize data from a wide range of current therapeutic approaches to PBS/IC, to quantify the effect size from randomised controlled trials (RCTs), and to reach clinical agreement on the efficacy of treatments for PBS/IC.

EVIDENCE ACQUISITION

We performed a systematic review of the literature to identify articles published between 1990 and September 2010 on the management of PBS/IC. We included articles restricted to the English language published since 1990 to date that reported on oral and intravesical treatment, multimodal or combined treatment, and surgical treatment. For all RCTs, standardised mean differences (SMDs) were extracted and combined in a meta-analysis applying a random-effect model that incorporated the heterogeneity of effects. The four outcomes assessed in all studies were a change in the Interstitial Cystitis Symptom Index (ICSI), pain, urgency, and frequency. Non-RCTs (nRCTs) were analysed with a narrative synthesis of the evidence from all research designs.

EVIDENCE SYNTHESIS

We included 7709 adult patients from 29 RCTs and 57 nRCTs. Meta-analysis of RCTs showed that only cyclosporine A provided a simultaneous great effect size of SMD on ICSI, pain, and frequency. Amitriptyline at different dosages showed a great effect size of SMD on pain and urgency or on ICSI and frequency. The remaining RCTs showed sporadic significant changes in only one of the four considered parameters. The attributed levels of evidence for treatments reported in RCTs were 1b; grades of recommendations ranged from A to C. According to the Jadad score, 11 RCTs were high-quality studies. Meta-analysis of RCTs showed a great heterogeneity in the applied methodologies, clinical outcomes assessed, and the obtained results in different studies. The results from the nRCTs showed that the most frequently adopted treatment is oral pentosan polysulfate and that the use of botulinum A toxin intradetrusorial injections in PBS/IC is increasing. A high heterogeneity in drugs and treatment modalities, clinical outcomes, and obtained results was also found for nRCTs.

CONCLUSIONS

Limited evidence exists for the few treatments for PBS/IC. The lack of definitive conclusions is due to the great heterogeneity in methodology, symptoms assessment, duration of treatment, and follow-up in both RCTs and nRCTs.

Loss of muscarinic and purinergic receptors in urinary bladder of rats with hydrochloric acid-induced cystitis

OBJECTIVES

To clarify the basic mechanism involved in the pathophysiology of cystitis by characterizing the urodynamic parameters, pharmacologically relevant (muscarinic and purinergic) receptors, and the in vivo release of adenosine triphosphate (ATP) in the bladder of hydrochloric acid (HCl)-treated rats.

METHODS

The muscarinic and purinergic receptors in rat tissue were measured by radioreceptor assays using (N-methyl-³H) scopolamine methyl chloride ([³H]NMS) and αβ-methylene-ATP (2,8-³H) tetrasodium salt ([³H]αβ-MeATP), respectively. The urodynamic parameters and ATP levels were measured using a cystometric method and the luciferin-luciferase assay, respectively.

RESULTS

In the HCl-treated rats, the micturition interval and micturition volume were significantly (48% and 55%, respectively, P <.05) decreased and the number of micturitions was significantly (3.2-fold, P <.05) increased compared with those of the control rats. The maximal number of binding sites for [³H]NMS and [³H]αβ-MeATP was significantly (55% and 72%, respectively, P <.001) decreased in the bladder of HCl-treated rats, suggesting downregulation of both muscarinic and purinergic receptors. In the HCl-treated rats, the inhibition constant, K(i), values for oxybutynin, solifenacin, and darifenacin were significantly (1.3-1.4-fold, P <.05) increased, but those for tolterodine and AF-DX116 were unchanged. Similarly, the inhibition constant for A-317491, pyridoxal-phosphate-6-azophenyl-2',4'-disulfonic acid tetrasodium, and MRS2273 was significantly (5.5, 11, and 7.6-fold, respectively, P <.001) increased. Furthermore, the in vivo release of ATP was significantly (P <.05) enhanced in the HCl-treated rat bladder.

CONCLUSIONS

Both muscarinic and purinergic mechanisms might be, at least in part, associated with the urinary dysfunction due to 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.

Prevalence of painful bladder syndrome (PBS) symptoms in adult women in the general population in Japan

AIMS

The aim of this study was to clarify the prevalence of painful bladder syndrome (PBS) symptoms in adult women in the general population in Japan.

METHODS

Web-based survey through an internet-based market research company that enrolled 561,631 men and women in Japan was conducted from January 9 to January 11, 2007. After the women allocated to four age groups; 20s, 30s, 40s, and 50s or older, a total of 80,367 women, comprising an almost equal number from each age group, were then randomly invited to participate. The O'Leary and Sant symptom index was used as the questionnaire. The following classification was defined on the basis of the total points score: 0 to 3 points for negligible PBS symptoms, 4 to 6 points for mild symptoms, 7 to 11 points for moderate symptoms, and 12 to 20 points for severe symptoms. A category of possible cases of PBS was defined as severe PBS symptoms including nocturia (twice or more) and pain (2 points or more).

RESULTS

A total of 32,074 women ranging in age from 20 to 88 years participated. 76.6% of respondents had negligible PBS symptoms, 17.3% had mild symptoms, 5.6% had moderate symptoms, and 0.5% had severe symptoms, respectively. The incidence rate of women with possible cases of PBS was 0.265% (85/32,074).

CONCLUSIONS

Comparison with previous reports revealed no difference in the prevalence of PBS symptom in adult women in the general population between Japan and Western countries.

Beneficial effects of suplatast tosilate (IPD-1151T) in a rat cystitis model induced by intravesical hydrochloric acid

OBJECTIVE

To examine the effects of suplatast tosilate (IPD-1151T), a Th2 cytokine inhibitor recently recognized to improve the symptoms in patients with interstitial cystitis (IC), in a rat model of HCl-induced chronic cystitis, to elucidate the possible mechanisms by which the drug improves the symptoms of IC.

MATERIALS AND METHODS

Chronic cystitis was induced by intravesical instillation of 0.2 mL of 0.4 m HCl in female adult rats. After a once-daily oral administration of IPD-1151T (0.1-100 mg/kg) or prednisolone (5 mg/kg) for 7 days, cystometry was performed under urethane anaesthesia. The bladder from HCl-induced cystitis rats was also assessed histopathologically.

RESULTS

On cystometrography there was frequent voiding in cystitis rats. Administration of IPD-1151T for 7 days after intravesical HCl instillation dose-dependently increased the micturition volume and intercontraction intervals. Treatment with prednisolone had similar therapeutic effects. Histological analyses in the bladder from cystitis rats revealed oedema and infiltration of inflammatory cells such as mast cells and eosinophils in the lamina propria and the transitional epithelial thickening. These histological changes and the number of mast cells and eosinophils were reduced by administration of IPD-1151T or prednisolone.

CONCLUSION

The present results indicate that IPD-1151T improves bladder function and pathological changes in HCl-induced cystitis rats, as previously observed in patients with IC. The rat cystitis model induced by HCl could provide useful information for studying proposed therapies for IC which might involve T cell-dependent inflammatory responses as one of its potential pathophysiologies.

Treatment approaches for painful bladder syndrome/interstitial cystitis

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a disease of unknown aetiology, characterised by severe pressure and pain in the bladder area or lower pelvis that is frequently or typically relieved by voiding, along with urgency or frequency of urination in the absence of urinary tract infections. PBS/IC occurs primarily in women, is increasingly recognised in young adults, and may affect as many as 0.1-1% of adult women. PBS/IC is often comorbid with allergies, endometriosis, fibromyalgia, irritable bowel syndrome and panic syndrome, all of which are worsened by stress. As a result, patients may visit as many as five physicians, including family practitioners, internists, gynaecologists, urologists and pain specialists, leading to confusion and frustration. There is no curative treatment; intravesical dimethyl sulfoxide, as well as oral amitriptyline, pentosan polysulfate and hydroxyzine have variable results, with success more likely when these drugs are given together. Pilot clinical trials suggest that the flavonoid quercetin may be helpful. Lack of early diagnosis and treatment can affect outcomes and leads to the development of hyperalgesia/allodynia.

Intravesical Suplatast Tosilate (IPD-1151T) Inhibits Experimental Bladder Inflammation

PURPOSE

Interstitial cystitis is a painful bladder disease characterized by urgency, frequency and variable inflammation but there is no curative therapy. Suplatast tosilate (IPD-1151T) is an immunoregulatory compound that decreases interstitial cystitis symptoms but to our knowledge its mechanism of action is unknown. We investigated the effect of intravesical IPD-1151T on mediator release from bladder explants in experimental cystitis.

MATERIALS AND METHODS

A catheter was inserted into the bladder of female mice. After urine was emptied normal saline, carbachol (100 nM) or lipopolysaccharide (10 mg/ml) was introduced with or without 10-minute pretreatment with IPD-1151T. Urine was removed after 45 minutes for histamine and tumor necrosis factor-alpha assays. The bladder was removed after 4 hours, minced into 1 mm2 pieces and cultured with or without triggers overnight for mediator release. The effect of IPD-1151T was also tested on rat skin vascular permeability as well as on purified rat peritoneal mast cells and human cord blood derived mast cells.

RESULTS

Carbachol significantly increased histamine release in urine (61.3% in 8 preparations, p<0.05) but not in explant medium. IPD-1151T inhibited this effect by 77%. Lipopolysaccharide induced a 350% urine histamine increase in 9 preparations (p<0.05) and a 300% tumor necrosis factor-alpha increase in explant medium. IPD-1151T inhibited the lipopolysaccharide induced medium tumor necrosis factor-alpha increase by 95% in 5 preparations (p<0.05). IPD-1151T did not inhibit rat skin vascular permeability or purified rat peritoneal mast cell activation by compound 48/80 or human cord blood derived mast cells by anti-IgE.

CONCLUSIONS

IPD-1151T inhibits bladder release of histamine and tumor necrosis factor-alpha through a mechanism that does not appear to involve direct mast cell inhibition. These findings may justify a beneficial effect of IPD-1151T in interstitial cystitis.

APF, HB-EGF, and EGF biomarkers in patients with ulcerative vs. non-ulcerative interstitial cystitis

Background

Interstitial cystitis (IC) is a chronic bladder disorder, with symptoms including pelvic and or perineal pain, urinary frequency, and urgency. The etiology of IC is unknown, but sensitive and specific biomarkers have been described, including antiproliferative factor (APF), heparin-binding epidermal growth factor-like growth factor (HB-EGF), and epidermal growth factor (EGF). However, the relative sensitivity of these biomarkers in ulcerative vs. nonulcerative IC is unknown, and these markers have yet to be validated in another laboratory. We therefore measured these markers in urine from patients with or without Hunner's ulcer, as well as normal controls, patients with bladder cancer, and patients with bacterial cystitis, at the First Hospital of China Medical University.

Methods

Urine specimens were collected from two groups of Chinese IC patients (38 IC patients with Hunner's ulcers, 26 IC patients without Hunner's ulcers), 30 normal controls, 10 bacterial cystitis patients and 10 bladder cancer patients. APF activity was determined by measuring ³H-thymidine incorporation in vitro, and HB-EGF and EGF levels were determined by ELISA.

Results

APF activity (inhibition of thymidine incorporation) was significantly greater in all IC patient urine specimens than in normal control specimens or in specimens from patients with bacterial cystitis or bladder cancer (p < 0.0001 for each comparison). Urine HB-EGF levels were also significantly lower and EGF levels significantly higher in both groups of IC patients than in the three control groups (p < 0.0001 for each comparison). Although APF and HB-EGF levels were similar in ulcerative and nonulcerative IC patients, EGF levels were significantly higher in IC patients with vs. without ulcers (p < 0.004).

Conclusion

These findings indicate that APF, HB-EGF and EGF are good biomarkers for both ulcerative and nonulcerative IC and validate their measurement as biomarkers for IC in Chinese patients.

CORRELATION BETWEEN 2 INTERSTITIAL CYSTITIS SYMPTOM INSTRUMENTS

PURPOSE

Two statistically validated interstitial cystitis (IC) symptom instruments have been used in clinical research. In this study we report what is to our knowledge the first direct comparison of the University of Wisconsin Symptom Instrument (UWI) with the O'Leary-Sant instruments, that is the IC Symptom Index (ICSI) and IC Problem Index (ICPI).

MATERIALS AND METHODS

A convenience sampling of 107 patients with IC evaluated at the urology clinic at our institution from March through August 2000 were asked to complete ICSI, ICPI and UWI. The scores were analyzed and graphed.

RESULTS

Mean ICSI, ICPI and UWI scores +/- SD were 12.6 +/- 4.3, 10.5 +/- 3.8 and 25.5 +/- 10.8, respectively. UWI and ICSI scores correlated at r = 0.80 (p <0.01) and ICSI/ICPI scores correlated at r = 0.83 (p <0.01). ICSI and ICPI contain 4 symptom-problem pairs. There are relevant differences in the correlation of symptom severity (ICSI question) and its associated problem (ICPI question). The symptom of urgency correlated best with the associated problem (r = 0.84), followed by nocturia (r = 0.82), pain (r = 0.70) and frequency (r = 0.68).

CONCLUSIONS

The ICSI and UWI symptom instruments correlate strongly in a large population of patients with IC. The data presented will aid in interpreting the literature. A relatively poor correlation between pain symptom-problem pairs in the O'Leary-Sant instruments is probably an artifact of wording. The word pressure appears in ICPI but not in ICSI. We suggest using parallel wording of the pain symptom-problem pair containing the identical phrase, burning, pain, discomfort or pressure, to improve the ICSI/ICPI correlation and more accurately reflect the clinical condition.

Treatment of interstitial cystitis

Although the symptoms of interstitial cystitis (IC)--a debilitating, chronic disease characterized by urinary urgency and frequency, and bladder and pelvic pain on bladder filling--are easily confused with those of urinary tract infections, there is an absence of an underlying infection, and antibiotic therapy is of no therapeutic benefit. Severe cases of this disorder, which affects mainly women, can have a great negative impact on the quality of life of patients because of extreme urinary frequency. The diagnosis of IC is difficult and should be based on patient history, physical examination, and cystoscopy. A large number of pharmacologic treatments have been used to treat this condition with limited success, including pentosan polysulfate, heparin, antihistamines, tricyclic antidepressants, intravesical dimethyl sulfoxide, and bacille Calmette-Guérin. Among the potentially effective new treatment modalities currently under investigation are suplatast tosilate, resiniferatoxin, botulinum toxin, and gene therapy to modulate the pain response. As knowledge of the pathogenesis of IC increases through intensified research, the ability to provide effective treatment to patients with this disease will improve.

Interstitial cystitis: a chronic pelvic pain syndrome

Interstitial cystitis, an enigmatic chronic pelvic pain syndrome that occurs primarily in women, is much more common than originally believed. Its etiology is unknown, its evaluation and diagnosis remain controversial, and its treatment is largely empiric. Recent basic and clinical research is unlocking some of the mystery surrounding this clinical syndrome. Diagnostic awareness, willingness to consider recently studied therapies, and reasonable therapeutic expectations on the part of both the physician and the patient seem to be the key to successful management of this condition.

Current and future directions in diagnostic markers in interstitial cystitis

Interstitial cystitis (IC) is a chronic bladder disorder of unknown etiology that is often diagnosed by symptom criteria with or without cystoscopic findings. Several potential diagnostic markers have recently been described that may facilitate diagnosis of this disorder. A summary of the literature and a discussion regarding these biomarkers is provided, along with a brief discussion of new biomarkers presented at the meeting.

Prolongation of heart allograft survival of rats treated by a Th2 inhibitor

In terms of Th1/Th2 balance in response to signals given during donor antigen presentation, induction of tolerance is more often correlated with Th2-type than with Th1-type reactions. However, in our study, heart allograft survival was prolonged by treatment of rats with a Th2 inhibitor. Suplatast tosilate (IPD; Taiho; Tokyo, Japan) is a novel immunoregulator that suppresses IgE production and eosinophil infiltration through selective inhibition of interleukin (IL)-4 and IL-5 synthesis by Th2-like cells but not IFN-gamma production in Th1 cells. Five LEW rats of DA heart grafts were treated with IPD (100 microg/day, p.o.) for 10 days. Heart allograft survival of all IPD-treated cases was prolonged more than 14 days while the beating of heart grafts in control groups was stopped within 9 days. In an in vitro study, the cell proliferation both in Con A blast and in mixed lymphocyte reaction assay was suppressed by IPD in dose-dependent manner. We could at least in part conclude that Th2 inhibition might temporarily suppress heart allograft rejection.

Interstitial cystitis: an update

PURPOSE OF REVIEW

Interstitial cystitis is a chronically progressive, severely debilitating, heterogeneous syndrome affecting the urinary bladder, mainly associated with urgency, frequency and pain. Though known for over a century, its etiology is poorly understood and universally effective treatments are lacking. This review focuses on recently published literature on the disorder.

RECENT FINDINGS

Appropriate diagnostic tests for interstitial cystitis remain uncertain. The diagnostic criteria developed by the US National Institutes of Health represent research definitions which are subject to controversial debate for their overenthusiastic clinical application. The diagnosis is made clinically and by cystoscopy with hydrodistention and sometimes biopsy when other pathologies have been excluded. In symptomatic patients, glomerulations upon bladder distension are indicative but not pathognomonic for nonulcerative interstitial cystitis. Patients with ulcerative disease represent a separate subgroup with distinct characteristics and treatment implications. The role of bladder permeability tests remains controversial. Promising noninvasive markers for interstitial cystitis have been described but are not yet clinically available. Validated symptom scores are appropriate to assist in diagnostics and to monitor disease course and treatment efficacy. Lately investigated hypotheses for causative factors include occult or resistant microorganisms, urothelial hyperpermeability, neurogenic or hormonal pathomechanisms, and mast cell activation. Increasing evidence for a genetic susceptibility is emerging.

SUMMARY

Among the multitude of oral, intravesical, interventional and complementary treatments suggested few studies have high levels of evidence. Newly proposed agents must await further controlled studies. Treatment remains empiric until radical surgical procedures should ultimately be considered for severe refractory cases.

Efficacy of oral doxepin and piroxicam treatment for interstitial cystitis

OBJECTIVE

To establish the efficacy of a multidrug oral treatment with the tricyclic antidepressant agent doxepin and the cyclooxygenase (COX) inhibitor piroxicam in patients with interstitial cystitis (IC), who had failed standard therapy in an open, prospective, nonrandomized study.

METHODS

A total of 37 patients diagnosed with IC received 75 mg doxepin and 40 mg piroxicam daily. The treatment was termed DOXCAM. Effectiveness of therapy was assessed with frequency-volume charts, an IC symptom score and with cystometry prior to treatment, 8 weeks after the start and 4 weeks after termination of drug treatment.

RESULTS

Medication was not tolerated by five patients. Twenty-six of 32 patients have experienced virtual total remission of symptoms (81%) and six patients had significant relief (19%). DOXCAM treatment resulted in a significant percent decrease in pain (65% versus 21%). Daytime frequency decreased from 17.6+/-5.7 to 11.3+/-3.6 voids while nocturia did not improve significantly. Twenty-three of the 26 patients who became symptom free and four of the six patients who showed significant improvement had a return of symptoms after cessation of therapy.

CONCLUSION

It is reasonable to consider oral treatment with DOXCAM in those patients who have failed first-line therapies.

Targeting afferent hyperexcitability for therapy of the painful bladder syndrome

The involvement of C-fiber afferent pathways in urinary frequency and pain associated with painful bladder syndrome raises the possibility of multiple targets for the treatment of this disease. Using an in vivo measurement of bladder activity as well as whole-cell patch clamp recording techniques to examine the properties of bladder afferent neurons in animal models of chronic cystitis, we have documented that tetrodotoxin-resistant sodium channels encoded by the Na(v) 1.8 (PN3/SNS) gene and nitric oxide acting via a cyclic guanosine monophosphate (cGMP)-dependent mechanism are important in modulating bladder pain responses. Thus, suppression of C-fiber afferent nerve activity by blocking specific sodium channels, elevating nitric oxide levels, or activating cGMP-dependent pathways might represent novel strategies for the treatment of symptoms in patients with painful bladder syndrome. Another treatment strategy is suppression of release or activity of proinflammatory agents that can cause normally unexcitable C-fiber afferents to become hyperactive or hyperexcitable. This approach to management of bladder pain was tested in patients with painful bladder syndrome by examining the effectiveness of the antiallergic agent suplatast tosilate (IPD-1151T), which suppresses urinary frequency in a rat model of cystitis. IPD-1151T is an immunoregulator that suppresses cytokine production in T-helper 2 cells and inhibits immunoglobulin E antibody formation and antigen-induced histamine release from mast cells. Preliminary data from an open-label clinical trial showed that 16 of 23 (70%) patients responded to treatment with IPD-1151T (300 mg/day orally for 12 months). The finding that expression of platelet-derived endothelial cell growth factor, which can activate mast cells, was lower in the bladder of responders than nonresponders indicates that bladder levels of platelet-derived endothelial cell growth factor may be a useful marker for this disease.

Understanding chronic pelvic pain syndrome

Patients with non-inflammatory chronic pelvic pain syndrome, the largest group of prostatitis patients according to the US National Institute of Diabetes and Digestive and Kidney Diseases classification, are characterized by the absence of objective findings. Nothing thus links the symptoms of this disease to the prostate or other male organs in particular. For this reason, observations on interstitial cystitis in women are of interest to understand the chronic pelvic pain syndrome. New information from studies on the inflammatory response in expressed prostatic secretion in patients with chronic pelvic pain syndrome and in bladder tissue from patients with interstitial cystitis indicates that complex systems on the cytokine gene expression level may be operating in these diseases. Research findings point to a common denominator at the level of molecular biology that might explain how the symptoms of chronic pelvic pain syndrome and interstitial cystitis can be precipitated by pathogens, inflammatory reactions and even neurological mechanisms. The initial clinical trial reports of drugs that modulate the inflammatory response in interstitial cystitis are met with great interest.

Interstitial cystitis

Appropriate diagnostic tests for interstitial cystitis remain uncertain. One or more promising markers for this disease have been described which may provide a noninvasive means for diagnosis as well as clues to pathogenesis of this disease. Treatment remains empiric.