Transurethral resection of Hunner's ulcer

Diagnostic and therapeutic cystoscopy in bladder pain syndrome/interstitial cystitis: systematic review of literature and consensus on methodology

INTRODUCTION AND HYPOTHESIS

Cystoscopy has been routinely performed in patients suspected to be suffering from bladder pain syndrome/interstitial cystitis (BPS/IC) across the globe. The methodology reported by various guidelines appears to have differences in the techniques and hence there is a need for a review of all those techniques in order to arrive at a consensus. The aim was to review the literature describing the prevalent techniques of cystoscopy for patients of BPS/IC and try to evolve a consensus.

METHODS

The group the Global Interstitial Cystitis, Bladder Pain Society (GIBS) has worked collectively to systematically review the literature using the key words, "Cystoscopy in Hunner's lesions, bladder pain syndrome, painful bladder syndrome and interstitial cystitis" in the PubMed, COCHRANE, and SCOPUS databases. A total of 3,857 abstracts were studied and 96 articles referring to some part of technique of cystoscopy were short-listed for review as full-length articles. Finally, six articles with a description of a technique of cystoscopy were included for final tabulation and comparison. The group went on to arrive at a consensus for a stepwise technique of diagnostic and therapeutic cystoscopy in cases of BPS/IC. This technique has been compared with the previously described techniques and may serve to be a useful practical guide for treating physicians.

CONCLUSION

It is important to have a uniform standardized technique for performing a diagnostic and therapeutic cystoscopy in patients with BPS/IC. Consensus on one such a technique has been arrived at and described in the present article.

Hunner lesion disease differs in diagnosis, treatment and outcome from bladder pain syndrome: an ESSIC working group report

Objectives: There is confusion about the terms of bladder pain syndrome (BPS) and Interstitial Cystitis (IC). The European Society for the Study of IC (ESSIC) classified these according to objective findings [9]. One phenotype, Hunner lesion disease (HLD or ESSIC 3C) differs markedly from other presentations. Therefore, the question was raised as to whether this is a separate condition or BPS subtype.Methods: An evaluation was made to explore if HLD differs from other BPS presentations regarding symptomatology, physical examination findings, laboratory tests, endoscopy, histopathology, natural history, epidemiology, prognosis and treatment outcomes.Results: Cystoscopy is the method of choice to identify Hunner lesions, histopathology the method to confirm it. You cannot distinguish between main forms of BPS by means of symptoms, physical examination or laboratory tests. Epidemiologic data are incomplete. HLD seems relatively uncommon, although more frequent in older patients than non-HLD. No indication has been presented of BPS and HLD as a continuum of conditions, one developing into the other.Conclusions: A paradigm shift in the understanding of BPS/IC is urgent. A highly topical issue is to separate HLD and BPS: treatment results and prognoses differ substantially. Since historically, IC was tantamount to Hunner lesions and interstitial inflammation in the bladder wall, still, a valid definition, the term IC should preferably be reserved for HLD patients. BPS is a symptom syndrome without specific objective findings and should be used for other patients fulfilling the ESSIC definitions.

Does repeated hydrodistension with transurethral fulguration for interstitial cystitis with Hunner's lesion cause bladder contraction?

Objective: To evaluate the effect of repeated bladder hydrodistension with transurethral resection or fulguration (TUF) of Hunner's lesions on bladder capacity and interstitial cystitis (IC) symptoms. TUF for Hunner's lesion is recommended in several IC/BPS guidelines, although recurrence is highly probable. Patients and methods: The study cohort comprised 44 IC patients with Hunner's lesions who underwent multiple bladder hydrodistensions with TUF and electrocautery (EC) at our institution between July 2005 and June 2018. We analysed their frequency-volume chart, O'Leary Sant Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), and visual analogue scale (VAS) for pain, before and at 2, 6, and 12 months after surgery. Results: The 44 Hunner-type IC patients underwent a total of 117 surgeries. Patients were divided into three groups based upon the number of hydrodistensions with TUF they underwent. Group 1 (n = 44), Group 2 (n = 44) and Group 3 (n = 21) underwent one, two, and three surgeries, respectively. At 6 months after surgery, the mean average voided volume (AVV) and maximum voided volume (MVV) were 157 mL and 228 mL in Group 1; 203 mL, 283 mL in Group 2; and 193 mL, 264 mL in Group 3. The AVV in Group 2 (P < 0.01) and Group 3 (P < 0.03), and the MVV in Group 2 (P < 0.02) increased significantly compared to Group 1. ICSI, ICPI and VAS pain score in groups 2 (P < 0.003, P < 0.01, P < 0.05) and 3 (P < 0.001, P < 0.001, P < 0.001) decreased significantly compared to Group 1. Conclusion: Repeated hydrodistension and TUF with EC of Hunner's lesions for recurrent Hunner-type IC patients improved their symptoms. There was a tendency toward an increase in bladder capacity and repeated hydrodistension with TUF did not appear to be a direct cause of bladder contraction. Abbreviations: AVV: average voided volume; BPS: bladder pain syndrome; EC: electrical cautery; IC: interstitial cystitis; ICPI: Interstitial Cystitis Problem Index; ICSI: Interstitial Cystitis Symptom Index; MVV: maximum voided volume; TUF: transurethral fulguration; TUR: transurethral resection; VAS: visual analogue scale.

What is the Role of Surgery in Bladder Pain Syndrome?

The role of surgery in the management of bladder pain syndrome is unclear; particularly the optimum surgical approach. Treatment refractory patients should be managed in a multi-disciplinary setting including psychological support. Further prospective studies using validated assessments and clear diagnostic criteria would be useful to guide patient selection.

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.

Elimination of Hunner's Ulcers by Fulguration in Patients With Interstitial Cystitis: Is It Effective and Long Lasting?

PURPOSE

To evaluate the outcome of fulguration of Hunner's ulcers (HUs) in painful bladder syndrome/interstitial cystitis (PBS/IC) that is refractory to conservative treatment.

MATERIALS AND METHODS

Patients diagnosed with refractory PBS/IC and treated with fulguration between 2011 and 2013 were identified through screening of medical records. To evaluate treatment outcomes, voiding diaries, the visual analogue scale (VAS) for pain, and two IC symptom questionnaires (pelvic pain and urgency/frequency scale [PUF] and O'Leary-Sant IC symptom index and IC problem index [OS]) were used. Fulguration was deemed to be successful if the VAS score was <2 or less than half of the preoperative VAS score.

RESULTS

In total, 27 patients with PBS/IC in whom conservative treatments had failed were enrolled. Two months after fulguration, decreases were observed in the mean 24-hour urinary frequency (from 16.0 to 10.2), 24-hour urgency episodes (8.0 to 1.8), and the VAS (5.8 to 1.2), PUF symptom (15.1 to 7.0), PUF bother (8.4 to 2.7), OS symptom (15.1 to 7.2), and OS problem (13.8 to 6.0) scores. At 5 and 10 months, all variables had worsened. At 2, 5, and 10 months, the success rates were 94.1%, 70.0%, and 33.3%, respectively. Four patients underwent one repeat fulguration on average 11.3 months after the first fulguration. Repeat fulguration was not significantly associated with any clinical characteristics.

CONCLUSIONS

In PBS/IC that was refractory to medication or other conservative treatments, HU elimination by fulguration effectively improved symptoms. However, this effect decreased gradually over time.

Effect of transurethral resection with hydrodistention for the treatment of ulcerative interstitial cystitis

PURPOSE

Many treatment options to help relieve the symptoms of interstitial cystitis (IC) are available, but none are effective. Because no reports of transurethral ulcer resection with hydrodistention are available, we assessed the effects of such combined surgery for ulcerative IC.

MATERIALS AND METHODS

Between June 2006 and June 2011, 87 female patients with IC who underwent transurethral resection with hydrodistention and were followed up for at least 12 months were included. Improvements in patients' voiding symptoms and pain were analyzed retrospectively by using a 3-day micturition chart and a 10-point visual analogue scale (VAS) before and after the operation. The global response assessment (GRA) was used to assess treatment satisfaction.

RESULTS

The mean age of the 87 female patients was 59.1±10.1 years, and the mean follow-up period was 26.7±14.4 months. Mean maximum functional bladder capacity increased from 168.4±92.4 mL to 276.3±105.4 mL (1 month) and to 227.3±91.7 mL (12 months). The mean frequency of voiding decreased from 17.2±8.5 before to 10.6±5.3 after (1 month) surgery; however, it increased again to 13.3±4.8 at 12 months. The 10-point VAS score decreased from 9.1±0.8 to 1.2±0.3 (1 month); however, it increased again to 2.5±0.4 (3 months), 3.2±0.4 (6 months), and 5.3±0.5 (12 months) (p<0.001). Symptom improvement based on the GRA was observed in 83 of the 87 patients (95.4%) at 1 month and in 55 of 87 patients (63.2%) at 12 months.

CONCLUSIONS

Transurethral resection with hydrodistention is an effective treatment option for ulcerative IC because it provides improvements in voiding symptoms and pain.

Endoscopic ablation of Hunner's lesions in interstitial cystitis patients

INTRODUCTION

We report our experience with endoscopic ablation of Hunner's lesions in women with interstitial cystitis (IC).

METHODS

A chart review was performed on 14 patients with IC symptoms who were identified to have bladder lesions and underwent endoscopic ablation. A Hunner's lesion was identified as an area of erythema that reproduced the patients' pain when touched by the cystoscope. Pathology reports were reviewed and improvement in pain was used as the main outcome measure.

RESULTS

Of the 14 patients, 12 had more than 50% symptomatic improvement and 8 patients reported 100% improvement. Mean improvement was 76%. In all patients who improved, the biopsy specimen showed inflammatory cystitis, often with epithelial denudation. Four patients had symptomatic recurrence, but all had improvement after repeat ablation.

CONCLUSION

Endoscopic ablation of Hunner's lesions improves symptoms in IC patients. Recurrence of symptoms should prompt repeat cystoscopy to identify recurrent lesions, as repeat ablation offers symptomatic improvement.

[Specific treatments for painful bladder syndrome]

INTRODUCTION

Painful bladder syndrome is defined as chronic pelvic pain present for more than 6 months, causing discomfort perceived as being related to the bladder and accompanied by a persistent and strong urge to urinate or urinary frequency. The purpose of this article is to review the treatment of painful bladder syndrome.

MATERIAL AND METHODS

A comprehensive review of the literature was performed by searching PUBMED for articles on specific treatments for painful bladder syndrome.

RESULTS

Many treatments have been proposed for the management of painful bladder syndrome: local intravesical treatments (glucosaminoglycan [pentosan polysulfate], dimethylsulfoxide [DMSO], heparin, bacillus Calmette-Guérin [BCG], anticholinergic agents [oxybutynin, etc.] or oral treatments [glucosaminoglycan (pentosan polysulfate), antihistamines, antidepressants, immunosuppressives, etc.]) with an action on the pathophysiology of this syndrome. The efficacy of these various treatments has been limited, with trials based on small numbers of patients and not always conducted according to a randomized, prospective design. Other salvage treatments (neuromodulation, botulinum toxin, surgery, etc.) have also been reported with limited efficacy, but allowing salvage of treatment failures.

CONCLUSION

The therapeutic management of painful bladder syndrome is complex. The large number of proposed treatment modalities present a limited efficacy with discordant results from one study to another making comparisons and analyses difficult.

Does mast cell density predict the outcome after transurethral resection of Hunner's lesions in patients with type 3C bladder pain syndrome/interstitial cystitis?

OBJECTIVE

This study aimed to assess mast cell density in the lamina propria for possible correlation with duration of symptom amelioration after transurethral resection of the bladder (TURB).

MATERIAL AND METHODS

Twelve patients (eight women and four men) referred to the tertiary referral facility, treated between June 2003 and June 2009, were included in the study. All had undergone three consecutive complete TURB procedures, where the first one was also diagnostic. All patients fulfilled the NIH-NIDDK criteria and the ESSIC bladder pain syndrome/interstitial cystitis type 3C criteria; they had Hunner's lesions and biopsy findings with inflammatory infiltrates, granulation tissue and mastocytosis. Bladder biopsies were evaluated for mast cell density by immunochemistry and symptom amelioration was recorded by self-report of symptom relapse.

RESULTS

Median mast cell density in the lamina propria at the first, second and third TURB was high. No statistically significant correlation between mast cell density in the urothelium, lamina propria or detrusor, and duration of symptom amelioration could be seen after the first, second or third TURB.

CONCLUSION

Mast cell density does not appear to correlate with duration of symptom amelioration after complete transurethral resection of Hunner's lesions, either in the lamina propria or in the urothelium or detrusor.

Sensory bladder disorders

Sensory bladder disorders include disorders involving abnormal sensations resulting from many diseases of the urinary bladder. In a proportion of patients no cause can be found and if pain or pelvic pressure is a part of the symptomatology, they are labelled as having painful bladder syndrome (PBS). In a subgroup of these patients abnormal findings can be demonstrated at cystoscopy and/or by histological examination of bladder biopsies. These patients are categorised as having interstitial cystitis (IC). This paper looks into the differential diagnosis, evaluation and treatment of patients with PBS.

Surgical treatment of painful bladder syndrome/interstitial cystitis

Painful bladder syndrome/interstitial cystitis is a disabling disease of the urinary bladder that mainly affects women. It is of unknown etiology and can appear in all age groups. The main symptoms - bladder pain and urinary frequency - may completely govern the life of the unlucky person suffering from the disease. Treatment includes diet, behavioral modifications, medical treatments, inclusive specific-pain treatment and surgery, but it is unfortunately often insufficient. The disease is rare and lacks a specific definition as well as proper diagnostic criteria. Surgical treatments include neuromodulation, transurethral surgery, bladder augmentation and urinary diversion with or without cystectomy. This article examines the documentation, or lack of, for the often drastic surgical procedures performed to improve quality of life in patients with this disorder.

Supratrigonal cystectomy and ileocystoplasty in management of interstitial cystitis

BACKGROUND

Interstitial cystitis is a chronic non-infectious inflammatory disease of the bladder of unknown aetiology which is characterized by irritative voiding symptoms and suprapubic pain related to bladder filling. Surgical treatment is indicated in severely symptomatic patients when medical therapies have failed, usually after a period of several years. The authors' experience with a modified technique of ileocystoplasty following supratrigonal cystectomy performed in five patients with interstitial cystitis is presented here.

METHODS

A modified technique of bladder augmentation using ileum following supratrigonal bladder resection is described.

RESULTS

All patients experienced relief from their symptoms. No patient had residual bladder pain and urinary frequency settled down in all. Bladder capacity was increased significantly. Three patients voided spontaneously postoperatively and two required clean intermittent self-catheterization.

CONCLUSIONS

Supratrigonal cystectomy and ileocystoplasty can be a satisfactory option in refractory cases of interstitial cystitis. A simplified technique of ileal bladder construction that provides satisfactory bladder capacity is presented. Most urologists are familiar with ileal surgery, having used the ileum as a conduit after cystectomy for urinary diversion.

The treatment of interstitial cystitis with supratrigonal cystectomy and ileocystoplasty: difference in outcome between classic and nonulcer disease

PURPOSE

Interstitial cystitis is a chronic debilitating condition that mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer type seems to respond less favorably to various conservative treatments than the classic type. Supratrigonal cystectomy with ileocystoplasty is established treatment for interstitial cystitis refractory to conservative treatment. We evaluate whether classic interstitial cystitis responds differently than nonulcer disease to subtotal bladder resection and ileocystoplasty.

MATERIALS AND METHODS

We evaluated 13 patients 27 to 79 years old with interstitial cystitis who underwent supratrigonal cystectomy and ileocystoplasty due to failure to respond to conservative treatment.

RESULTS

In all 10 patients with classic interstitial cystitis symptoms were relieved after ileocystoplasty. In the 3 patients with nonulcer interstitial cystitis pain remained, while the frequency of voiding somewhat decreased. In these patients trigonal resection and urinary diversion with a Kock pouch resolved the symptoms.

CONCLUSIONS

Our study confirms that supratrigonal cystectomy with ileocystoplasty results in a good outcome in classic interstitial cystitis. However, this method seems to be unsuitable for nonulcer disease. Identification of the relevant subtype of interstitial cystitis is of crucial importance for selecting the appropriate method of lower urinary tract reconstruction.

Treatment of interstitial cystitis with the neodymium-YAG laser

Five patients with severe interstitial cystitis that had not responded to conventional means of therapy were treated with the neodymium-YAG laser. Of the 5 patients 4 demonstrated cessation of severe bladder pain and frequency of urination within several days after therapy. These patients also were studied objectively by measuring bladder capacity, which was found to be increased over-all. Complication rates from this modality of therapy were extremely low. The patients have been followed for 3 to 15 months after treatment and to date have had no recurrent symptoms of severe interstitial cystitis, although some have had mild recurrent voiding symptoms.

A clinicopathological and virological study of interstitial cystitis

We studied 41 patients with chronic interstitial cystitis. Histological examination of bladder lesions revealed mucosal ulceration, pancystitis and perineural inflammatory infiltrates. Perineural cell infiltration is related probably to the characteristic symptoms of the disease. A search for a viral etiology, particularly herpes simplex virus, rendered negative results.

Conservative management of chronic interstitial cystitis: transcutaneous electrical nerve stimulation and transurethral resection

Transcutaneous electrical nerve stimulation was used in a prospective series of 23 patients with classical interstitial cystitis. This treatment reduced pain in 18 patients and urinary frequency returned to normal in 8. Four women with a history of cystitis for 1 or 2 decades had no symptoms during transcutaneous electrical nerve stimulation for 7 or more years and lesions disappeared or were hardly detectable. A 2 to 3-fold increase in bladder capacity with anesthesia also was registered. Complete transurethral resection of visible lesions in 30 patients resulted in initial disappearance of pain in all and a decrease in urinary frequency in 21. The mode of action of the 2 methods and registered complications are discussed.

The surgical treatment of intractable interstitial cystitis

Nineteen patients with severe intractable interstitial cystitis were treated surgically with either cecocystoplasty, urinary diversion with or without cystectomy, cystolysis or segmental bladder resection. Of the 6 patients who underwent an augmentation cecocystoplasty 4 were cured and 2 ultimately had urinary diversion before cure. Of the 7 patients who underwent urinary diversion with or without total cystectomy 6 were cured. In the cystolysis group the suprapubic pain was relieved either totally or partially in all 5 cases, and nocturia and urinary frequency were reduced substantially in each. However, only 1 patient was cured completely of all symptoms. The patient who underwent segmental resection of the bladder experienced only temporary symptomatic relief. Postoperative complications included pyocystis in 2 patients who had urinary diversion without cystectomy and hydroureteronephrosis in 1 patient after ureterosigmoidostomy that required multiple procedures. The place for each of these major surgical procedures in the treatment of intractable interstitial cystitis is discussed.

Electrical stimulation in interstitial cystitis

We treated 14 women with chronic interstitial cystitis with long-term intravaginal or transcutaneous nerve stimulation. Clinical and urodynamic evaluations were done after 6 months to 2 years. Improvement was not immediate but required a considerable period of continuous, daily use of electrical stimulation. The results were favorable--a substantial decrease in pain and frequency of micturition in all patients after long-term treatment. Since the methods seem effective and are simple, cheap and non-destructive electrical stimulation is recommended for all patients with chronic interstitial cystitis.

Interstitial cystitis: experience and review of recent literature

The history, clinical findings, endoscopic appearance, and physiopathology of this disease is reviewed. The different modalities of therapy are analyzed and compared with our series of 110 patients with this disease. This group was treated on a conservative but more efficient form with superficial electrofulguration and overdistention with silver nitrate solution. The importance of the cancer incidence in the male patient is also stressed.