Effect of pentosan polysulfate therapy on intravesical potassium sensitivity

Heterogeneity in the pharmacological management of radiation-induced hemorrhagic cystitis

BACKGROUND

Radiation-induced hemorrhagic cystitis is a complication of pelvic radiotherapy, with an incidence of up to 5%. The resultant hematuria may be severe and refractory to conservative measures. Our objective was to describe the pattern of inpatient treatments among a cohort of patients with radiation-induced hemorrhagic cystitis requiring pharmacological management.

METHODS

We conducted a retrospective case series to identify all inpatient admissions at a single institution during which patients with radiation cystitis underwent pharmacological intervention for refractory hematuria between 2004 and 2019. Patient demographics, medical history, details of radiation therapy, and relevant admission data were collected. Details of treatment, including the use of pharmacotherapy and surgical treatment, were reviewed and summarized.

RESULTS

We identified 21 patients who were treated during 26 admissions. Most were male (91%) with a history of external beam radiation therapy (86%), primarily for prostate cancer (85%), and a median age of 73 (IQR: 67-85). Most patients received continuous bladder irrigation as the first intervention during their admission (65%), for a median duration of 40 hours (IQR: 25-59). Eleven separate pharmacologic agents were used, with variations in initial pharmacotherapy utilization over time. Most patients were treated with a combination of surgical and pharmacological interventions (85%). The median length of stay was 9 days (IQR: 5-17) and the 90-day readmission rate was 35%.

CONCLUSIONS

Pharmacologic treatment for refractory radiation-induced hemorrhagic cystitis is inconsistent and lacks evidence to support treatment strategies. Further work is needed to determine the optimal management for this morbid complication.

Prevalence of Bladder Pain Syndrome-like Symptoms: a Population-based Study in Korea

OBJECTIVES

To investigate the prevalence of bladder pain syndrome (BPS)-like symptoms in the general population of South Korea.

METHODS

Between April 16, 2016 and April 29, 2016, we conducted an online survey and computer-assisted personal interviews with adults aged 40-79 years in Korea using structured questionnaires. The sample size was 3,000 (95% confidence level standard error ± 1.79%), and the sampling method was simple randomization according to sex, age, and residential area in proportion to the resident registration demographics of the Korean Ministry of Interior and Safety as of March 2016. All participants were surveyed using the Korean version of the Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale and Geriatric Depression Scale (GDS). The primary outcome was the prevalence of BPS-like symptoms, defined as a total PUF score of ≥ 12.

RESULTS

Overall, the prevalence of BPS-like symptoms was 16.4% (483 of 3,000 participants). Women (21.4%) had a significantly higher prevalence of BPS-like symptoms than men (10.7%) (P < 0.01). The prevalence by age was significantly higher in the 70s group than in the other age groups (P < 0.01), and increased significantly with the increasing severity of depression on the GDS (P < 0.01). The prevalence of BPS-like symptoms according to the marital status was significantly different, that is, the prevalence among divorced/bereaved individuals was higher than those of married or unmarried individuals (P < 0.01).

CONCLUSION

Our large, representative population-based study showed that BPS-like symptoms are widespread among the general population of South Korea. BPS is considered a disease that deserves greater attention as it is far more common than previously thought and can negatively affect many people's quality of life.

Development of a Management Algorithm for Acute and Chronic Radiation Urethritis and Cystitis

OBJECTIVE

The purpose of this review was to summarize the current literature on the assessment and treatment of radiation urethritis and cystitis (RUC) for the development of an evidenced-based management algorithm.

MATERIAL AND METHODS

The PubMed/MEDLINE database was searched by a multidisciplinary group of experts in January 2021.

RESULTS

In total, 48 publications were identified. Three different types of RUC can be observed in clinical practice: inflammation-predominant, bleeding-predominant, and the combination of inflammation- and bleeding-RUC. There is no consensus on the optimal treatment of RUC. Inflammation-predominant RUC should be treated symptomatically based on the existence of bothersome storage or voiding lower urinary tract symptom as well as on pain. When bleeding-predominant RUC has occurred, hydration and hyperbaric oxygen therapy (HOT) should be used first and, if HOT is not available, oral drugs instead (sodium pentosane polysulfate, aminocaproic acid, immunokine WF 10, conjugated estrogene, or pentoxifylline + vitamin E). If local bleeding persists, focal therapy of bleeding vessels with a laser or electrocoagulation is indicated. In case of generalized bleeding, intravesical installation should be initiated (formalin, aluminium salts, and hyaluronic acid/chondroitin). Vessel embolization is a less invasive treatment with potentially less complications and good clinical outcomes. Open- or robot-assisted surgery is indicated in patients with permanent, life-threatening bleeding, or fistulae.

CONCLUSIONS

Treatment of RUC, if not self-limiting, should be done according to the type of RUC and in a stepwise approach. Conservative/medical treatment (oral and topic agents) should primarily be used before invasive (transurethral) treatments.

GAG replenishment therapy for bladder pain syndrome/interstitial cystitis

AIMS

To present a rationale for the inclusion of urothelial coating dysfunction in the etipathogenesis of bladder pain syndrome/interstitial cystitis (BPS/IC) and the preclinical and clinical evidence in support of glycosaminoglycan (GAG) replenishment therapy in the treatment of BPS/IC, supplemented by the clinical experience of medical experts in the field and patient advocates attending a symposium on GAG replenishment at ESSIC'17, the annual Meeting of the International Society for the Study of Bladder Pain Syndrome, held in Budapest, Hungary in 2017.

RESULTS

The urothelial GAG layer has a primary role in providing a permeability barrier to prevent penetration of urinary toxins and pathogens into the bladder wall. Disruption of the GAG layer contributes to the development of BPS/IC. The evidence shows that replenishment of GAGs can restore the GAG layer in BPS/IC, reducing inflammation, pain, and other symptoms.

CONCLUSIONS

Although data from large randomized controlled studies are limited, long clinical observation and the experience of clinicians and patients support the beneficial effects of intravesical GAG replenishment therapy for providing symptomatic relief for patients with BPS/IC.

Broad Th2 neutralization and anti-inflammatory action of pentosan polysulfate sodium in experimental allergic rhinitis

Background

Th2 cytokines like interleukin‐4, ‐5, and ‐13 are regarded as important drivers of the immunopathology underlying allergic rhinitis (AR) and asthma. The present study explores the capacity of pentosan polysulfate sodium (PPS), a semi‐synthetic heparin‐like macromolecular carbohydrate, to bind Th2 cytokines and exert biological neutralization in vitro, as well as anti‐inflammatory actions in vivo.

Methodology

The capacity of PPS to bind recombinant Th2 cytokines was tested with surface plasmon resonance (SPR) technology and biological Th2 neutralization was assessed by Th2‐dependent proliferation assays. The in vivo anti‐inflammatory action of PPS was studied using a validated Guinea‐pig model of AR.

Results

Binding studies revealed a strong and specific binding of PPS to IL‐4, IL‐5, and IL‐13 with IC values suggesting as stronger cytokine binding than for heparin. Cytokine binding translated to a biological neutralization as PPS dose dependently inhibited Th2‐dependent cell proliferation. Topical administration of PPS 30 min prior to nasal allergen challenge of sensitized animals significantly reduced late phase plasma extravasation, luminal influx of eosinophils, neutrophils, and total lavage leukocytes. Similar, albeit not statistically secured, effects were found for tissue leukocytes and mucus hyper‐secretion. The anti‐inflammatory effects of PPS compared favorably with established topical nasal steroid treatment.

Conclusion

This study points out PPS as a potent Th2 cytokine‐binding molecule with biological neutralization capacity and broad anti‐inflammatory effects in vivo. As such PPS fulfills the role as a potential candidate molecule for the treatment of AR and further studies of clinical efficacy seems highly warranted.

The Challenges of Interstitial Cystitis: Current Status and Future Prospects

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a syndrome of unpleasant bladder sensations and lower urinary tract symptoms. The three main proposed etiologies are bladder urothelial dysfunction, bladder inflammation (possible neurogenic), and neuropathic pain. Despite decades of basic and clinical research, IC/BPS remains difficult to treat. A variety of treatments are used, each aimed towards one etiology. For example, glycosaminoglycans are thought to improve the urothelial permeability barrier, anti-inflammatory agents are used to decrease general inflammation, and mast cell stabilizers and/or antagonists of mast cell products are used in the treatment of neurogenic inflammation. In the (unfortunately frequent) event that a treatment fails, possible reasons are that (1) the clinician is aiming towards the wrong etiology for that patient (i.e., the treatment is off target) or (2) the correct etiology is being targeted, but the treatment is not ameliorating it (i.e., the treatment is sub-therapeutic). This is a crucial distinction, because an off-target treatment should be abandoned, but a sub-therapeutic treatment should be escalated. Currently, our inability to make this crucial distinction is the greatest obstacle to effective treatment. An important future advance would be to identify urine or serum biomarkers specific to each etiologic target. Then, each biomarker could be used to select appropriate patients for each treatment and monitor the treatment's effect on its intended target.

Efficacy of intravesical pentosan polysulfate sodium in cats with obstructive feline idiopathic cystitis

OBJECTIVES

Obstructive feline idiopathic cystitis is a common emergency in small animal practice. There is evidence for a defective glycosaminoglycan layer in the urinary bladder of affected cats. The aim of this study was to investigate the effect of intravesical pentosan polysulfate sodium (PPS) in cats with obstructive feline idiopathic cystitis in a randomised, placebo-controlled, blinded clinical study.

METHODS

Thirty-five cats with obstructive feline idiopathic cystitis were enrolled into the study. On day 0, cats were randomised to receive either 30 mg PPS in saline (18 cats) or saline alone as placebo (17 cats) at the time of indwelling urinary catheter placement and then after 24 and 48 h. The catheter was clamped for 30 mins after administration before connecting it to a sterile urine collection system. The procedure was repeated after 24 and 48 h, and then the indwelling catheter was removed. Treatment success was assessed via the incidence of recurrent urethral obstruction, results of a scoring system for physical examination and daily urinalysis from day 0 to 5.

RESULTS

Recurrent urethral obstruction occurred in 3/18 cats of the verum group and 3/17 of the placebo group (P = 1.000). The verum group showed a significantly lower degree of microscopic haematuria between day 5 and day 0 (P ⩽0.05). The placebo group showed a significantly lower degree of dipstick haematuria between day 5 and day 0 (P ⩽0.05). There was no difference in the clinical score between the groups in the investigated time period.

CONCLUSIONS AND RELEVANCE

Intravesical instillation of PPS three times within 48 h in the chosen dose had no influence on the incidence of recurrent urethral obstruction and clinical signs in cats with obstructive feline idiopathic cystitis.

Therapeutic Potential of Human Chorionic Gonadotropin Against Painful Bladder Syndrome/Interstitial Cystitis

Painful bladder syndrome/interstitial cystitis is a debilitating chronic bladder disease that primarily affects women. The disease is due to a damage of urothelial cell lining. As a result, potassium particles and other toxic substances in urine can leak into bladder mucosa, causing the symptoms of lower abdominal/pelvic discomfort, pain, increased urination frequency, urgency, nocturia, and so on, all of which can substantially reduce the quality of daily life. There are multiple symptom reliving therapies. Among them, only pentosan polysulfate sodium, sold under the brand name of Elmiron, has been approved for oral use by US Food and Drug Administration. It provides the relief after several months of use. Based on the scientific leads presented in this article, we propose that human chorionic gonadotropin has a therapeutic potential that is worth investigating for the treatment of this disease.

Interstitial cystitis/bladder pain syndrome and glycosaminoglycans replacement therapy

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating chronic disease characterized by discomfort or recurrent abdominal and pelvic pains in the absence of urinary tract infections. Its symptomatology includes discomfort, increased bladder pressure, sensitivity and intense pain in the bladder and pelvic areas, increased voiding frequency and urgency, or a combination of these symptoms. For these reasons, this pathology has a very negative impact on quality of life. The etiology of IC/BPS is still not well understood and different hypotheses have been formulated, including autoimmune processes, allergic reactions, chronic bacterial infections, exposure to toxins or dietary elements, and psychosomatic factors. The finding of an effective and specific therapy for IC/BPS remains a challenge for the scientific community because of the lack of a consensus regarding the causes and the inherent difficulties in the diagnosis. The last recent hypothesis is that IC/BPS could be pathophysiologically related to a disruption of the bladder mucosa surface layer with consequent loss of glycosaminoglycans (GAGs). This class of mucopolysaccharides has hydrorepellent properties and their alteration expose the urothelium to many urinary toxic agents. It has been hypothesized that when these substances penetrate the bladder wall a chain is triggered in the submucosa. In order to improve the integrity and function of the bladder lining, GAG layer replenishment therapy is widely accepted as therapy for patients with IC/BPS who have poor or inadequate response to conventional therapy. Currently, Chondroitin sulfate (CS), heparin, hyaluronic acid (HA), and pentosan polysulphate (PPS), and combinations of two GAGs (CS and HA) are the available substances with different effectiveness rates in patients with IC/BPS. There are four different commercially available products for GAG replenishment including CS, heparin, HA and PPS. Each product has different concentrations and dosage formulations. Recently, a combination of CS and HA is the latest commercially available product with promising results.

Review of intravesical therapies for bladder pain syndrome/interstitial cystitis

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic pain condition characterised by urinary frequency, urgency and pain or discomfort which the patient attributes to the bladder. It is a complex condition to manage and treat and requires a multi-disciplinary and multi-modal approach. As well as lifestyle and behavioural modifications, physical therapy and oral medications, intravesical treatments can be used in the treatment algorithm for BPS/IC. A number of intravesical agents are reviewed in this paper along with the available evidence for their use.

Diagnosing the bladder as the source of pelvic pain: successful treatment for adults and children

The key to successful therapy of interstitial cystitis (IC) is to correctly diagnose it. The significant majority of patients with IC have a dysfunctional bladder epithelium that allows urinary solutes (primarily potassium) to leak into the bladder wall, causing symptoms and tissue damage. Drugs that correct this dysfunction and suppress symptoms are important to achieve successful outcomes in patients. Today over 95% of females with IC are misdiagnosed as having gynecologic chronic pelvic pain, vulvodynia, vaginitis, endometriosis, overactive bladder or urinary tract infection. Men are misdiagnosed as having prostatitis. Often children are not diagnosed at all. Multimodal drug therapy may be required and can achieve successful resolution of IC in over 90% of patients. IC in children can be treated successfully with pentosan polysulfate.

Biomimetic urothelial tissue models for the in vitro evaluation of barrier physiology and bladder drug efficacy

The bladder is an important tissue in which to evaluate xenobiotic drug interactions and toxicities due to the concentration of parent drug and hepatic/enteric-derived metabolites in the urine as a result of renal excretion. Breaching of the barrier provided by the bladder epithelial lining (the urothelium) can expose the underlying tissues to urine and cause harmful effects (e.g., cystitis or cancer). Human urothelium is most commonly represented in vitro as immortalized or established cancer-derived cell lines, but the compromised ability of such cells to undergo differentiation and barrier formation means that nonimmortalized, normal human urothelial (NHU) cells provide a more relevant cell culture system. The impressive capacity for urothelial self-renewal in vivo can be harnessed in vitro to generate experimentally-useful quantities of NHU cells, which can subsequently be differentiated to form a functional or "biomimetic" urothelium. When seeded onto permeable membranes, these barrier-forming human urothelial tissue models enable the modeling of serum and luminal (intravesical) exposure to drugs and metabolites, thus supporting efficacy/toxicity assessments. Biomimetic human urothelial constructs provide a potential step along the preclinical trail and may support the extrapolation from rodent in vivo data to determine human relevance. Early evidence is beginning to demonstrate that human urothelium in vitro can provide information that supersedes conventional rodent studies, but further validation is needed to support widespread adoption.

Pharmacokinetic considerations for therapies used to treat interstitial cystitis

INTRODUCTION

Interstitial cystitis (IC) or bladder pain syndrome (BPS) is defined as supra-pubic pain related to bladder filling. IC is characterized by a particular symptom complex with no identifiable causes; as with bladder hypersensitivity it is usually associated with urinary frequency and urgency with bladder pain. No current treatments have a significant impact on symptoms over time.

AREAS COVERED

This systematic review examines the pharmacokinetic aspects and adverse event of present IC therapy to highlight appropriate treatment to improve the symptoms of IC. This article reviews material obtained via Medline, PubMed, and EMBASE literature searches up to October 2013.

EXPERT OPINION

The correct approach to IC should consider a multidisciplinary team of specialists and a multimodal treatment package that include psychotherapy, behavior change, physical activation, and analgesic treatment. Unfortunately, a single therapeutic target for IC is not yet known. With regard to pathophysiology and therapy, there is more to discover. The first insult damages the bladder urothelium, hence vehicles that lead the drug to penetrate the wall of the bladder might be a novel strategic approach.

Urothelial signaling

The urothelium, which lines the inner surface of the renal pelvis, the ureters, and the urinary bladder, not only forms a high-resistance barrier to ion, solute and water flux, and pathogens, but also functions as an integral part of a sensory web which receives, amplifies, and transmits information about its external milieu. Urothelial cells have the ability to sense changes in their extracellular environment, and respond to chemical, mechanical and thermal stimuli by releasing various factors such as ATP, nitric oxide, and acetylcholine. They express a variety of receptors and ion channels, including P2X3 purinergic receptors, nicotinic and muscarinic receptors, and TRP channels, which all have been implicated in urothelial-neuronal interactions, and involved in signals that via components in the underlying lamina propria, such as interstitial cells, can be amplified and conveyed to nerves, detrusor muscle cells, and ultimately the central nervous system. The specialized anatomy of the urothelium and underlying structures, and the possible communication mechanisms from urothelial cells to various cell types within the bladder wall are described. Changes in the urothelium/lamina propria ("mucosa") produced by different bladder disorders are discussed, as well as the mucosa as a target for therapeutic interventions.

Intravesical hyaluronic acid for interstitial cystitis/painful bladder syndrome: a comparative randomized assessment of different regimens

OBJECTIVES

To compare the clinical effectiveness of different regimens of intravesical hyaluronic acid instillation for patients with interstitial cystitis/painful bladder syndrome.

METHODS

A total of 60 patients (age 16-77 years) diagnosed with interstitial cystitis/painful bladder syndrome were enrolled in this prospective, randomized study. A total of 30 patients were assigned to receive four weekly intravesical instillations of 40 mg of hyaluronic acid followed by five monthly instillations (hyaluronic acid-9 group). Another 30 patients received 12 intravesical instillations of 40 mg hyaluronic acid every 2 weeks (hyaluronic acid-12 group). Symptomatic changes after hyaluronic acid treatments were assessed using Interstitial Cystitis Symptom and Problem Indexes, pain visual analog scale, functional bladder capacity, frequency and nocturia in voiding diary, maximum flow rate, voided volume, postvoid residual volume, and Quality of Life Index at 1, 3 and 6 months.

RESULTS

Of the 60 patients, 59 were evaluable at the end of the study. The Interstitial Cystitis Symptom Index, Interstitial Cystitis Problem Index and total score, pain visual analog scale, functional bladder capacity, maximum flow rate, and Quality of Life Index improved significantly after 6 months in both groups. The frequency and voided volume improved significantly only in the hyaluronic acid-12 group. However, patients with moderate and marked improvement were clinically similar in both groups. The measured variables did not differ between the two groups over the course of the study.

CONCLUSION

No significant difference was noted in the therapeutic effect between two hyaluronic acid instillation regimens for treatment of interstitial cystitis/painful bladder syndrome patients. Both groups showed significant improvement in symptom scores and Quality of Life Index.

Role of inflammation in bladder function and interstitial cystitis

Cystitis, or inflammation of the bladder, has a direct effect on bladder function. Interstitial cystitis is a syndrome characterized by urinary bladder pain and irritative symptoms of more than 6 months duration. It commonly occurs in young to middle-aged women with no known cause and in fact represents a diagnosis of exclusion. Many factors have been suggested, including chronic or subclinical infection, autoimmunity and genetic susceptibility, which could be responsible for initiating the inflammatory response. However, a central role of inflammation has been confirmed in the pathogenesis of interstitial cystitis. Patients with interstitial cystitis are usually managed with multimodal therapy to break the vicious cycle of chronic inflammation at every step. Patients who develop irreversible pathologies such as fibrosis are managed surgically, which is usually reserved for refractory cases.

Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis

INTRODUCTION AND HYPOTHESIS

While the short-term efficacy of intravesical hyaluronan for bladder pain syndrome/interstitial cystitis (BPS/IC) has been demonstrated, no data exist on the long-term outcome of this therapy.

METHODS

Seventy BPS/IC patients treated with intravesical hyaluronan therapy from 2001 to 2003 were asked to rate their present status of bladder symptoms on a visual analog scale.

RESULTS

Forty-eight of 70 patients responded after a mean follow-up of 4.9 years. The average initial VAS score of 8.15 had been reduced to 2.71 after therapy and further to 2.14 5 years later. Fifty percent of patients (24/48) reported complete bladder symptom remission at 5 years follow-up without any additional therapy; 41.7% (20/48) with symptom recurrence was improved with hyaluronan maintenance therapy. No improvement was reported by four patients.

CONCLUSIONS

Besides a high rate of acute symptom remission, intravesical hyaluronan also shows long-term efficacy in a considerable number of BPS/IC patients.

The overlap of interstitial cystitis/painful bladder syndrome and overactive bladder

Results of this study suggest that patients who have failed therapies for overactive bladder might be more effectively treated using therapies directed towards uroepithelial dysfunction and neural upregulation associated with interstitial cystitis.

Objective:

We evaluated the prevalence of positive potassium sensitivity and cystoscopy with hydrodistention findings in patients with overactive bladder.

Method:

This was a prospective cohort study of 98 patients who presented with overactive bladder symptoms. The diagnosis of overactive bladder is established by the presence of irritable voiding symptoms. All patients completed a PUF questionnaire and underwent potassium sensitivity testing. Eighty patients underwent urodynamic testing, and 42 patients underwent cystoscopic hydrodistention while under general anesthesia.

Results:

The Potassium Sensitivity Test was positive in 59 (60.2%) of the 98 patients, 37 (56%) of wet overactive bladder patients, and 22 (68.8%) of dry overactive bladder patients. Their mean PUF score was 7. Thirty-three (78.5%) of the patients who underwent cystoscopic hydrodistention had glomerulations consistent with NIH criteria for interstitial cystitis, and 26 of these patients tested positive for potassium sensitivity. Fifty-one (63.8%) of the patients who underwent urodynamics tested positive for potassium sensitivity.

Conclusion:

Many patients with symptoms of overactive bladder with little or no pain have cystoscopic evidence of interstitial cystitis and a positive Potassium Sensitivity Test. Therapies directed toward the uroepithelial dysfunction and neural upregulation associated with interstitial cystitis/painful bladder syndrome may be an important adjunct for patients who have failed or have had a partial response to anticholinergic therapy and behavior modification.

[Urethral syndrome in men--chronic pelvic pain syndrome]

INTRODUCTION

Chronic pelvic pain syndrome (CPPS) is defined as pelvis minor pain of nonmalignant nature repeating in different time intervals. Urethral syndrome (US) represents a most poorly defined entity within CPPS.

OBJECTIVE

The estimation of US influence on quality-of-life as well as the determination of the way of treatment and therapy optimal length.

MATERIAL AND METHODS

A prospective one-year study included 166 men with CPPS, median age of 54 years; they were monitored clinically. During the patient monitoring the NIH-CPSI questionnaire (National Institute of Health-Chronic Prostatis Symptom Index) was used. US was diagnosed in 79 patients (47%), and according to the most intensive pain localization they were divided into three groups. All the patients were treated with alpha adrenergic blockers and non-steroidal anti-inflammatory drugs, and the treatment of the patients with positive urethral smear also included antibiotherapy. The values of total NIH-CPSI, as well as of its individual components were analyzed after three and six months of treatment.

RESULTS AND DISCUSSION

The therapy application had a significant influence on the decrease of total NIH-CPSI--23.3% (p < 0.01), pain symptoms (p < 0.0) and urinary difficulties (p < 0.01), and the point values of quality-of-life score were diminished by 0.7 to 1.9 points depending on the group of those monitored (p < 0.01).

CONCLUSION

Our study indicated a significant influence of CPPS on quality-of-life and a necessity of a serious approach to patients and their treatment.

Effect of intravesical glycosaminoglycan substitution therapy on bladder pain syndrome/interstitial cystitis, bladder capacity and potassium sensitivity

OBJECTIVE

To evaluate changes in bladder capacity and potassium sensitivity after glycosaminoglycan (GAG) substitution therapy.

MATERIAL AND METHODS

The study population comprised two groups of female patients with bladder pain syndrome/interstitial cystitis (BPS/IC): responders (those with symptom improvement) and non-responders (those without symptom improvement) after a 10-week period of intravesical, episodic, weekly, GAG substitution therapy. A total of 27 volunteers with increased pre-therapeutic potassium sensitivity were enrolled in the study and re-evaluated using the modified comparative potassium test (maximal bladder capacity with a saline solution versus a 0.2 M KCl solution) following intravesical GAG substitution therapy.

RESULTS

In the 13 responders, the average maximal bladder capacity increased by 17% with the saline solution and by 101.5% with the 0.2 M KCl solution. In the 14 non-responders, post-therapeutic average maximal bladder capacity was decreased by 35% with the saline solution and remained relatively unchanged after instillation with a 0.2 M KCl solution.

CONCLUSION

These data demonstrate that in patients who respond symptomatically to intravesical GAG substitution therapy, cystometric bladder capacity is increased, whereas non-responders experience a decrease in bladder capacity.

The relationship between subjective and objective assessments of sacral neuromodulation effectiveness in patients with urgency-frequency

AIMS

Global response assessment (GRA) has been used to evaluate patients' perceptions of treatment effectiveness. However, few studies have scrutinized the relationship between GRAs and objective voiding diary outcomes data. This study explores the relationship between self-reported symptom-specific GRA responses and objective changes in frequency, urgency and pelvic pain in patients with urgency-frequency with or without pelvic pain after implantation of a prosthetic sacral nerve stimulation device.

METHODS

Patients scheduled for a staged procedure were enrolled in a prospective, observational, longitudinal study. Post implantation, patietns were grouped into "responders" or "non-responders" based on their answers to symptom-specific GRAs at three and six months. Treatment responders were defined as those reporting "moderately" or "markedly improved" on a 7-point scale, and all others were considered non-responders. Pre- and post-implant changes in mean 24-hour voiding frequency, voided volume, urgency and pelvic pain scores as recorded on voiding diaries were compared between groups using paired t-test.

RESULTS

At three months, responders demonstrated corresponding statistically significant improvement in voiding frequency (P < 0.001), average voided volume (P = 0.003), urgency (P = 0.022) and pelvic pain (P = 0.039). At six months, responders demonstrated statistically significant improvements in frequency (P = 0.025) and urgency (P = 0.006). None of the symptom changes were statistically significant in treatment non-responders.

CONCLUSIONS

The GRA non-responders groups' perceptions of treatment response agreed with their objective changes in bothersome symptoms and responders' changes agreed with their perception of improvement in the majority of symptoms. Further study is needed to standardize the GRA, and explore its potential for use in clinical practice.

Herpes simplex virus vector-mediated gene delivery for the treatment of lower urinary tract pain

Interstitial cystitis (IC)/painful bladder syndrome (PBS) is a painful debilitating chronic visceral pain disorder of unknown etiology that affects an estimated 1 million people in the United States alone. It is characterized by inflammation of the bladder that results in chronic pelvic pain associated with bladder symptoms of urinary frequency and urgency. Regardless of the etiology, IC/PBS involves either increased and/or abnormal activity in afferent nociceptive sensory neurons. Pain-related symptoms in patients with IC/PBS are often very difficult to treat. Both medical and surgical therapies have had limited clinical utility in this debilitating disease and numerous drug treatments, such as heparin, dimethylsulfoxide and amitriptyline, have proven to be palliative at best, and in some IC/PBS patients provide no relief whatsoever. Although opiate narcotics have been employed to help alleviate IC/PBS pain, this strategy is fraught with problems as systemic narcotic administration causes multiple unwanted side effects including mental status change and constipation. Moreover, chronic systemic narcotic use leads to dependency and need for dose escalation due to tolerance; therefore, new therapies are desperately needed to treat refractory IC/PBS. This has led our group to develop a gene therapy strategy that could potentially alleviate chronic pelvic pain using the herpes simplex virus-directed delivery of analgesic proteins to the bladder.

Hyaluronan treatment of interstitial cystitis/painful bladder syndrome

The aim of this study is to evaluate the efficacy of intravesical hyaluronan therapy in interstitial cystitis/painful bladder syndrome (IC/PBS). One hundred twenty-six patients with IC/PBS and an average disease duration of 6.1 years were treated with weekly instillations of a 50-cm3 phosphate-buffered saline solution containing 40 mg sodium hyaluronate. To be eligible for hyaluronan treatment, a positive modified potassium test was requested as a sign of a urine-tissue barrier disorder. Data were obtained by a visual analogue scale (VAS) questionnaire rating from 0 to 10 that asked for global bladder symptoms before and after therapy. Additional questions evaluated the therapeutic impact on quality of life. A positive and durable impact of hyaluronan therapy on IC/PBS symptoms was observed--103 (85%) of the patients reported symptom improvement (> or =2 VAS units). The mean initial VAS score of 8.5 decreased to 3.5 after therapy (p < 0.0001). Out of 121 patients, 67 (55%) remained with no or minimal bladder symptoms after therapy (VAS 0-2). The majority (101, 84%) reported significant improvement of their quality of life. Intravesical therapy had to be initiated again with good success in 43 patients (34.5%) as symptoms recurred after discontinuation of treatment, while the rest stayed free of symptoms for up to 5 years. In general, hyaluronan therapy was well tolerated and, with the exception of mild irritative symptoms, no adverse reactions were reported for a total of 1,521 instillations. Timely hyaluronan instillation therapy may lead to complete symptom remission or even cure in part of the IC/PBS patients, while some responders need continuous intravesical therapy. The present results suggest that selection of patients for hyaluronan therapy by potassium testing improves the outcome of intravesical therapy with a response rate of >80%.

Intravesical Botulinum Toxin A Injections Plus Hydrodistension Can Reduce Nerve Growth Factor Production and Control Bladder Pain in Interstitial Cystitis

OBJECTIVES

To investigate the level of nerve growth factor (NGF) mRNA in bladder tissue and the effect of botulinum toxin A (BTX-A) treatment in patients with interstitial cystitis (IC).

METHODS

A total of 19 patients with IC were treated with 100 U or 200 U of intravesical BTX-A injections followed by cystoscopic hydrodistension 2 weeks later. Bladder mucosa biopsies were performed before BTX-A injection and immediately after hydrodilation and in 12 controls. The NGF mRNA and protein levels in bladder tissues were assessed by real-time polymerase chain reaction and immunohistochemistry studies to determine differences in NGF expression between patients with IC before and after BTX-A treatment and compare with controls.

RESULTS

At 3 months, 14 patients had symptomatic improvement (responders) and 5 did not (nonresponders). The NGF mRNA levels at baseline in the overall IC patient group were significantly greater than those in the controls (0.65 +/- 0.33 versus 0.42 +/- 0.25, P = 0.046). At 2 weeks after BTX-A treatment, the NGF mRNA levels had decreased to 0.47 +/- 0.23 (P = 0.002, compared with baseline) and were no longer significantly different from those of the controls. The NGF mRNA levels decreased significantly in responders and were significantly decreased after BTX-A in 11 patients with a visual analog pain scale reduction of 2 or more. The immunoreactivity study of bladder tissue from patients with IC showed greater NGF density at baseline compared with controls, but the difference was no longer significant after successful BTX-A treatment.

CONCLUSIONS

Intravesical BTX-A injections plus hydrodistension reduce bladder pain in patients with IC. The NGF levels in the bladder tissue were significantly increased in patients with IC and decreased to normal level after treatment in responders.

Rational approaches to the treatment of patients with interstitial cystitis

Symptoms of interstitial cystitis can usually be successfully managed with heparinoid therapy to theoretically alter bladder urothelial abnormalities, and with oral medications to inhibit neural upregulation or to control mast cell dysfunction. Other forms of care ranging from intravesical therapy to endoscopic, percutaneous, or open surgery are options that may be used singly or in combination to optimize symptom reduction.

Bladder defense molecules, urothelial differentiation, urinary biomarkers, and interstitial cystitis

It has long been recognized that interstitial cystitis (IC) is a disease of the urothelium. In this article, we review the results of published studies and present new data concerning the precise role of the bladder epithelium in IC. We discuss bladder defenses against both the penetration of urinary solutes and bacterial adherence, and we present new information about the proteoglycans that are present on the normal bladder. Previously published results and new data presented here support the conclusion that IC involves an aberrant differentiation program in the bladder urothelium that leads to altered synthesis of several proteoglycans, cell adhesion and tight junction proteins, and bacterial defense molecules such as GP51. These findings lend support to the rationale for glycosaminoglycan replacement therapy for the treatment of patients with IC.

The Role of the Urinary Epithelium in the Pathogenesis of Interstitial Cystitis/Prostatitis/Urethritis

The urothelium plays a pivotal role as a barrier between urine and its solutes and the underlying bladder. Bladder surface mucus is a critical component of this function. The biologic activity of mucus that imparts this barrier function is generated by the highly anionic polysaccharide components (eg, glycosaminoglycans), which are extremely hydrophilic and trap water at the outer layer of the umbrella cell. This trapped water forms a barrier at the critical interface between urine and the bladder. The result is a highly impermeable urothelium that serves as a key protective barrier for the bladder interstitium. In interstitial cystitis (IC), disruption of the urothelial barrier may initiate a cascade of events in the bladder, leading to symptoms and disease. Specifically, epithelial dysfunction leads to the migration of urinary solutes, in particular, potassium, that depolarize nerves and muscles and cause tissue injury. Exogenous heparinoids can restore the barrier function of the urothelium and thus successfully treat patients with IC. Groups of patients who have been given a diagnosis of IC, chronic prostatitis, and urethritis have been shown to have IC by virtue of their shared potassium sensitivity. It would seem, therefore, that mucous deficiency may be present throughout the lower urinary tract. If one is to rename these diseases, perhaps it is best to do so in reference to a shared loss of epithelial barrier function. A name such as lower urinary dysfunctional epithelium would incorporate all of these diseases under a single pathophysiologic process. As a result of these discoveries, a new paradigm for diagnosis and treatment is emerging.

Potassium sensitivity test (PST) as a measurement of treatment efficacy of painful bladder syndrome/interstitial cystitis: A prospective study with cyclosporine A and pentosan polysulfate sodium

AIMS

Potassium sensitivity test (PST) has been used as an optional tool in diagnosing painful bladder syndrome/interstitial cystitis (PBS/IC). The role of PST in the follow-up of patients with PBS/IC is elusive. We performed PST before and after treatment of PBS/IC with cyclosporine A (CyA) or pentosan polysulfate sodium (PPS), to test whether the result of repeated PST correlates with alleviation of PBS/IC-related symptoms.

MATERIALS AND METHODS

Sixty-four patients who participated in a randomized clinical study comparing CyA and PPS in the treatment of PBS/IC were recruited to the present study. Patients underwent 0.4 M PST before and after 6 months of treatment. The primary end point was a change from positive PST to negative among patients who responded to both treatments determined by global response assessment (GRA).

RESULTS

Potassium sensitivity test (PST) was more likely to change from positive to negative among patients who responded to their treatment according to GRA (P < 0.001). The PST change follows the clinical course (ICSI score, voiding frequency, VAS score), which was more beneficial in the CyA-treated patients.

CONCLUSIONS

Potassium sensitivity test (PST) reflects symptom severity of PBS/IC patients. Change of pre-treatment positive PST to negative correlates well with clinical alleviation of PBS/IC-related symptoms. In patients with persistent symptoms it may be painful and does not offer additional information. Thus, we do not recommend PST to be used as a routine clinical test in monitoring of PBS/IC treatment efficacy.

Oncologic Emergencies

It has been estimated that genitourinary malignancies will account for 25% of new cancer diagnoses in the United States in 2005 (Jemal et al. 2005). While the incidence of many of these malignancies has increased over the past two decades, the mortality rates appear to be decreasing. Early cancer detection combined with improvements in surgical and nonsurgical oncologic therapy account for these trends. Although not common, newly diagnosed cancer patients occasionally present in an emergent, life-threatening manner that warrants immediate medical or surgical intervention. As the prevalence of genitourinary malignancies continues to expand, additional patients can be expected to develop disease or treatment-related complications. This chapter will serve to review the diagnosis and management of oncologic emergencies as they pertain to the urologist.

Heat/burning sensation induced by topical application of capsaicin on perineal cutaneous area: New approach in diagnosis and treatment of chronic prostatitis/chronic pelvic pain syndrome?

OBJECTIVES

To investigate the feasibility, safety, and efficacy of perineal cutaneous application of capsaicin as a test for the diagnosis, as well as a potential therapeutic tool, in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

We recruited 22 patients (mean age 34.5 years, range 19 to 56), who had been diagnosed with CP/CPPS according to the National Institutes of Health criteria, and 6 healthy control subjects. Both groups received a topical application of 5 mL capsaicin at a concentration of 10(-5) M to the perineal body skin. The patients were asked to mark on a visual analogue scale the intensity of any heat or burning sensation. All the patients had completed a National Institutes of Health Chronic Prostatitis Symptom Index before and 1 week after the test. The scores of the two groups were compared using the Mann-Whitney U test.

RESULTS

The patients with CP/CPPS reported a heat/burning sensation intensity that was statistically greater than that of the healthy controls (7.5 versus 4.3, P <0.001) and a shorter time to heat sensation onset and maximal intensity (1.5 versus 3.4 minutes, P <0.001, and 2.5 versus 7 minutes, P <0.001, respectively). Of the 22 patients, 16 reported an improvement of symptoms after 7 days and the mean National Institutes of Health Chronic Prostatitis Symptom Index score decreased from 27 to 16 (P <0.01).

CONCLUSIONS

We found a statistically significant difference in the pain visual analogue scale and interval between topical application and the onset of the heat/burning sensation between patients with CP/CPPS and healthy controls. The small sample size strongly suggests the need for additional larger and more controlled studies.

Advances in the treatment of interstitial cystitis

Recent years have brought dramatic advances in the clinician's ability to offer effective pharmacotherapy to patients who have interstitial cystitis. Medical treatments have been developed and applied to reduce the interstitial cystitis symptoms of pelvic pain and urinary urgency/frequency, and to address underlying causes of the disorder. In addition, advances in the understanding of the natural history of interstitial cystitis have revealed that it is insidiously progressive and the classical definition--rare, severe and difficult to treat--is in fact the relatively uncommon, advanced stage of a disorder that affects most individuals in a mild-to-moderate and readily treatable form. This recognition has led to the identification of large numbers of previously unsuspected cases of interstitial cystitis, and the successful treatment of many individuals in the early stages of interstitial cystitis when it is far more responsive to therapy. A heparinoid-based multimodal medical regimen can effectively control symptoms and address disease pathophysiology in the majority of cases. Intravesical therapeutic solutions are new and promising adjunctive therapies that can offer immediate symptom relief during symptom flares, and for patients who are just beginning medical therapy.

Measurement of electrolyte concentrations in expressed prostatic secretion and urine from patients with chronic prostatitis and its implications

This study was aimed at measuring concentration of electrolytes, especially K+ in expressed prostatic secretion (EPS) and urine from patients with chronic prostatitis. The concentration of potassium, sodium, chloride, calcium in EPS and urine of 31 controls and 79 patients with prostatitis were measured and analyzed. There was no significant difference in the concentrations of potassium, sodium, chloride and calcium between the patients and the controls. Among the patients treated effectively, potassium concentration was 40.66 +/- 17.10 mmol/l before treatment and 33.42 +/- 17.27 mmol/l after treatment. While among the patients treated ineffectively, potassium concentration was measured as 37.57 +/- 16.93 mmol/l and 50.66 +/- 18.77 mmol/l before and after treatment respectively. The concentrations of electrolytes in prostatic fluid varied greatly between individuals. Potassium concentration in EPS decreased significantly after treatment among the patients with obvious treatment effectiveness, while increased among those who failed the treatment. EPS potassium concentration was also found to be lower in patients with pain than those without pain. No significant difference was found between the normal group and the no-pain patients.

Pentosan Polysulfate

Pentosan polysulfate (pentosan polysulfate sodium; ELMIRON), a heparin-like, sulfated polysaccharide, is used to manage bladder pain and discomfort in adults with interstitial cystitis (IC). Preliminary clinical models suggest that pentosan polysulfate repairs damaged glycosaminoglycan (GAG) layers lining the urothelium and in vitro data suggest it may provide an anti-inflammatory effect in patients with IC. Pentosan polysulfate shows beneficial effects in a proportion of patients with IC in terms of the improvement of a patient's overall condition and the relief of pain, and it is a generally well tolerated therapy. It is the only US FDA-approved oral treatment for the relief of bladder pain or discomfort associated with IC, and data support its role as an important option in the treatment of patients with IC.

K+ channel expression in prostate epithelium and its implications in men with chronic prostatitis

OBJECTIVE

To investigate the effect of the Kv1.3 K(+) channel on the pathogenesis of chronic prostatitis.

MATERIALS AND METHODS

The expression of the Kv1.3 K(+) channel in prostatic epithelia was detected using streptavidin/peroxidase immunohistochemistry in tissue samples from 75 men with benign prostatic hyperplasia, including 42 with and 33 without chronic inflammation. All of the men were sampled in our hospital between January 2000 and December 2003.

RESULTS

There was strong and moderate immunostaining in 14 of the prostatic epithelial specimens with inflammation and in 21 from patients without inflammation, compared to 28 and 12 with low staining, respectively (chi-squared, P < 0.05).

CONCLUSIONS

The expression of the Kv1.3 K(+)channel was lower in prostatic epithelial cells from patients with chronic inflammation than from those without. Opening the Kv1.3 K(+) channel could promote the efflux of K(+) from the cells, causing an increase in [K(+)] in the prostate cavity. The increase in [K(+)] can then infiltrate the stroma through the epithelial gap, exciting the nerve fibres and causing pain and other clinical symptoms.

Safety and efficacy of concurrent application of oral pentosan polysulfate and subcutaneous low-dose heparin for patients with interstitial cystitis

OBJECTIVES

To conduct a prospective controlled study assessing the safety and efficacy of the additional administration of subcutaneous low-dose heparin in patients receiving oral pentosan polysulfate (PPS) medication for interstitial cystitis.

METHODS

A total of 41 patients with interstitial cystitis who reported efficacy of oral PPS medication were divided into three groups (major, intermediate, and minor PPS response), according to their therapeutic response to PPS. Patients received 3 x 5000 IU/day heparin for 2 days, followed by 2 x 5000 IU/day for 12 days. The maintenance dose was 5000 IU/day heparin. We used 17 patients randomly taking PPS alone as the control group. The primary endpoint was a change in overall well-being. Secondary endpoints were changes in pain, urgency, frequency, functional bladder capacity, and the O'Leary-Sant index.

RESULTS

Overall, 10 patients were identified as responders at 3 months (24.4%) and 9 patients at 6 months (21.9%) compared with no responders in the control group (P < or = 0.001). At 3 months, 7 (31.8%) of 22 patients in the minor response group reported a statistically significant overall improvement in their well-being compared with 1 (12.5%, P < or = 0.001) of 8 patients of the intermediate group and 2 (18.2%, P < or = 0.001) of 11 patients of the major response group. A significant amelioration of pain intensity was observed in the minor response group at 3 and 6 months.

CONCLUSIONS

The concurrent administration of low-dose heparin and oral PPS appears to be a safe and efficacious treatment modality. The subcutaneous administration of heparin appeared to be predominantly of value for patients with interstitial cystitis and an initial minor response to PPS.

Abnormal urinary potassium metabolism in patients with interstitial cystitis

PURPOSE

If most patients with interstitial cystitis (IC) have epithelial leakage allowing urinary K to penetrate the interstitium and provoke symptoms, urinary K should be lower in untreated patients than in healthy subjects and it should increase with successful heparinoid treatment. This study tested these hypotheses.

MATERIALS AND METHODS

Na, K and creatinine (Cr) were determined in spot urine samples from new, symptomatic, untreated patients with IC meeting all National Institute of Diabetes and Digestive and Kidney Diseases clinical diagnostic criteria, returning patients with IC reporting 50% or greater symptom improvement after 4 or greater months of oral heparinoid therapy and control subjects, and in 24-hour urine samples from new untreated patients and controls.

RESULTS

In spot urine specimens of 37 new patients with IC K-to-Cr ratios were significantly lower than in 18 controls (0.51 vs 0.88 mg/mg Cr, p = 0.001). A total of 50 successfully treated patients with IC had significantly higher K-to-Cr ratios than those in 37 new patients (0.66 vs 0.51 mg/mg Cr, p = 0.025). Na-to-Cr ratios in the 3 groups were not significantly different. In 24-hour urine specimens 30 new patients had lower average K (31.0 vs 46.2 mEq/l, p = 0.01) and lower K-to-Cr ratios (0.43 vs 0.52 mg K/mg Cr, p = 0.01) than in 47 controls, while Na was not significantly different.

CONCLUSIONS

Our finding of lower urinary K in new, untreated patients supports the concept of abnormal epithelial permeability and K absorption in IC. Higher urinary K in successfully treated vs untreated patients may reflect decreasing urinary K absorption due to mucosal repair and a resulting decrease in epithelial permeability. K/mg Cr appears accurate for normalizing urinary K.

Management of patients with interstitial cystitis or chronic pelvic pain of bladder origin: a consensus report

BACKGROUND

Interstitial cystitis (IC) remains a challenging disease to treat, but increased awareness, better diagnostic tools, and effective pharmacologic agents can help non-urologists successfully manage this condition. Interstitial cystitis is much more prevalent than previously thought and is often misdiagnosed. Left untreated, IC can have a deleterious effect on the quality of life of the affected individual. In-office symptom-based techniques have been developed to screen for the presence of IC in both women and men presenting with symptoms of chronic pelvic pain (CPP) or chronic prostatitis (CP), and effective pharmacologic treatments exist that can provide acute and long-term symptom relief. Individual patient response to therapy varies, with some patients taking up to several months to achieve an optimal therapeutic response. To optimize patient response, a comprehensive algorithm for the diagnosis and management of IC should be utilized. Symptoms and progress should be assessed at each follow-up visit and changes in therapy made accordingly. Patients should be encouraged to learn as much as possible about IC and to take charge of the management of symptoms using their physician for guidance in decision making. The importance of this aspect of therapy should be reinforced at each subsequent visit. The entire office staff also has an important role in understanding and acknowledging each patient's pain and frustration as well as in providing support and education about IC.

SCOPE

This paper presents recommendations from a multidisciplinary panel for the evaluation, diagnosis, treatment, and follow-up care of patients with IC or CPP of bladder origin.