Prolonged hydrodistention of the bladder for symptomatic treatment of interstitial cystitis: efficacy at 6 months and 1 year

Effects of electroacupuncture on refractory interstitial cystitis/bladder pain syndrome: A one-year follow-up case report

BACKGROUND

Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) commonly face a decline in their quality of life and social functioning upon discontinuation of conventional therapy, which is known for its limited efficacy and the risk of relapse. While the existing evidence is somewhat restricted, acupuncture is being explored as a potential and effective treatment option for IC/BPS.

CASE PRESENTATION

A 67-year-old woman, diagnosed with refractory IC/BPS, underwent treatment at the Medical Acupuncture Department of Sanming Integrated Traditional Chinese and Western Medicine Hospital. She reported symptoms of lower urinary system dysfunction, including urgency, frequency, and nocturia, along with chronic pelvic pain, and a persistent feeling of pressure and discomfort lasting over 8 years. The patient's visual analog scale (VAS) score for pelvic pain was 7 points prior to receiving acupuncture treatment. Throughout the day, she had more than 10 urinations, and at night, she urinated about once per hour. The O'Leary-Sant interstitial cystitis symptom index/interstitial cystitis problem index (ICSI/ICPI) score was 34 points, and the pelvic pain and urgency frequency (PUF) score was 19 points.

RESULTS

The patient's complaints were significantly alleviated after 12 sessions of electroacupuncture treatment at BL32, BL33, BL35, and SP6 over 4 weeks. The patient claimed total relief from pelvic pain, with a VAS score of 0. The patient achieved a PUF score of 4 points and an ICSI/ICPI score of 7 points. In addition, there was a significant reduction in the frequency and urgency of urination. The patient experienced a frequency of 4-5 urinations during the day and 1-2 times at night. Subsequently, the patient's mental state and sleep quality were improved. The patient's symptoms did not change at one-year follow-up.

CONCLUSION

Electroacupuncture has proven to be an effective management method for IC/BPS, as evidenced by the patient's alleviated lower urinary system symptoms and reduced pelvic pain.

Modified Botulinum Toxin Type A Injections Improve Symptoms Associated With Interstitial Cystitis/Bladder Pain Syndrome in Women: A Retrospective Cohort Study

OBJECTIVE

To investigate the efficacy and safety of modified botulinum toxin type A (BoNT-A) injections (with additional periurethral injection [PUI] of BoNT-A) for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

This single-center, retrospective cohort study included 52 adult female patients with IC/BPS, with 24 patients receiving conventional BoNT-A injections and 28 receiving modified BoNT-A injections. The primary outcome measure was patient-reported global response assessment. Secondary outcomes included daytime frequency, nocturia, number of urinary urgency episodes in the voiding diary, pain visual analog score, O'Leary-Sant interstitial cystitis symptom index and interstitial cystitis problem index, pelvic pain and urgency/frequency scores, risk factors for recurrence, and postoperative recurrence-free time.

RESULTS

The median duration of follow-up was 16.0 months (interquartile range 11.75-21 months). Patients who underwent modified BoNT-A injections showed significant improvement in postoperative global response assessment, symptom questionnaires, and pain assessment compared with those who underwent conventional surgery. A statistically significant difference was observed between the 2 groups in terms of recurrence-free time (12.5 vs 18.0 months, P = .02). Subgroup analysis suggested that additional PUI of BoNT-A was more effective in patients with combined severe periurethral pain. No serious complications occurred in both groups, and all minor postoperative complications were temporary.

CONCLUSION

Modified BoNT-A injection is an effective treatment for IC/BPS that significantly reduces pain and improves voiding symptoms. It is particularly effective in patients with combined periurethral pain. In such patients, PUI of BoNT-A should be added to the routine intravesical injection of BoNT-A.

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.

Prospective randomized controlled trial comparing fulguration versus fulguration and hydrodistension for Hunner-type interstitial cystitis/bladder pain syndrome

PURPOSE

In Hunner-type interstitial cystitis/bladder pain syndrome (IC/BPS), it is unclear whether suburothelial afferents underlying normal-appearing background areas contribute to symptom development. We examined whether adding hydrodistension (HD) to transurethral fulguration (TUF) of Hunner lesions, for the purpose of treating the background areas, is superior to TUF alone.

METHODS

This randomized controlled trial included 52 patients with Hunner-type IC/BPS allocated at a 1:1 (TUF:TUF+HD) ratio. HD was performed at 80 cmH₂O for 8 min before TUF in the TUF+HD group. Thirty-three patients remained until the end of the 6-month observational period. The primary endpoint was the visual analogue scale (VAS) pain score at 1 month. Major secondary endpoints were the treatment-failure rate, VAS pain scores at ≥ 2 months, and frequency-volume chart parameters.

RESULTS

Both TUF and TUF+HD showed significant improvement in VAS pain score at 1 month (95% confidence interval [CI]: - 1.62 to 0.16, P = 0.106). VAS pain scores were significantly lower in TUF+HD than TUF at 2 (95% CI: - 1.97 to - 0.28, P = 0.011), 4 (95% CI: - 2.83 to - 0.72, P = 0.002), and 6 (95% CI: - 3.11 to - 0.07, P = 0.040) months. Treatment-failure rate was higher in TUF (36.4%) than TUF+HD (17.4%), without significance (odds ratio: 2.714, 95% CI: 0.68 to 10.84, P = 0.189). Functional capacity and urgency were not significantly different between groups.

CONCLUSION

The addition of HD to TUF tended to be superior to TUF monotherapy for controlling pain in Hunner-type IC/BPS. This indicates that not only Hunner lesions but also normal-appearing background areas may have a role in the pain of IC/BPS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03987594, date of registration: 2019-06-17 (retrospectively registered).

Flavonoid Nobiletin Attenuates Cyclophosphamide-Induced Cystitis in Mice through Mechanisms That Involve Inhibition of IL-1β Induced Connexin 43 Upregulation and Gap Junction Communication in Urothelial Cells

Bladder inflammatory diseases cause various urinary symptoms, such as urinary frequency and painful urination, that impair quality of life. In this study, we used a mouse model of cyclophosphamide (CYP)-induced bladder inflammation and immortalized human urothelial (TRT-HU1) cells to explore the preventive potential of nobiletin (NOB), a polymethoxylated flavone enriched in citrus fruit peel, and investigate its mechanism of action in the bladder. Prophylaxis with PMF90 (60% NOB) attenuated the development of bladder inflammation and urinary symptoms in CYP-treated mice. PMF90 also reduced the upregulation of connexin 43 (Cx43), a major component of gap junction channels, in the bladder mucosa of CYP-treated mice. Stimulation of TRT-HU1 cells with the pro-inflammatory cytokine IL-1β increased Cx43 mRNA and protein expression and enhanced gap junction coupling-responses that were prevented by pre-treatment with NOB. In urothelium-specific Cx43 knockout (uCx43KO) mice, macroscopic signs of bladder inflammation and changes in voiding behavior induced by CYP treatment were significantly attenuated when compared to controls. These findings indicate the participation of urothelial Cx43 in the development of bladder inflammation and urinary symptoms in CYP-treated mice and provide pre-clinical evidence for the preventive potential of NOB through its anti-inflammatory effects on IL-1β signaling and urothelial Cx43 expression.

Chronic bladder diseases: overactive bladder and interstitial cystitis/bladder pain syndrome

Background: Overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS) are debilitatingchronic bladder diseases that affect patients’ quality of life. Their etiologies and clinical phenotypes vary, and management strategies should be selected after excluding the possibilities of other pathological conditions with careful consideration of a multidisciplinary integrated approach to ensure optimal success.Current Concepts: OAB is a symptom complex characterized by urinary urgency and frequency and nocturia with or without urge incontinence, and its key symptom is urinary urgency. IC/BPS has symptoms similar to lower urinary tract symptoms (LUTS) associated with OAB but also has distinctly different symptoms, including the key symptom of an unpleasant sensation or pain perceived to be related to the urinary bladder associated with LUTS. Recent studies have revealed that these key symptoms of OAB or IC/BPS are also observed in some patients with other diseases. Patients showing no evidence of bacterial infection on urine culture and experiencing LUTS or pain for more than 6 weeks should be considered as having OAB or IC/BPS. Treatment strategies for OAB and IC/BPS focus on managing LUTS and bothersome pain. Noninvasive management should be considered initially, whereas surgical options should be considered only after conservative treatment failure.Discussion and Conclusion: OAB and IC/BPS symptoms overlap considerably in many patients. A more accurate differentiation of symptoms, including LUTS, would help achieve better treatment outcomes.

Optimising the management of bladder pain syndrome

Objective:

Clinicians have shown variable practice in the diagnosis and management of bladder pain syndrome (BPS). This study assessed pain localisation sites, common co-morbidities, investigations and treatment patterns in clinical practice.

Patients and methods:

We performed a retrospective analysis of 412 patients attending our pelvic pain clinic between 2004 and 2016. Frequency counts were used to summarise findings.

Results:

Pain in women ( N=388) was localised to the lower abdomen (92.0%), lower back (71.1%) and vagina (60.8%). Men ( N=24) typically presented with testicular pain with painful ejaculation (70.8%). Nearly all (95.4%) patients reported sexual dysfunction. Visceral neuropathic pain and autoimmune co-morbidities, such as irritable bowel syndrome, chronic headaches or migraines and skin lesions, were more prevalent in our cohort than in the general population. All patients had urine culture and sensitivities and flexible cystoscopy. Laparoscopy, urodynamic studies and bladder biopsies were mostly normal, but were essential in excluding other pathologies. Good pain control was achieved on amitriptyline (83.0%). Hydro-distension and benign bladder ulcer cauterisation provided temporary symptomatic relief.

Conclusion:

This study demonstrates that patient expectation management and education is essential in BPS, with most achieving good pain control with conservative measures and amitriptyline. Those receiving intravesical treatments will most likely require subsequent revisions.

Level of evidence:

Not applicable for this single-centre audit.

Comparison of bladder autoaugmentation by transurethral vesicomyotomy and hydrodistention for ketamine cystitis

Background

To illustrate the bladder autoaugmentation by transurethral vesicomyotomy (BATV) and compare the efficacy and safety of BATV to bladder hydrodistention (BH) for managing ketamine cystitis (KC).

Methods

We retrospectively analyzed clinical data for 53 patients with KC who received surgical intervention between 2014 and 2019 at our hospital. Of these, 41 (77.4%) underwent BH and 12 (22.6%) were subjected to BATV, with a minimum of 1-year follow-up. These groups were compared with reference to urodynamic parameters, subjective symptom scores as well as all complications.

Results

Both groups were matched in age, addiction time, preoperative urodynamic parameters, postvoid residual urinary volume (PVR), and symptom scores. All urodynamic parameters including maximum cystometric capacity (MCC), maximum detrusor pressure (P_{det max}), compliance, maximum urinary flow rate (Q_max) and symptom scores had improved significantly in two groups whether at 3 or 12 months. Moreover, the MCC was significantly increased after BATV than BH, at a mean [standard deviation (SD)] of 281.0 (25.7) vs. 213.5 (35.6) mL (P<0.001) at 12-month follow-up. The Q_max and the Pelvic Pain and Urgency/Frequency (PUF) symptom score were still noted better in the BATV group at 3 months after surgery. Additionally, patients in both groups had similarly low rates of complications.

Conclusions

BATV is superior to BH with increased bladder capacity and urodynamic outcomes, although showing equivalent in symptom relief and a similar rate of complications.

Long-term outcomes of ulcerative interstitial cystitis after complete transurethral resection with therapeutic hydrodistention

PURPOSE

We analyzed the long-term efficacy of simultaneous transurethral resection (TUR) and therapeutic hydrodistention in patients with ulcerative interstitial cystitis (IC) who did not experience recurrence on long-term follow-up.

METHODS

We studied 132 female patients (mean age = 56.45 ± 11.56 years) who underwent TUR followed by hydrodistention to treat ulcerative IC between January 2010 and January 2017, and who were available for follow-up, for more than 36 months (mean = 52.3 ± 10.51 months). Of the 132 patients, those who did not suffer recurrence within 36 months after surgery were allocated to group I and those who had a recurrence within the same period were assigned to group II. Preoperative factors, including age, were compared between the groups. In group I, improvements in pain and voiding symptoms were recorded using a 10-point visual analog pain scale (VAS) and a 3-day micturition chart. A global response assessment (GRA) was used to evaluate patient satisfaction.

RESULTS

In group II, the maximum functional bladder capacity (FBC) was smaller, and voiding frequency was higher, than in group I. Follow-up of patients in group I for more than 3 years showed that pain decreased after surgery. The 10-point VAS scores were 9.68 before surgery, and 1.54, 0.93, 0.55, and 0.46 at 1, 6, 12, and 36 months after surgery (p < 0.001), respectively. Maximum FBCs were 174.82 mL before surgery and 237.14, 250.71, and 254.46 mL at 1, 12, and 36 months after surgery (p < 0.001), respectively; thus, FBC increased after surgery. Urination frequency decreased significantly after surgery; the number of daily urinations was 12.77 before surgery, and 9.88, 9.21, and 9.25 at 1, 12, and 36 months after surgery (p < 0.001), respectively. Overall patient satisfaction improved after surgery; the GRA scores were 2.39, 2.71, and 2.8 points at 1, 12, and 36 months after surgery (p < 0.001), respectively.

CONCLUSION

Upon simultaneous performance of TUR and therapeutic hydrodistention in patients with ulcerative IC, 49.2% showed favorable outcomes for 3 years.

Therapeutic Endoscopic Treatment Plus Maintenance Dimethyl Sulfoxide Therapy Prolongs Recurrence-Free Time in Patients With Hunner Type Interstitial Cystitis: A Pilot Study

Purpose

To evaluate whether hydrodistention with fulguration of Hunner lesions (HD/FUL) plus maintenance dimethyl sulfoxide (DMSO) therapy prolongs the recurrence-free time in patients with Hunner type interstitial cystitis (IC).

Methods

The study enrolled patients with Hunner type IC who required repeat HD/FUL due to recurrence of IC symptoms after the first HD/FUL at our institution. All patients received a second HD/FUL plus maintenance DMSO therapy. The maintenance DMSO therapy was performed every 2 weeks for a total of 8 instillations, and then once every 4 weeks thereafter. The recurrencefree time from HD/FUL to therapeutic failure was estimated using the Kaplan-Meier method. The recurrence-free time between the first HD/FUL and second HD/FUL plus maintenance DMSO therapy was statistically compared using the log-rank test.

Results

A total of 21 patients (mean age, 66.3±10.8 years) with Hunner type IC were evaluated. The recurrence-free time for the second HD/FUL plus maintenance DMSO therapy was significantly longer than that for the first HD/FUL (P<0.0001). The median recurrence-free time for the first HD/FUL was 10.1 months, while that for the second HD/FUL plus maintenance DMSO therapy has yet to be reached. The recurrence-free rate for the first HD/FUL was 81.0% at 6 months, 38.1% at 1 year, 9.5% at 2 years, and 4.8% at 3 years. In contrast, the rate for the second HD/FUL plus maintenance DMSO therapy was 100% at 6 months, 94.7% at 1 year, 82.6% at 2 years, and 82.6% at 3 years. There were no significant differences in efficacy between the first and second HD/FUL.

Conclusions

HD/FUL plus maintenance DMSO therapy clearly prolongs the recurrence-free time compared with HD/FUL alone in Hunner type IC.

Hyaluronic acid improves pain symptoms more than bladder storage symptoms in women with interstitial cystitis

OBJECTIVE

Intravesical hyaluronic acid (HA) therapy is one of acceptable methods to treat bladder pain and storage symptoms (i.e., urgency, frequency and nocturia) of interstitial cystitis/bladder pain syndrome (IC/BPS). We aim to assess the impacts of intravesical HA on bladder pain and storage symptoms, respectively, and to investigate their associated factors in patients with IC/BPS.

MATERIALS AND METHODS

In this prospective, multicenter study, 103 women with refractory IC/BPS undergoing a standard protocol of intravesical HA therapy were enrolled. A pain Visual Analog Scale (VAS) and the Interstitial Cystitis Symptom and Problem Index (ICSI & ICPI) were used to assess symptoms and bother associated with IC/BPS. The Scaled Global Response Assessment (GRA) was used to evaluate patients' perception of overall changes in bladder pain and storage symptoms, respectively, after treatment.

RESULTS

Mean age of participants was 43.6 ± 11.8 years. The average duration of symptoms was 5.1 ± 5.0 years. Significant improvements in pain VAS, ICSI and ICPI scores were observed after treatment. However, patients reported significantly different rates of moderate/marked improvement in bladder pain and storage symptoms (73.8% vs. 47.6%; P < 0.001) on the GRA, respectively. "Lower pain VAS score" and "reduced functional bladder capacity" were found to be the factors that adversely affected the treatment responses of bladder pain and storage symptoms, respectively, after repeated statistical analyses.

CONCLUSION

Bladder instillation of HA seemed more efficient in improving bladder pain than storage symptoms associated with IC/BPS. The persistence of bladder storage symptoms after treatment might result from a reduced functional bladder capacity.

Potassium sensitivity test predicts hydrodistention efficacy in patients with bladder pain syndrome/interstitial cystitis

OBJECTIVE

To determine the possible role of potassium sensitivity test (PST) in predicting the success of hydrodistention (HD) in patients with bladder pain syndrome/interstitial cystitis (BPS/IC).

MATERIAL AND METHODS

Patients who underwent PST before diagnostic cystoscopy and HD were evaluated to collect data regarding the visual analog score (VAS) to assess pain, the voiding diary for frequency of urination/nocturia, mean urine volume per void, interstitial cystitis symptom index, and problem index before HD. Patients were requested to provide the VAS of pain at 1 month and 6 months post-HD. A reduction 2 or more on the VAS of pain was considered as a response adequate to be noted.

RESULTS

The median age of the patients was 46 years. The PST was positive for 27 patients (27/39; 69.2%). At 1 month post-HD, out of the 27 patients with positive PST, 23 (85.2%) were found to have been responsive to HD and 4 (14.8%) were non-responsive. Of the 12 (12/39; 30.8%) patients who showed a negative PST, 7 (58.3%) were non-responsive and 5 (41.7%) were responsive to HD. A logistic regression analysis revealed that PST (p=0.009) was the only parameter that was able to predict HD efficacy at 1 month post-HD.

CONCLUSION

PST was found to be a predictive factor for the short-term efficacy of HD. BPS/IC patients with positive PST are likely to be more susceptible to the damage of mucosal afferent nerve endings, which results in them benefiting from HD to a greater degree.

Identification of experimental bladder sensitivity among dysmenorrhea sufferers

BACKGROUND

Dysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction.

OBJECTIVE

We sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome.

STUDY DESIGN

We compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures.

RESULTS

Women with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0-100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R² = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R² = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain.

CONCLUSION

Women experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.

A systematic review of the literature on cystodistension in bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

There is significant variability in technique for cystodistension and an international discrepancy in the role in its treatment of bladder pain syndrome (BPS). The authors evaluate the evidence base for the use of cystodistension for BPS with particular reference to patient-related outcomes.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, a prospective search and evaluation protocol was prepared and registered with the PROSPERO database (ID CRD42017053710). A review of the literature was performed using the search terms cystodistension and hydrodistension of the bladder using the PubMed database on 6 October 2016.

RESULTS

A total of 59 papers were reviewed, but only 17 studies contained original data available for analysis from 1975 to 2016. Ten studies evaluated the outcome of cystodistension in a single arm design or used cystodistension as the control for evaluating adjunctive treatments. Seven studies evaluated cystodistension in combination with other agents or therapies. The best symptomatic responses reported a subjective improvement in 56% of men with moderate to severe prostatitis and 57% in patients with "inflammatory cystitis" respectively. There were no studies that employed a validated outcome measure, neither a questionnaire nor an analogue scale, to assess the effect of cystodistension alone.

CONCLUSIONS

Cystodistension is increasingly popular, despite a weak evidence base by current standards. The quality of available evidence falls below the level that would be expected of a new intervention. This review highlights the need for cystodistension to be further investigated with randomised control trials.

Effective treatment of ketamine-associated cystitis with botulinum toxin type a injection combined with bladder hydrodistention

Objective Ketamine-associated cystitis (KAC) has been described in a few case reports, but its treatment in a relatively large number of patients has not been documented. This study aimed to describe our experience of treatment of 36 patients with KAC. Methods Thirty-six patients (30 males and 6 females, aged 19-38 years) with KAC, who had previously taken a muscarinic receptor blocker and/or antibiotics, but without symptomatic relief, were treated with botulinum toxin A injection combined with bladder hydrodistention. Urodynamic testing, and the O'Leary-Sant interstitial cystitis symptom index (ICSI) and problem index (ICPI) were used to evaluate baseline values and improvement before and after the treatment. Results One month post-treatment, all patients achieved marked relief of symptoms. The nocturia time was markedly reduced, while bladder capacity, the interval between micturition, the void volume, and the maximum flow rate were remarkably increased at 1 month. Additionally, the ICSI and ICPI were significantly improved. Conclusion Botulinum toxin A injection along with bladder hydrodistention is effective for managing KAC.

Efficacy and safety of bladder hydrodistension for decreased bladder capacity induced by intravesical BCG therapy

OBJECTIVE

Intravesical BCG therapy is widely used for the treatment of high-risk, non-muscle-invasive bladder cancer. Among various reported side-effects, decreased bladder capacity is a serious side-effect that significantly worsens patients' quality of life. This article reports the efficacy and safety of bladder hydrodistension (BHD) in six patients with seriously decreased bladder capacity caused by BCG treatment.

METHODS

Six patients with low bladder capacity (<100 ml in voiding diaries) and complaint of grade 3 irritative symptoms were diagnosed with decreased bladder capacity and treated with BHD. Alleviation of symptoms was defined as medication being discontinued or reduced after BHD.

RESULTS

Five patients were male and one was female, and the mean age was 67.7 years. The mean interval between the last transurethral resection and BCG therapy was 26.0 days. Before BHD, all patients had been treated with antibiotics, anticholinergics and non-steroidal anti-inflammatory drugs (NSAIDs). The median bladder capacity before treatment was 40 ml (range 30-100 ml), and the median capacity increased to 200 ml (175-250 ml) within 2 weeks following BHD therapy. Four patients stopped NSAID use and three patients stopped anticholinergic use. One patient needed total cystectomy for recurrent symptoms. With a median follow-up period of 32 months, the bladder capacity remained stable without symptomatic deterioration in the remaining five patients. There was neither tumor spread nor disseminated tuberculosis infection.

CONCLUSIONS

BHD appears to be an effective treatment option in patients with severely decreased bladder capacity. Its efficacy and safety were acceptable.

Transurethral Resection Alone Vs Resection Combined With Therapeutic Hydrodistention as Treatment for Ulcerative Interstitial Cystitis: Initial Experience With Propensity Score Matching Studies

OBJECTIVE

To compare the therapeutic efficacy of transurethral resection (TUR) alone with that of TUR combined with therapeutic hydrodistention in patients with ulcerative interstitial cystitis (IC).

METHODS

The study subjects were 44 female patients newly diagnosed with IC who underwent TUR to treat ulcerative IC and who were available for follow-up, without recurrence of disease for 12 months. We retrospectively studied both patients who underwent TUR alone (group I) and those who underwent TUR combined with therapeutic hydrodistention (group II). Improvements in pain and voiding symptoms were retrospectively evaluated using a 10-point visual analog scale for pain and a 3-day micturition chart.

RESULTS

Group I included 22 patients and group II included 22 patients of mean ages 58.45 ± 11.01 and 56.27 ± 11.86 years, respectively. Use of a 10-point visual analog scale showed that pain decreased after the procedures in both groups, but the improvement did not differ between groups. The maximum functional bladder capacities of patients in group I were 161.36, 192.47, and 204.12 mL, respectively, before, at 6 months, and at 12 months after the operation; the maximum functional bladder capacities of patients in group II were 175.45, 263.14, and 291.17 mL, respectively. The voiding frequencies of group I were 12.59, 10.67, and 9.89 times daily, respectively, before, at 6 months, and at 12 months after the operation; the voiding frequencies of group II were 12.95, 9.5, and 8.29 times daily, respectively.

CONCLUSION

TUR combined with therapeutic hydrodistention increased bladder capacity and improved voiding symptoms more so than did TUR alone for ulcerative IC.

Hydrodistension with or without fulguration of hunner lesions for interstitial cystitis: Long-term outcomes and prognostic predictors

AIMS

Hydrodistension of the bladder, with optional fulguration of Hunner lesions, is one of the recommended therapies for interstitial cystitis (IC). The aims of this study are to evaluate long-term outcomes of hydrodistension and identify outcome predictors.

METHODS

The study cohort was 191 newly diagnosed IC patients (155 women and 36 men) who underwent hydrodistension with fulguration of Hunner lesions if detected between 2007 and 2013 at our institution. The primary outcome was therapeutic failure, which was defined as repeat hydrodistension, bladder instillation therapy, or narcotic use for pain control. Clinical features, including comorbidities and endoscopic findings, were analyzed along with the outcome.

RESULTS

The cohort comprised 126 patients of Hunner type IC and 65 patients of non-Hunner type IC. The mean time to therapeutic failure was 28.5 months in Hunner type IC and 25.2 months in non-Hunner type IC. The therapeutic failure rate was higher in non-Hunner type IC at 17.3 months; however, the long-term outcomes reversed thereafter. The mean time to therapeutic failure was shorter in patients with lumbar spinal stenosis (LSS) or irritable bowel syndrome (IBS). Multivariate analysis identified LSS as a predictor for failure in Hunner type IC and non-Hunner type IC (HR = 18.8, P = 0.001; HR = 3.8, P = 0.028, respectively) and IBS in non-Hunner type IC (HR = 18.0, P = 0.008).

CONCLUSIONS

Bladder hydrodistension, with fulguration of the Hunner lesions, improved IC symptoms. The outcome was worse in non-Hunner type IC shortly after hydrodistension but eventually comparable across the two types. Concomitant LSS and IBS were predictors for poor outcome. Neurourol. Urodynam. 35:965-969, 2016. © 2015 Wiley Periodicals, Inc.

Botulinum toxin type A injection for refractory interstitial cystitis: A randomized comparative study and predictors of treatment response

OBJECTIVES

To determine whether botulinum toxin type A can represent an alternative treatment option for patients with interstitial cystitis refractory to conventional therapies.

METHODS

This is a single-center, prospective, open labeled, randomized comparative study. Patients with refractory interstitial cystitis were randomly divided into two groups: immediate injection (group A) or 1-month delayed injection (group B) of botulinum toxin type A after allocation. The rate of treatment response (global response assessment ≥+1: slightly improved), and changes in symptom scores and frequency volume chart variables were compared between groups 1 month after allocation. Using subjects of both groups as a single cohort, predictive factors for treatment response at 1 month post-injection and the duration of response were explored.

RESULTS

A total of 34 patients (group A n = 18, group B n = 16) were allocated. The response rate was significantly higher in group A than group B (72.2% vs 25.0%, P = 0.01). All symptom measures showed significant improvement in group A than group B. When both groups were combined as a single cohort, the response rate was 73.5% at 1 month, 58.8% at 3 months, 38.2% at 6 months and 20.6% at 12 months. The mean duration of response was 5.4 months. Multivariate analysis showed that past exposure to hydrodistension more than three times correlated with better outcomes.

CONCLUSIONS

Botulinum toxin type A injection could be an alternative treatment option for patients with interstitial cystitis refractory to conventional therapies, especially for those who have received repeated hydrodistensions and transurethral fulguration.

Grading of evidence for bladder pain syndrome: a comparative review of study quality assessment methods

INTRODUCTION AND HYPOTHESIS

Clinical guidelines on bladder pain syndrome (BPS) report quality ratings for evidence based on study design. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system takes into account several domains in addition to limitations of study design for assigning quality ratings. We compared the quality of evidence described in current BPS literature.

METHODS

All existing systematic reviews and guidelines on BPS management were reviewed, and included evidence was rated according to GRADE on a four-point scale (1-4, from very low to high). These ratings were compared to the two reported quality assessments that assigned levels or strengths to evidence; both had a four-point scale: level of evidence 1-4 from meta-analysis of randomised studies to expert opinion; and strength of evidence 1-4 from very low to high.

RESULTS

Of the 19 treatments for BPS with GRADE ratings, comparison with level of evidence ratings showed that, on average, the latter overestimated quality by 1.8 points [1.1 v 2.9; 95% confidence interval (CI) 1.2-2.3; p = <0.0001). Comparison of GRADE ratings with strength of evidence ratings showed that, on average, the latter overestimated quality by 1.7 points (1.1 v 2.8; 95% CI 1.3-2.1; p = <0.0001).

CONCLUSION

GRADE, a refined method of assigning quality to evidence, provided a more conservative gauge, giving a realistic assessment of the value of recommendations for consideration in practice.

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.

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.

Risk factors that affect the treatment of interstitial cystitis using intravesical therapy with a dimethyl sulfoxide cocktail

INTRODUCTION AND HYPOTHESIS

Dimethyl sulfoxide (DMSO) bladder instillation is a standard therapy for interstitial cystitis (IC); however, there are varying degrees of success. We hypothesize that first-line intravesical therapy with a DMSO cocktail will optimize treatment outcome.

METHODS

Ninety women with newly diagnosed IC were enrolled consecutively for the treatment. The IC symptom and problem index was used as an outcome measure.

RESULTS

Six (6.7%) patients dropped out of the treatment due to intolerable bladder irritation. Fifty-five (65.5%) of the remaining 84 patients, who completed the treatment, experienced ≧50% symptomatic improvement. After a regression analysis, three clinical variables were found to affect treatment adversely, i.e., the presence of advanced cystoscopic glomerulations, microscopic hematuria, and urodynamic detrusor underactivity, respectively.

CONCLUSIONS

Our results suggest bladder instillation with a DMSO cocktail may well be considered as first-line therapy for IC patients. However, there exists a subgroup of nonresponders who may have severe disease.

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.

Caudal clonidine-bupivicaine block with bladder hydrodistension: a novel combined treatment for the painful bladder

The authors describe a new combination procedure consisting of bladder hydrodistension with clonidine-bupivicaine caudal block for the symptomatic relief of bladder pain. They report this new technique whereby patients who had tried multiple forms of therapy with little response, including bladder hydrodistension under general anaesthesia for their chronic pelvic bladder pain, responded to this novel combination therapy.

AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome

PURPOSE

To provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® database (search dates 1/1/83-7/22/09) was conducted to identify peer reviewed publications relevant to the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Insufficient evidence-based data were retrieved regarding diagnosis and, therefore, this portion of the Guideline is based on Clinical Principles and Expert Opinion statements. The review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. These publications were used to create the majority of the treatment portion of the Guideline. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. See text and algorithm for definitions, and detailed diagnostic management, and treatment frameworks.

RESULTS

The evidence-based guideline statements are provided for diagnosis and overall management of interstitial cystitis/bladder pain syndrome as well as for various treatments. The panel identified first through sixth line treatments as well as developed guideline statements on treatments that should not be offered.

CONCLUSIONS

Interstitial cystitis/bladder pain syndrome is best identified and managed through use of a logical algorithm such as is presented in this Guideline. In the algorithm the panel identifies an overall management strategy for the interstitial cystitis/bladder pain syndrome patient. Diagnosis and treatment methodologies can be expected to change as the evidence base grows in the future.

Hydrodistension under local anesthesia for patients with suspected painful bladder syndrome/interstitial cystitis: safety, diagnostic potential and therapeutic efficacy

OBJECTIVES

To evaluate the safety, diagnostic potential and therapeutic efficacy of cystoscopy with hydrodistension under local anesthesia in patients with suspected painful bladder syndrome/interstitial cystitis (PBS/IC).

METHODS

Thirty-six patients with frequency, urgency or bladder pain for > or = 6 months and an average voided volume of <200 mL were enrolled in the study. Hydrodistension was carried out 10 min after instillation of 10 mL of 4% lidocaine. The instilled saline volume for hydrodistension was determined based on each patient's level of tolerance of urinary sensation and symptoms.

RESULTS

Overall, 30 patients (median age 54 years, range 25-76) were evaluated. The median instilled saline volume was 450 mL (250 to 580 mL). No patients were admitted to hospital due to adverse events associated with hydrodistension. Glomerulation was found in 23 patients and two had Hunner's ulcers. Therapeutic efficacy at one month after hydrodistension was shown in 21/30 patients (71%). A median efficacy period of 20 + or = 3.7 weeks was determined by Kaplan-Meier analysis. Factors with an independent influence on therapeutic efficacy of hydrodistension were not identified, but patients with an instilled volume greater than the median volume had significantly longer efficacy periods (P < 0.022).

CONCLUSIONS

Cystoscopy with hydrodistension under local anesthesia provides a simple and safe method for differential diagnosis and has some therapeutic efficacy in patients with suspected PBS/IC.

[Interstitial cystitis in 2008]

Interstitial cystitis (IC) is a chronic, debilitating condition that is often associated with late diagnosis and a delay in initiation of appropriate IC-specific therapy. The typical patient with interstitial cystitis (IC) is symptomatic for many years and consults multiple physicians before IC is diagnosed. These observations suggest that the clinical presentation of IC is not widely recognized. The resultant underdiagnosis may be explained in part by the nonspecific nature of IC symptoms, such as urinary urgency, frequency, nocturia and pain, as well as by the lack of an objective diagnostic test. Pelvic pain of bladder origin may refer to pain in any location in the pelvis, is affected by the menstrual cycle and flares with sexual intercourse. As a result of variations in disease definition and diagnostic criteria for interstitial cystitis (IC), the performance of epidemiologic studies has been challenging. The true prevalence of IC is much greater than the early studies suggested. Over the last decade, the recognized prevalence of IC has increased and it is consistently greater among women as compared to men.

Treatment of chronic pelvic pain in men and women

Chronic pelvic pain syndrome (CPPS) is a common condition that is encountered by a variety of healthcare professionals. Unfortunately, physicians often misdiagnose this problem or recommend inappropriate and sometimes dangerous treatments that offer little hope of successful outcome. In addition, CPPS is typically a multifaceted disorder, simultaneously compromising psychological, peripheral nerve, autonomic, central nervous, visceral, connective tissue, hormonal and other systems. Thus, solo practitioners who may correctly diagnose CPSS are often ill-equipped to provide adequate comprehensive, multidisciplinary treatment. This article is intended as an overview of the most recent literature in support of various treatment modalities for chronic pelvic pain in men and women. We advocate a team-oriented approach in the treatment of CPPS, which employs the coordinated efforts of multiple practitioners, ideally in a subspecialty care setting.

Interleukin-6, histamine, and methylhistamine as diagnostic markers for interstitial cystitis

OBJECTIVES

To examine the specificity and sensitivity of the inflammatory markers histamine, methylhistamine, and interleukin-6 (IL-6) in the urine of patients with interstitial cystitis compared with that in healthy controls.

METHODS

A total of 40 women with interstitial cystitis and 29 healthy controls collected 24-hour urine samples. During the 24 hours before urine collection, all participants refrained from consuming foods and medications that could contain bioactive amines. Methylhistamine and histamine were measured using radioimmunoassay kits and were normalized to urinary creatinine levels; IL-6 was measured using enzyme-linked immunosorbent assay. The data were analyzed by t tests, logistic regression analysis, and receiver operating characteristics.

RESULTS

IL-6 and histamine were significantly greater in the patients with interstitial cystitis than in the controls (P = 0.0003 and P = 0.038, respectively). The methylhistamine levels were also greater in the patients with interstitial cystitis than in the controls, but the results did not reach significance (P = 0.063). Using a combination of IL-6 and methylhistamine/creatinine, cutoff points were established. Using these cutoff points, the sensitivity was 70.0%, specificity 72.4%, positive predictive value 77.8%, and negative predictive value 63.6%.

CONCLUSIONS

All three markers--histamine, methylhistamine, and IL-6--were greater in the patients with interstitial cystitis than in the controls. A combination of methylhistamine and IL-6 could be used as a sensitive and specific marker for interstitial cystitis.

Interstitial cystitis

Interstitial cystitis is an enigmatic and frustrating condition to manage as a physician and to cope with as a patient. Traditionally, it has been defined as a chronic sterile inflammatory disease of the bladder of unknown aetiology. However, the International Continence Society prefers the term painful bladder syndrome and it has been decided to follow this terminology and refer to the disease as painful bladder syndrome/interstitial cystitis (PBS/IC). The condition is characterized by bladder pain, urinary frequency, urgency and nocturia. The quality of life of patients with PBS/IC is significantly degraded. Its aetiology is unknown, but might involve microbiologic, immunologic, mucosal, neurogenic and other yet unidentified agents. History, physical examination, urine analysis and culture as well as cystoscopy and hydrodistension are useful diagnostic tools but the final diagnosis tends to be a diagnosis of exclusion. This article will review the major theories of aetiology for PBS/IC and discuss diagnosis as well as the current treatment options with relevance to the proposed aetiologies.

How do you stretch a bladder? A survey of UK practice, a literature review, and a recommendation of a standard approach

AIMS

To assess how and why hydrodistension of the bladder is performed by UK urologists and to compare this practise with the published literature on distension. To suggest a standardised technique for hydrodistension to allow comparison of diagnostic and therapeutic studies.

METHODS

A questionnaire was sent to all UK consultant urologists. Questions addressed the indications for short bladder distension (SBD), details of technique, evaluation of outcome, and awareness of evidence base. The literature on bladder distension was reviewed.

RESULTS

The majority of respondents perform SBD, principally in the diagnosis and therapy of interstitial cystitis (IC). There was considerable variation in the duration of distension, repetition of distension, the pressure used for distension, and the measurement of bladder capacity. The literature on the technique of hydrodistension is imprecise and no respondent was able to cite literature to support his or her practice. We suggest a simple, more objective technique for performing hydrodistension.

CONCLUSIONS

SBD is widely used. There is marked variability in technique and little more than anecdotal evidence to support any particular approach. Research into the evaluation and treatment of painful bladder syndrome in general and IC in particular would be facilitated by the adoption of a standardised technique.