Interstitial cystitis and the gynecologist

Squamous cell carcinoma of the bladder mimicking interstitial cystitis and voiding dysfunction

Squamous cell carcinoma (SCC) of the bladder is a relatively uncommon cause of bladder cancer accounting for <5% of bladder tumors in the western countries. SCC has a slight male predominance and tends to occur in the seventh decade of life. The main presenting symptom of SCC is hematuria, and development of this tumor in the western world is associated most closely with chronic indwelling catheters and spinal cord injuries. A 39-year-old Caucasian female presented with bladder and lower abdominal pain, urinary frequency, and nocturia which was originally believed to be interstitial cystitis (IC) but was later diagnosed as SCC of the bladder. Presentation of SCC without hematuria is an uncommon presentation, but the absence of this symptom should not lead a practitioner to exclude the diagnosis of SCC. This case is being reported in an attempt to explain the delay and difficulty of diagnosis. Background on the risk factors for SCC of the bladder and the typical presenting symptoms of bladder SCC and IC are also reviewed.

Symptom profile variability of interstitial cystitis/painful bladder syndrome by age

Study Type--Diagnostic (symptom prevalence). Level of Evidence 2b. What's known on the subject? And what does the study add? Symptom variability is profound in the population of patients diagnosed with interstitial cystitis and painful bladder syndrome because these diagnoses represent a very heterogeneous patient population. Recently, younger patients are being diagnosed with these pain syndromes, without any specific investigation into the symptoms they experience. We identified that patients diagnosed with interstitial cystitis and painful bladder syndrome have variable clinical symptom profiles depending on the age at the time of their diagnosis. Dyspareunia, external genitalia pain, urgency, frequency and dysuria were more common in younger patients whereas nocturia, urinary incontinence and the presence of Hunner's ulcers were more common in older patients. Better defining symptom profiles for patients at the time of evaluation may potentially aid in more accurate and expedited diagnosis of these conditions, particularly in the youngest patient population which is being recognized more commonly in recent times.

OBJECTIVE

• To investigate the clinical profile differences among patients with interstitial cystitis/painful bladder syndrome (IC/PBS) based upon age at the time of diagnosis from childhood into the geriatric age group.

METHODS

• An analysis of 268 patients with IC/PBS seen between 1990 and 2008 was performed. • Three age cohorts were analysed: <30 years, ≥30 years but <60 years, and ≥60 years of age at time of diagnosis. • Patient demographics, disease characteristics and IC/PBS-associated symptoms were compared across the three groups.

RESULTS

• Of the 268 patients, 60 were <30 years of age at the time of IC diagnosis (median 22, range 11-29), 105 were ≥30 but <60 years (median 48, range 30-59) and 103 patients were ≥60 years of age (median 69, range 60-88). • Of the patients in the youngest, middle and oldest age cohorts: 12.0, 42.0 and 39.8% had Hunner's ulcers, respectively (P<0.001). • Dyspareunia and external genitalia pain were more common in the youngest age cohort, P<0.001 and P=0.001, respectively. • Urinary urgency (P=0.033), frequency (P=0.006) and dysuria (P<0.001) were also more common in patients diagnosed before 30 years of age. • The reported rate of nocturia and urinary incontinence increased with age, P=0.002 and P<0.001, respectively.

CONCLUSIONS

• Patients with IC/PBS analysed across a wide spectrum of ages at time of diagnosis portrayed a unique symptom profile pattern. • Patients diagnosed at the youngest ages experienced significantly more urinary urgency, frequency, dysuria, dyspareunia and pain in their external genitalia. • Older patients had higher rates of nocturia, urinary incontinence and Hunner's ulcer disease.

Interstitial cystitis is an etiology of chronic pelvic pain in young women

STUDY OBJECTIVE

The prevalence of interstitial cystitis (IC) in young women, especially in those 18 years old or younger, is not well defined. This case series was performed to investigate IC as a cause of chronic pelvic pain (CPP) in young women.

DESIGN

Case series.

SETTING

University medical center.

PARTICIPANTS

Twenty-eight women with CPP, ages 13 to 25, who underwent concomitant laparoscopy and cystoscopy.

INTERVENTIONS

All subjects underwent concomitant diagnostic laparoscopy and cystoscopy with hydrodistension for evaluation of CPP. Charts were reviewed to discern preoperative symptoms, operative findings, and postoperative diagnoses.

MAIN OUTCOME MEASURE

Diagnosis of IC based on symptoms and cystoscopic findings.

RESULTS

All 28 women had CPP, 23 (82%) had dysmenorrhea, and 12 of 25 (48%) sexually active subjects had dyspareunia. Twenty-six subjects (93%) had urinary symptoms including frequency (75%), nocturia (32%), urgency (25%), and dysuria (18%). Eleven (39%) subjects were diagnosed with IC and 18 (64%) with endometriosis, including 7 (25%) subjects with both IC and endometriosis. Laparoscopic findings were normal in 6 (21%) subjects. Of the 26 subjects with urinary symptoms, 21 (81%) had findings on laparoscopy or cystoscopy. In this cohort of young women with chronic pelvic pain, urinary frequency and dyspareunia were significantly associated with the diagnosis of IC.

CONCLUSIONS

The results of this study suggest that interstitial cystitis is an etiology of CPP in young women. Evaluation of the bladder as an origin of pelvic pain is warranted in young women with CPP and urinary frequency or dyspareunia.

Interstitial cystitis

PURPOSE

To describe the pathophysiology, assessment, diagnosis, and management of interstitial cystitis.

DATA SOURCES

Selected professional publications and presentations.

CONCLUSIONS

Interstitial cystitis (IC) is a chronic and disabling condition. Symptoms include urinary frequency and urgency, pain, dyspareunia, and nocturia. It occurs primarily in women. Onset is predominately in adulthood although IC does occur in childhood. Bladder wall defects, auto-immune disorder, viral and/or bacterial infection, toxin exposure, pelvic floor dysfunction and inflammatory response are possible causes. Diagnosis is by history, physical examination, laboratory tests, and cystoscopic examination. The management of interstitial cystitis includes dietary changes, antihistamines, tricyclic antidepressants, oral and intravesicle glucosaminoglycans, hydrodistention, pain management and emotional support.

IMPLICATIONS FOR PRACTICE

Nurse practitioners need to be knowledgeable about the occurrence and debilitating effect of IC. Inclusion of IC into the differential diagnoses related to urgency, frequency, and abdominal pain will help assure the timely and effective diagnosis and management of this unusual disease.

Pathophysiology of interstitial cystitis

Despite being described over 80 years ago, interstitial cystitis remains a disease of undetermined aetiology and poor treatment outcomes. Generally agreed diagnostic criteria of this condition, which occurs primarily in females, are frequency, urgency and pain, a low-capacity hypersensitive bladder, and mucosal haemorrhages and tearing on bladder distention. Although current theories of pathophysiology are predominantly conjecture, important elements of the disease process are increased afferent and efferent neuronal activity, an excess of inflammatory mediators, increased epithelial permeability and possibly reduced bladder vascularity. Improved treatment outcome will follow a better understanding of pathophysiology.

Causes of chronic pelvic pain

Chronic pelvic pain (CPP) is a common and debilitating condition, and yet remarkably little is known about what causes the pain. In this chapter we present a model of CPP which emphasizes the multifactorial nature of the problem. A range of physical causes are discussed, including endometriosis, pelvic inflammatory disease (PID), adhesions, irritable bowel syndrome, interstitial cystitis, musculo-skeletal factors and nerve-related pain. The role of the nervous system in the genesis and moderation of pain is explored. The importance of psychological factors is discussed, both as a primary cause of pain and as a factor which affects the pain experience. As with other chronic syndromes, the biopsychosocial model offers a way of integrating physical causes of pain with psychological and social factors.

Activation of the kallikrein kinin system in interstitial cystitis

PURPOSE

We investigated whether the kallikrein kinin system is activated in interstitial cystitis by measuring urinary excretion rates of kinin peptides, active and total kallikrein, and the kininase neutral endopeptidase in women with interstitial cystitis. We compared these excretion rates to a control group of women with stress incontinence and normal bladder function.

MATERIALS AND METHODS

Catheter urine was collected from subjects during a water diuresis (approximately 10 ml. per minute) before and after distention of the bladder with 100 ml. water. The contribution of the bladder wall to urinary kinins was assessed by measuring the change in kinin levels after 2 minutes of bladder stasis before and after distention.

RESULTS

Absolute bradykinin and kallidin excretion rates were similar in women with interstitial cystitis and control subjects. Two minutes of bladder stasis after bladder distention increased urinary bradykinin (p = 0.02) but not kallidin excretion rates. Active and total kallikrein excretion rates were similar in patients with interstitial cystitis and control subjects. Neutral endopeptidase excretion rates were reduced in the initial urine collection from subjects with interstitial cystitis but were similar in both groups during later collection periods.

CONCLUSIONS

These data provide evidence for increased bradykinin levels in the bladder wall of subjects with interstitial cystitis, which may be due in part to reduced neutral endopeptidase levels. These increased bradykinin levels may participate in the pathogenesis and symptomatology of interstitial cystitis.