Clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome

Wnt/β-catenin signaling inhibits oxidative stress-induced ferroptosis to improve interstitial cystitis/bladder pain syndrome by reducing NF-κB

BACKGROUND

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a bladder syndrome of unknown etiology. Reactive oxygen species (ROS) plays a major role in ferroptosis and bladder dysfunction of IC/BPS, while the role of ferroptosis in IC/BPS progression is still unclear. This study aims to investigate the role and mechanism of ROS-induced ferroptosis in IC/BPS using cell and rat model.

METHODS

We collected IC/BPS patient bladder tissue samples and established a LPS-induced IC/BPS rat model (LRM). The expression of oxidative stress and ferroptosis in IC/BPS patients and LRM rats were analyzed. Function and regulatory mechanism of ferroptosis in IC/BPS were explored by in vitro and in vivo experiments.

RESULTS

The patients with IC/BPS showed mast cells and inflammatory cells infiltration in bladder epithelial tissue. Expression of NRF2 was up-regulated, and GPX4 was decreased in IC/BPS patients compared with normal tissues. IC model cells undergo oxidative stress, which induced ferroptosis. These above results were validated in LRM rat models, and inhibition of ferroptosis ameliorated bladder dysfunction in LRM rats. Wnt/β-catenin signaling was deactivated in IC/BPS patients and animals, and activation of Wnt/β-catenin signaling reduced cellular free radical production thereby inhibited ferroptosis in IC model cells. Mechanistically, Wnt/β-catenin signaling pathway inhibited oxidative stress-induced ferroptosis by down-regulating NF-κB, thus contributing to recover IC/BPS both in vitro and in vivo.

CONCLUSIONS

We demonstrate for the first time that oxidative stress-induced ferroptosis plays an important role in the pathology of IC/BPS. Mechanistically, Wnt/β-catenin signaling suppressed oxidative stress-induced ferroptosis by down-regulating NF-κB to improve bladder injury in IC/BPS.

Urine biomarker could be a useful tool for differential diagnosis of a lower urinary tract dysfunction

A precision diagnosis of lower urinary tract dysfunctions (LUTD) such as bladder outlet obstruction, detrusor overactivity (DO), interstitial cystitis/bladder pain syndrome (IC/BPS), dysfunctional voiding (DV), or detrusor underactivity (DU) needs invasive videourodynamic study. Exploring non-invasive tools to help screening LUTD is necessary for clinicians in their daily practice. This article reviews recently clinical studies of using urinary inflammatory proteins and oxidative stress biomarkers in the identification of specific LUTD among men and women with lower urinary tract symptoms (LUTS). Some important findings have been reported: (1) Using urine chemokines CXCL-1 and interleukin-8 (IL-8), we may discriminate overactive bladder (OAB) symptoms in women between DO and urinary tract infection. (2) Urinary levels of oxidative stress biomarkers such as 8-hydroxydeoxyguanosine (8-OHdG) and 8-isoprostane have a potential being used as a tool to identify women with mixed DO and stress urinary incontinence. (3) Urine levels of total antioxidant capacity (TAC), and prostaglandin E2 (PGE2) are positively correlated with voiding detrusor pressure in patients with DU. (4) Urine levels of brain-derived neurotrophic factor (BDNF) and PGE2 were significantly higher in the DU patients with detrusor function recovery. (5) Women with DV had higher urinary levels of tumor necrosis factor-alpha (TNF-α) and 8-OHdG, and urinary IL-2 level was significantly lower. (6) Urine level of 8-isoprostane was higher in the patients with idiopathic DO and neurogenic DO. (7) Higher urine cytokine levels of monocyte chemoattractant protein-1 (MCP-1), regulated on activation, normal T-cell expressed and secreted (RANTES), CXCL-10, IL-7, and eotaxin-1 in patients with IC/BPS than controls. (8) The urine levels of IL-8, CXCL-10, BDNF, IL-6, and RANTES were significantly higher in patients with Hunner's IC than non-Hunner's IC. (9) Male patients with IC/BPS had a significantly higher level of eotaxin, MCP-1, TNF-α, 8-OHdG, and TAC. Combining a higher eotaxin and a higher TNF-α can provide a satisfactory diagnostic value in discriminating IC/BPS from other LUTD in men. These studies provide evidence that measurement of cluster of urine biomarkers could be used as a diagnostic tool to differentiate different LUTD in patients with similar LUTS.

Role of cystoscopy as primary initial investigation in interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic painful bladder condition characterized by pelvic pain and urinary symptoms without another identifiable cause. Cystoscopy as primary initial investigation for IC/BPS has not been accepted yet and needs more studies to definitely conclude.

AIMS AND OBJECTIVES

We aimed to assess cystoscopy findings in patients of interstitial cystitis/bladder pain syndrome and to prove role of cystoscopy as primary initial investigation for interstitial cystitis/bladder pain syndrome.

MATERIALS AND METHODS

Our prospective observational study included 35 female patients aged 18-69 years presenting to the Urology OPD at SMS Hospital with suprapubic or pelvic pain for 6 months, bladder pain that worsens with bladder filling and reduced with voiding, dysuria, urinary frequency and urgency, nocturia, dyspareunia. Those with history of bladder capacity more than 350 ml, duration of symptoms less than 6 months, day time frequency less than eight times per day, diagnosis of bacterial cystitis or prostatitis, bladder or ureteral calculi, active genital herpes, any existing urological malignancy, radiation cystitis were excluded from the study. They were then subject to cystoscopy and the findings of the cystoscopy were analyzed.

RESULTS

Out of the 35 patients, 11 (31.43%) had a normal cystoscopy. Of the 24 patients (68.57%) who had a positive cystoscopy, cystoscopy in seven patients (20.0%) revealed an ulcer. All these seven patients underwent fulguration. In the remaining 17 patients the abnormal findings were petechiae, large submucosal bleed. The sensitivity of cystoscopy in detecting the ulcerative type of Interstitial cystitis was found to be 20.0%.

CONCLUSION

Our study found that Cystoscopy, if employed in initial investigation can help early detection of ulcerative variety of IC/BPS and can act as therapeutic modality by using fulguration plus hydrodistension. Larger comparative studies are needed for diagnostic/Therapeutic value of cystoscopy.

Multimodal therapies and strategies for the treatment of interstitial cystitis/bladder pain syndrome in Taiwan

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by bladder pain, frequency, and nocturia. The most common pathologies include chronic inflammation and bladder urothelium dysfunction. According to the bladder condition with or without Hunner's lesions, IC/BPS can be divided into "IC" in patients with Hunner's lesion (HIC) and "BPS" in those without Hunner's lesion (NHIC). Previous studies have reported greater central sensitization and interorgan cross-talk in patients with NHIC. Multimodal treatments have been recommended in clinical guidelines under the biopsychosocial model. The bladder-gut-brain axis has also been speculated, and multimodal therapies are necessary. Unfortunately, currently, no treatment has been reported durable for IC/BPS. Patients with IC/BPS usually experience anxiety, depression, holistic physical responses, and even threats to social support systems. The lack of durable treatment outcomes might result from inadequate diagnostic accuracy and differentiation of clinical phenotypes based on the underlying pathophysiology. Precision assessment and treatment are essential for optimal therapy under definite IC/BPS phenotype. This article reviewed currently available literature and proposed a diagnosis and treatment algorithm. Based on bladder therapy combined with suitable physical and psychological therapies, a well-grounded multimodal therapy and treatment algorithm for IC/BPS following a diagnostic protocol are indispensable.

Cystoscopic characteristic findings of interstitial cystitis and clinical implications

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic inflammatory bladder disease of unknown etiology, characterized by bladder pain and frequency urgency symptoms. Based on the cystoscopic findings after hydrodistention under anesthesia, the phenotype of IC/BPS includes no glamerulation, characteristic glomerulation, and with Hunner's lesion. IC is specifically defined if there are characteristic Hunner's lesion appeared in cystoscopy or after hydrodistention. If there are glomerulations without Hunner's lesion, BPS should be considered. The definition of Hunner's lesion and glomerulations differs based on different definition and observations. Currently, there has been no clear description and grading of the glomerulations and Hunner's lesion. Because the classification of IC/BPS has an impact on the treatment strategy and associated with therapeutic outcome, it is unmet to have a clear definition and consensus on the characteristic cystoscopic findings of IC/BPS. This article reviews the literature and presents the figures of Hunner's lesions and description of different mucosal lesions after cystoscopic hydrodistention.

Laser Treatment for Patients With Vulvodynia and Interstitial Cystitis/Bladder Pain Syndrome: A Case Series (The UNICORN-3 Study)

Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain disorder characterized by urgency, frequency of urination, and pelvic pain. Women with IC/BPS often experience sexual dysfunction, vulvodynia, and vaginal health issues. Combined erbium and neodymium yttrium aluminum garnet (YAG) laser treatments targeting the vagina and vulva have shown promise in improving symptoms. Our study aims to investigate the effectiveness of these combined laser treatments in women with IC/BPS and vulvodynia. Methods Women diagnosed with vulvodynia and IC/BPS underwent combined laser treatment using vaginal erbium:YAG laser (VEL) and neodymium:YAG laser (Nd:YAG). Various parameters were evaluated, including the vulvodynia test, numeric rating scale (NRS-11) for pain, interstitial cystitis symptom index and problem index (ICSI and ICPI), pelvic pain and urgency/frequency symptom score (PUF), and mean urination volume/daily urination frequency in a three-day urination diary. Treatment was administered three times, with intervals of one month between each session, and follow-up evaluations were conducted at six and 12 months. All statistical analyses were designed and programmed by the AI chatbot GPT-4 (chatGPT-4). Results Fifteen female patients diagnosed with vulvodynia and IC/BPS were treated with three sessions of VEL + Nd:YAG. Significant improvements were observed in the vulvodynia test, NRS-11 scores, PUF, ICSI scores, ICPI scores, mean urination volume, and daily urination frequency at six and 12 months (p<0.01). Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test (p=0.007), suggesting a synergistic effect. However, no significant correlations were found at 12 months. Conclusion Combined laser treatments targeting the vagina and vulva showed significant therapeutic effects in women with IC/BPS and vulvodynia. The addition of Nd:YAG to the VEL treatment enhanced outcomes. Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test, indicating a synergistic effect. Long-term improvements in both vulvodynia and IC/BPS symptoms may occur independently. These findings highlight the importance of comprehensive approaches for treating coexisting vulvodynia and IC/BPS.

Interventional Pain Management in the Treatment of Chronic Pelvic Pain

PURPOSE OF REVIEW

Chronic pelvic pain syndrome (CPPS) is a common yet complex disease in the field of urology, gynecology, and pain management. This review article summarizes the anatomy and physiology of CPP with an in-depth discussion of established and emerging interventional treatment options.

RECENT FINDINGS

Though psychosocial variables play a significant role in the development and propagation of CPPS, interventional treatment strategies are available to ameliorate symptoms. Sympathetic and peripheral nerve blocks along with chemical and radiofrequency denervation are conventional, evidence-based treatments. Recent advances in spinal cord stimulation and dorsal root ganglion stimulation offer novel and effective therapeutic options to treat CPPS. A biopsychosocial model should be employed for effective management of CPPS with advances in neuromodulation offering newfound hope in alleviating symptoms and restoring function.

Sensory Receptor, Inflammatory, and Apoptotic Protein Expression in the Bladder Urothelium of Patients with Different Subtypes of Interstitial Cystitis/Bladder Pain Syndrome

The aim of this study was to investigate the expression levels of sensory receptors, inflammatory proteins, and pro-apoptotic proteins in the urothelium of non-Hunner's interstitial cystitis (NHIC) bladders of patients with different clinical and cystoscopic phenotypes. The urothelia from the bladders of 52 NHIC patients were harvested. The expression of sensory receptors, including TRPV1, TRPV4, TRPA1, H1-receptors, and sigma-1 receptors; the inflammatory proteins p38 and tryptase; and the pro-apoptotic proteins, such as caspase-3, BAD, and BAX in the urothelium, were investigated using immunohistochemistry and Western blotting. We compared the expression levels of these proteins in NHIC subtypes according to IC symptom scores, visual analog scores of bladder pain, maximal bladder capacity, glomerulation grades, and combined maximal bladder capacity and glomerulations after cystoscopic hydrodistention. The expression levels of TRPV1, TRPV4, sigma-1, P38, tryptase, caspase-3, and BAD were significantly increased in the urothelium of IC/BPS patients compared with the expression levels in the controls. TRPV1 was significantly associated with IC symptom severity. However, no significant differences in sensory receptor expression in the IC/BPS bladders with different bladder conditions were detected. Inflammatory and pro-apoptotic protein expression levels in the urothelium were similar among the IC/BPS subgroups. This study concluded that IC/BPS patients with frequency and bladder pain complaints have higher levels of urothelial sensory receptors, and inflammatory and pro-apoptotic proteins. The expression levels of these sensory receptors, inflammatory proteins, and pro-apoptotic proteins are not significantly different among IC/BPS bladders with different conditions.

Urine Oxidative Stress Biomarkers as Novel Biomarkers in Interstitial Cystitis/Bladder Pain Syndrome

Both hypoxia and chronic suburothelial inflammation are important pathophysiological findings in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). This study investigated the roles of urine oxidative stress biomarkers and inflammatory cytokines in patients with IC/BPS. Urine samples were collected from 159 IC/BPS patients and 28 controls. The targeted analytes included oxidative stress biomarkers (8-OHdG, 8-isoprostane, and total antioxidant capacity) and inflammatory cytokines (MCP-1, RANTES, CXCL10, Eotaxin, MIP-1β, and IL-8). IC/BPS patients were classified into four clinical subgroups, based on the glomerulation grade and the maximal bladder capacity under anesthesia. Patients with IC/BPS had urine oxidative stress biomarkers and inflammatory cytokines profiles that were distinct from those of the controls and among each subgroup. Both 8-OHdG and 8-isoprostane showed a high diagnostic ability to distinguish type 2 IC/BPS patients (as classified by the European Society for the Study of Interstitial Cystitis) from controls. Additionally, they both showed positive and negative correlations with the glomerulation grade and the maximal bladder capacity under anesthesia, respectively. Limitations included intra-individual variation and sex influence. Urine oxidative stress biomarkers might have a role in diagnosing IC/BPS and differentiating its clinical subtypes. In addition to inflammatory cytokines, urine oxidative stress biomarkers have the potential to be novel biomarkers in patients with IC/BPS.

The Diagnosis of Chronic Pelvic Pain: How Can We Detect Urological Pain?

Chronic pelvic pain (CPP) refers to pain perceived in the pelvic region for over 6 months. It is described more specifically according to the organs involved. The diagnosis and classification of CPP are not easy because of the vague diagnostic criteria, variety of presenting symptoms, absence of diagnostic tools, and coexisting symptoms due to accompanying other diseases. This concise review aims to help urologists diagnose CPP by focusing on identifying urological pain.

Anti-Inflammatory Diet for Women with Interstitial Cystitis/Bladder Pain Syndrome: The AID-IC Pilot Study

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by pelvic pain coupled with urinary frequency and urgency. The underlying cause of IC/BPS is unknown; there is no cure. Dietary components exacerbate symptoms. The Anti-Inflammatory Diet for Interstitial Cystitis (AID-IC) employs a randomized, crossover design to evaluate the effect of a plant-based, low saturated fat diet on the quality of life of women with IC/BPS. Insights on the implementation of the protocol and reflections on the facilitators and barriers experienced during the pilot study follow. The logistics of the protocol proved time-consuming; however, the barriers were surmountable. Quantitative and qualitative findings suggest that the AID-IC therapeutic diet may have lessened symptoms and improved the quality of life for many of the women in the study.

Inflammation and Barrier Function Deficits in the Bladder Urothelium of Patients with Chronic Spinal Cord Injury and Recurrent Urinary Tract Infections

Patients with spinal cord injury (SCI) commonly experience neurogenic voiding dysfunctions and urinary tract complications, including recurrent urinary tract infections (rUTI). The bladder mucosa barrier function contributes to UTI prevention. This study investigated changes in bladder urothelium protein expression in patients with SCI and rUTI. From June 2011 to November 2017, 23 patients (19 men and 4 women) with chronic SCI were enrolled (mean age: 43 years. Bladder tissues from 6 healthy adults served as the normal control group. Biopsy samples (9 partial cystectomies and 14 bladder biopsies) were analyzed for functional biomarkers using western blot and immunohistochemistry analysis. The barrier function proteins E-cadherin, zonula occludens 1 (ZO-1) and uroplakin III (UPK-3) were significantly reduced, whereas tumor protein p63 (TP63) was significantly increased in SCI patients compared with controls. No significant differences in basal cell progenitor proteins were observed between groups. The proliferation marker Ki-67, the proapoptotic marker BCL-2-associated X protein (BAX), and proinflammatory proteins were increased in patients with SCI compared with controls. No significant differences were observed between SCI patients with and without recently rUTI. These results suggest that SCI patients experience chronic bladder inflammation, increased apoptosis, and reduced barrier function, contributing to rUTI.

[S2K guideline on the diagnosis and treatment of interstitial cystitis (IC/BPS) : Discussion of the current guideline using a case study]

IC/BPS is a chronic progressive disorder that is often difficult and unsatisfactory for the person affected and the treating therapist. Treatment should therefore be comprehensive, interdisciplinary, multimodal and take into account the biopsychosocial model. The guideline forms a thread through the diverse diagnostic and therapeutic options and provides extensive background information on the definition, epidemiology and aetiopathogenesis of this rare disease. However, practice and theory/guideline are different. Adaptation to the individual case is therefore necessary and explicitly desired. The guideline should therefore serve as a source of ideas for colleagues to compile their own standards suitable for their practice. On the one hand, therapy approaches that have been tried and tested in everyday clinical practice are passed on. On the other hand, the frequent lack of evidence should also be viewed critically. Further studies, if possible multi-centre, specifically designed for different aspects of IC/BPS would be desirable. Close networking between therapists in private practice and special centres is essential for the best possible treatment of people with IC/BPS. The guideline is intended to show the limits of what can be done in practices and outpatient clinics and to provide guidance on when patients should be referred to a "Centre for Interstitial Cystitis and Pelvic Pain". Overall, the guideline has improved the presence of this rare disease among colleagues. A comprehensive supplement, update and further substantiation with the state of current research is thus desirable.

Urinary Biomarkers in Interstitial Cystitis/Bladder Pain Syndrome and Its Impact on Therapeutic Outcome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as a chronic bladder disorder with suprapubic pain (pelvic pain) and pressure and/or discomfort related to bladder filling accompanied by lower urinary tract symptoms, such as urinary frequency and urgency without urinary tract infection (UTI) lasting for at least 6 weeks. IC/BPS presents significant bladder pain and frequency urgency symptoms with unknown etiology, and it is without a widely accepted standard in diagnosis. Patients’ pathological features through cystoscopy and histologic features of bladder biopsy determine the presence or absence of Hunner lesions. IC/PBS is categorized into Hunner (ulcerative) type IC/BPS (HIC/BPS) or non-Hunner (nonulcerative) type IC/BPS (NHIC/BPS). The pathophysiology of IC/BPS is composed of multiple possible factors, such as chronic inflammation, autoimmune disorders, neurogenic hyperactivity, urothelial defects, abnormal angiogenesis, oxidative stress, and exogenous urine substances, which play a crucial role in the pathophysiology of IC/BPS. Abnormal expressions of several urine and serum specimens, including growth factor, methylhistamine, glycoprotein, chemokine and cytokines, might be useful as biomarkers for IC/BPS diagnosis. Further studies to identify the key molecules in IC/BPS will help to improve the efficacy of treatment and identify biomarkers of the disease. In this review, we discuss the potential medical therapy and assessment of therapeutic outcome with urinary biomarkers for IC/BPS.

The O'Leary-Sant Interstitial Cystitis Symptom Index is a clinically useful indicator of treatment outcome in patients with interstitial cystitis/bladder pain syndrome with Hunner lesions: A post hoc analysis of the Japanese phase III trial of KRP-116D, 50% dimethyl sulfoxide solution

OBJECTIVES

To evaluate the efficacy of intravesical KRP-116D, 50% dimethyl sulfoxide solution, in interstitial cystitis/bladder pain syndrome patients with Hunner lesions (Hunner-type interstitial cystitis), and to evaluate the correlations between efficacy variables and global response assessment to determine what constitutes a minimal clinically important change.

METHODS

We performed a post hoc analysis of the Japanese phase III trial of KRP-116D. Changes at Week 12 from baseline in objective and subjective outcomes were compared between the KRP-116D and placebo groups in Hunner-type interstitial cystitis or non-Hunner-type interstitial cystitis patients. Correlations between efficacy variables at Week 12 and global response assessment were analyzed. Area under the receiver operating characteristic curve and the cut-off value of efficacy valuables were calculated to determine clinically meaningful changes.

RESULTS

The effectiveness of intravesical treatment with KRP-116D was demonstrated in Hunner-type interstitial cystitis, but not in non-Hunner-type interstitial cystitis patients. Global response assessment was closely correlated with subjective outcomes including O'Leary-Sant Interstitial Cystitis Symptom Index, O'Leary-Sant Interstitial Cystitis Problem Index, and a numeric rating scale for bladder pain, but was less correlated with voiding variables including micturition frequency, voided volume, and maximum voided volume. In the receiver operating characteristic curve analyses, the cut-off value for the O'Leary-Sant Interstitial Cystitis Symptom Index was -5 (sensitivity 81.3%, specificity 83.3%).

CONCLUSIONS

Clinical benefit of intravesical KRP-116D in Hunner-type interstitial cystitis patients was confirmed in this post hoc analysis. A five-point reduction in O'Leary-Sant Interstitial Cystitis Symptom Index is a clinically meaningful indicator for assessing patient satisfaction with KRP-116D treatment in patients with Hunner-type interstitial cystitis.

Biomarkers in the Light of the Etiopathology of IC/BPS

In this review, we focused on putatively interesting biomarkers of interstitial cystitis/bladder pain syndrome (IC/BPS) in relation to the etiopathology of this disease. Since its etiopathology is still under discussion, the development of novel biomarkers is critical for the correct classification of the patients in order to open personalized treatment options, on the one hand, and to separate true IC/BPS from the numerous confusable diseases with comparable symptom spectra on the other hand. There is growing evidence supporting the notion that the classical or Hunner-type IC (HIC) and the non-Hunner-type IC (NHIC) are different diseases with different etiopathologies and different pathophysiology at the full-blown state. While genetic alterations indicate close relationship to allergic and autoimmune diseases, at present, the genetic origin of IC/BPS could be identified. Disturbed angiogenesis and impairment of the microvessels could be linked to altered humoral signaling cascades leading to enhanced VEGF levels which in turn could enhance leucocyte and mast cell invasion. Recurrent or chronic urinary tract infection has been speculated to promote IC/BPS. New findings show that occult virus infections occurred in most IC/BPS patients and that the urinary microbiome was altered, supporting the hypothesis of infections as major players in IC/BPS. Environmental and nutritional factors may also influence IC/BPS, at least at a late state (e.g., cigarette smoking can enhance IC/BPS symptoms). The damage of the urothelial barrier could possibly be the result of many different causality chains and mark the final state of IC/BPS, the causes of this development having been introduced years ago. We conclude that the etiopathology of IC/BPS is complex, involving regulatory mechanisms at various levels. However, using novel molecular biologic techniques promise more sophisticated analysis of this pathophysiological network, resulting in a constantly improvement of our understanding of IC/BPS and related diseases.

Low-pressure hydrodistension induces bladder glomerulations in female patients with interstitial cystitis/bladder pain syndrome

AIMS

The role of hydrodistension in the diagnosis of interstitial cystitis/bladder pain syndrome (IC/BPS) is controversial. This study evaluated the effect of low-pressure hydrodistension on glomerulation formation in female patients diagnosed with the disease.

METHODS

Sixty female patients with the clinical diagnosis of IC/BPS and 30 female controls without the disease underwent cystoscopy and hydrodistension. Cold-cup biopsy was taken from bladder posterior wall at sites with normal cystoscopic appearance before hydrodistension in the IC/BPS group. The tissue samples were processed for histology study. Low-pressure (40 cmH₂ O) hydrodistension for 2 min was performed and the appearance of glomerulations was compared between the two groups. High-pressure (80 cmH₂ O) hydrodistension for 8 min was then performed as a therapeutic measure for the IC/BPS patients. Further changes to the degree of glomerulations were recorded.

RESULTS

Histology showed pathological changes in the normal-appearing IC/BPS bladder mucosa including urothelium denudation, inflammatory cell infiltration, stromal edema, fibrosis, and vascular congestion. Low-pressure hydrodistension induced significant glomerulation formation in the patient group (percentage of patients with Grades 0-4: 0%, 8.3%, 40%, 35%, 10%, respectively) while none in the controls. High-pressure hydrodistension further increased the glomerulation grading in the IC/BPS patients.

CONCLUSIONS

Structural changes are present in prehydrodistension IC/BPS bladder wall, which may not be macroscopically detectable. Hydrodistension at low pressure is adequate to disrupt the integrity of such diseased mucosa and offers a more discriminative test in the diagnosis of IC/BPS.

Risk of Autoimmune Diseases in Patients With Interstitial Cystitis/Bladder Pain Syndrome: A Nationwide Population-Based Study in Taiwan

Objective: The association between autoimmune diseases (ADs) and interstitial cystitis/bladder pain syndrome (IC/BPS) has long been investigated. However, the lack of comprehensive descriptions of patients in the literature has made comparison and evaluation impossible. We aim to investigate the risk of systemic ADs in patients with IC/BPS in Taiwan using a population-based administrative database.

Methods: This study evaluated 1,095 patients newly diagnosed with IC/BPS between 2000 and 2013, using data from Taiwan's National Health Insurance Research Database. These patients were randomly matched by demographic characteristics with a comparison cohort of individuals without IC/BPS at a ratio of 1:20. Cox proportional hazards regression analysis was used to analyze the risk of ADs, adjusting for age, sex, urbanization, length of hospital stay, and comorbidities adjustment. Sensitivity analysis by propensity score was used to adjust for confounding factors.

Results: The adjusted Hazard Ratio (aHR) of ADs for IC/BPS patients was 1.409 (95% CI 1.152–1.725). The subgroup analysis indicated that female or 45–60 years of age had a greater risk of ADs. Furthermore, the subgroup analysis of primary outcomes indicated that IC/BPS had greater incidence with Hashimoto's thyroiditis (aHR = 2.767, 95% CI 1.039–7.368), ankylosing spondylitis (aHR = 2.429, 95% CI 1.264–4.67), rheumatoid arthritis (aHR = 1.516, 95% CI 1.001–2.296), and Sjogren's syndrome (aHR = 1.962, 95% CI 1.37–2.809).

Conclusion: IC/BPS was associated with the development of ADs in our study population, especially Hashimoto's thyroiditis, ankylosing spondylitis, rheumatoid arthritis, and Sjogren's syndrome. Clinicians are recommended to be alert to the increased likelihood of developing ADs, particularly for middle-aged women.

Difference in electron microscopic findings among interstitial cystitis/bladder pain syndrome with distinct clinical and cystoscopic characteristics

Urothelial dysfunction may be a key pathomechanism underlying interstitial cystitis/bladder pain syndrome (IC/BPS). We therefore examined if clinical severity is associated with the extent of urothelial damage as revealed by electron microscopic (EM) analysis of biopsy tissue. One hundred IC/BPS patients were enrolled and 24 patients with stress urinary incontinence served as controls. Clinical symptoms were evaluated by visual analog scale pain score and O’Leary-Sant Symptom score. Bladder biopsies were obtained following cystoscopic hydrodistention. The presence of Hunner’s lesions and glomerulation grade after hydrodistention were recorded and patients classified as Hunner-type IC (HIC) or non-Hunner-type IC (NHIC). HIC patients exhibited more severe defects in urothelium cell layers, including greater loss of umbrella cells, umbrella cell surface uroplakin plaque, and tight junctions between adjacent umbrella cells, compared to control and NHIC groups (all p < 0.05). Both NHIC and HIC groups demonstrated more severe lamina propria inflammatory cell infiltration than controls (p = 0.011, p < 0.001, respectively). O’Leary-Sant Symptom scores were significantly higher among patients with more severe urothelial defects (p = 0.030). Thus, urothelium cell layer defects on EM are associated with greater clinical symptom severity.

An Allergic Risk Factor Analysis of Extraordinary Daytime Only Urinary Frequency in Children

Objective

This study aims to investigate the risk factors of extraordinary daytime only urinary frequency (EDOUF) and propose a form of clinical treatment.

Methods

Correlation and binary logistic regression analyses were carried out on the medical records of children with EDOUF, including their history of eczema, urticaria, allergic rhinitis or allergic cough, and pruritus (eye rubbing, etc.).

Results

A total of 266 children with EDOUF, 127 boys and 139 girls, were enrolled in the present study; their average age was 5.60 ± 2.04 years. Binary logistic regression analysis revealed that the risk factors of EDOUF in children were eczema (odds ratio [OR] = 8.393), allergic rhinitis or allergic cough (OR = 4.459), pruritus (eye rubbing, etc.; OR = 3.879), and elevated total serum IgE level (OR = 7.927). The efficacy rate of oral administration of antihistamine (desloratadine) was 89.1%.

Conclusion

Systemic or local allergic conditions, such as eczema, allergic rhinitis or allergic cough, and pruritus (including eye rubbing), and elevated total serum IgE level, are risk factors for the occurrence of EDOUF in children. The oral administration of antihistamine (desloratadine) can alleviate the symptoms.

Current Understanding and Future Perspectives of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by suprapubic pain and lower urinary tract symptoms. Perhaps because of the heterogeneous nature of this disease and its multifactorial etiology, clinical trials in allinclusive populations of IC/BPS patients without phenotyping in the last decade have mainly failed to discover new therapeutic modalities of IC/BPS. Thus, phenotyping IC/BPS, aimed at identifying bladder-centric and/or bladder-beyond pathologies, including cystoscopic observation of Hunner or non-Hunner lesions of the bladder mucosa, is particularly important for the future of IC/BPS management. Based on recent discussions at international conferences, including the International Consultation on IC, Japan, it has been proposed that Hunner-lesion IC should be separated from other non-Hunner IC/BPS because of its distinct inflammatory profiles and epithelial denudation compared with non-Hunner IC/BPS. However, there are still no standard criteria for the diagnosis of Hunner lesions other than typical lesions, while conventional cystoscopic observations may miss atypical or small Hunner lesions. Furthermore, diagnosis of the bladder-centric phenotype of IC/BPS requires confirmation that identified mucosal lesions are truly a cause of bladder pain in IC/BPS patients. This review article discusses the current status of IC/BPS pathophysiology and diagnosis, as well as future directions of the proper diagnosis of bladder-centric IC/BPS, in which pathophysiological mechanisms other than those in inflammatory pathways, such as angiogenic and immunogenic abnormalities, could also be involved in both Hunner-lesion IC and non-Hunner IC/BPS. It is hoped that this new paradigm in the pathophysiological evaluation and diagnosis of IC/BPS could lead to pathology-based phenotyping and new treatments for this heterogeneous disease.

Factors associated with treatment outcomes after intravesical hyaluronic acid therapy in women with refractory interstitial cystitis: A prospective, multicenter study

BACKGROUND

Bladder instillation of hyaluronic acid (HA) is an acceptable treatment for bladder pain syndrome/interstitial cystitis (BPS/IC). The treatment is limited by a high proportion of non-responders (~30%-40%). Here, we aimed to evaluate predisposing factors associated with treatment outcomes.

METHODS

This is a prospective multicenter study. We enrolled a total of 137 (out of 140) women with refractory IC. They all underwent a standard protocol of 6-month intravesical HA therapy (initial 4 weeks, once weekly, followed by once monthly). To assess the outcomes, we used the pain Visual Analog Scale (Pain-VAS), Interstitial Cystitis Symptom and Problem Index (ICSI & ICPI), and a scaled Global Response Assessment (GRA).

RESULTS

The age of patients was 47.6 ± 27.5 (range 24-77) years. We found statistically significant improvement (p < 0.001) in the Pain-VAS and the ICSI & ICPI scores both after the initial 4-weekly instillations and at the end of 6-month treatment. Those who reported moderate/marked improvement on GRA at the 2 follow-up visits were considered responders: 39.4% (n = 54) at the first follow-up, and 59.9% (n = 82) at the second follow-up. No remarkable side effect was noted. After statistical analyses, treatment outcomes on GRA were positively associated with baseline functional bladder capacity and with Pain-VAS scores. The initial treatment responses optimally (p < 0.001) predicted final treatment outcomes (McNemar).

CONCLUSION

Intravesical HA therapy is safe and effective for most (~60%) of our patients with refractory IC. Functional bladder capacity and Pain-VAS scores before treatment, and the early treatment responses are helpful predictors of treatment outcomes.

Urine biomarkers in ESSIC type 2 interstitial cystitis/bladder pain syndrome and overactive bladder with developing a novel diagnostic algorithm

This study aimed to investigate the diagnostic values of urine cytokines in interstitial cystitis/bladder pain syndrome (IC/BPS) and overactive bladder (OAB) patients, and to develop a novel diagnostic algorithm. Urine samples were collected from 40 IC/BPS, 40 OAB patients, and 30 controls. Commercially available multiplex immunoassays were used to analyze 31 targeted cytokines. Urine cytokine profiles were significantly different among study groups and controls. MIP-1β showed the highest sensitivity (92.2%) for identifying diseased study patients from controls. The cytokines with high diagnostic values for distinguishing between IC and OAB included IL-10, RANTES, eotaxin, CXCL10, IL-12p70, NGF, IL-6, IL-17A, MCP-1, and IL-1RA. The diagnostic algorithm was subsequently developed according to the diagnostic values obtained. MIP-1β was selected for the initial screening test to diagnose diseased patients and controls with diagnostic rates of 81.6% and 68.4%, respectively. As confirmation tests for IC/BPS, the diagnostic rates of eotaxin, CXCL10, and RANTES were 73.3%, 72.7%, and 69.7%, respectively. As the confirmation test for OAB, the diagnostic rate of IL-10 was 60%. Urine cytokine profiles of IC/BPS and OAB patients differed from those of controls and might be useful as biomarkers for diagnosis. A novel pilot diagnostic algorithm was developed based on these profiles.

Current standard of care in treatment of bladder pain syndrome/interstitial cystitis

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a debilitating, systemic pain syndrome with a cardinal symptom of bladder related pain with associated systemic symptoms. It is characterized by an inflammation that partially or completely destroys the mucus membrane and can extend into the muscle layer; however, the etiology and pathogenesis is still enigmatic. It has been suggested that mast cell activation, defects in the glycosaminoglycan layer, non-functional proliferation of bladder epithelial cells, neurogenic inflammation, microvascular abnormalities in the submucosal layer, autoimmunity and infectious causes may cause BPS/IC. Available treatment options include general relaxation techniques, patient education, behavioral treatments, physical therapy, multimodal pain therapy, oral (amitriptyline, cimetidine, hydroxyzine) and intravesical treatments (heparin, lidocaine, hyaluronic acid and chondroitin sulfate), hydrodistension and other more invasive treatments. Available treatments are mostly not based on a high level of evidence. Lack of understanding of disease mechanisms has resulted in lack of targeted therapies on this area and a wealth of empirical approaches with usually inadequate efficacy. The aim of this article is to review the available evidence on the pathophysiological mechanisms of BPS/IC as they relate to available treatment options.

Effects of non-ablative vaginal erbium:YAG laser treatment for interstitial cystitis/bladder pain syndrome: a case series (UNICORN-2 study)

Purpose: There are no established treatments for treating interstitial cystitis/bladder pain syndrome (IC/BPS). We conducted a study to verify the effectiveness of non-ablative vaginal erbium:YAG laser (VEL) treatment for patients with IC/BPS who were resistant to conventional treatments.Methods: A total of 12 patients without improvement after several treatments before 2016 underwent VEL treatment once a month for 12 months as per their convenience. The numeric rating scale-11 (NRS-11), O'Leary-Sant interstitial cystitis symptom and problem indexes (ICSI and ICPI), functional bladder capacity, and daily urinary frequency were obtained.Results: In total, nine patients responded to the treatment and three did not. The NRS-11 scores and ICSI and ICPI improved in all responders. The bladder capacity and urinary frequency also normalized. The residual effect lasted for 18 months from the first treatment without long-term side-effects.Conclusions: VEL treatment is a safe and effective treatment in patients with IC/BPS.

Repeated intravesical injections of platelet-rich plasma improve symptoms and alter urinary functional proteins in patients with refractory interstitial cystitis

Repeated intravesical injections of autologous platelet-rich plasma (PRP) have been shown to improve symptoms in patients with interstitial cystitis/bladder pain syndrome (IC/BPS); however, there is a paucity of objective evidence of the effectiveness of this therapy. In this study, we investigated the changes in urinary markers after PRP treatment. Forty patients with IC/BPS who were refractory to conventional therapy received four injections of PRP at monthly intervals; 10 mL PRP solution with 2.5 times the peripheral blood platelet concentration was used. Urine levels of thirteen functional proteins, growth factors, and cytokines were assessed at baseline and at the 4th PRP injection. The clinical parameters included visual analog scale (VAS) pain score, daily urinary frequency, nocturia episodes, functional bladder capacity, and global response assessment (GRA). The GRA and symptom score significantly decreased post-treatment. In patients with GRA ≥ 2, the success rates at 1 month and at 3 months after the 4th PRP injection were 70.6% and 76.7%, respectively. The VAS pain score, frequency, and nocturia showed a significant decrease (all p < 0.05). Urinary levels of nerve growth factor, matrix metalloproteinase-13, and vascular endothelial growth factor significantly decreased post-treatment (p = 0.043, p = 0.02, and p = 0.000, respectively); platelet-derived growth factor-AB showed a significant increase (p = 0.004) at the 4th PRP treatment compared with baseline. In this study, repeated intravesical PRP injections provided significant symptom improvement in IC/BPS patients with concomitant changes in the related biomarker levels.Trial registration: ClinicalTrial.gov: NCT03104361; IRB: TCGH 105-48-A.

Clinical characterization of interstitial cystitis/bladder pain syndrome in women based on the presence or absence of Hunner lesions and glomerulations

OBJECTIVES

To compare the clinical characteristics of three groups of female patients with interstitial cystitis/bladder pain syndrome (IC/BPS) classified according to the presence or absence of Hunner lesions (HL) and glomerulations.

METHODS

The clinical records of 100 female patients with IC/BPS who underwent their first bladder hydrodistension at our institution were retrospectively reviewed. They were divided into patients having (HL-IC; n = 57) or lacking (BPS; n = 43) HL. BPS patients were further classified as those with (29) and without (14) glomerulations. Among these three subtypes, demographics, comorbidities, symptom parameters including a visual analog scale for pain scores, O'Leary and Sant Symptom and Problem (OSSI/OSPI) Indices, frequency volume chart variables, and bladder capacity at hydrodistension were compared.

RESULTS

HL-IC patients were older and had higher OSSI/OSPI scores, greater daytime frequency and nocturia, reduced maximum and average voided volumes, and smaller bladder capacity at hydrodistension compared with BPS patients. Pain intensity and illness duration were comparable among the three groups. HL-IC patients had autoimmune disorders as comorbidities more often, but had psychiatric disorders and irritable bowel syndrome less often compared with BPS patients. No discernible differences in clinical characteristics of symptom severity and comorbid disorders were evident between BPS patients with and without glomerulations.

CONCLUSIONS

The presence of HL is associated with distinctive clinical characteristics, while glomerulations are not in female patients with IC/BPS. The presence of HL, but not glomerulations, is a robust phenotypic feature of IC/BPS in women.

How can we improve the diagnosis and management of bladder pain syndrome? Part 2:ICI-RS 2018

BACKGROUND

This paper summarises the discussion in a think tank at the International Consultation on Incontinence-Research Society (ICI-RS) 2018 about the treatment of bladder pain syndrome.

AIMS

To review the treatments of bladder pain syndrome from behavioural treatments to surgical interventions.

MATERIALS AND METHODS

Review the literature in the light of the think tank discussions.

RESULTS

All guidelines recommend different levels of treatment starting with conservative behavioral treatments then introducing oral treatments followed by intravesical instillations. If these treatments fail then more invasive treatments such as botulinum toxin injections, neuromodulation, or surgery could be suggested.

CONCLUSION

Unfortunately for all treatments, the numbers are limited and, therefore, the evidence base is not strong. Further suggestions for research are suggested.

New Insights about Chronic Pelvic Pain Syndrome (CPPS)

BACKGROUND

Chronic pelvic pain syndrome (CPPS) is one of the common diseases in urology and gynecology. CPPS is a multifactorial disorder where pain may originate in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems. The symptoms of CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological, and endocrine systems. The aim of this article was to present new insight about CPPS in order to raise awareness of nursing and medical staff in the identification and diagnosis of the syndrome and to promote an appropriate treatment for each woman who suffers from CPPS.

METHODS

A literature review about the factors associated with CPPS and therapeutic interventions for CPPS was conducted.

RESULTS

CPPS represents a chronic pain syndrome that combines anatomic malfunction of the pelvic floor muscles with malfunction of pain perception linked with psychological and cognitive factors.

CONCLUSIONS

The therapeutic interventions in CPPS cases should, consequently, follow a multidisciplinary approach.

Urine cytokines as biomarkers for diagnosing interstitial cystitis/bladder pain syndrome and mapping its clinical characteristics

The objective of the present study was to investigate the diagnostic values of urine cytokines in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) and to identify their correlations with clinical characteristics. Urine samples were collected from 127 patients with IC/BPS [European Society for the Study of Interstitial Cystitis (ESSIC) types 1 and 2] and 28 controls. Commercially available multiplex immunoassays (MILLIPLEX map kits) were used to analyze 31 targeted cytokines. Cytokine levels between patients with IC/BPS and controls were analyzed using ANOVA. Receiver-operating characteristic curves of each cytokine to distinguish IC/BPS from controls were generated for calculation of the area under the curve. Patients with IC/BPS had urine cytokine profiles that differed from those of controls. Between patients with ESSIC type 1 and 2 IC/BPS, urine cytokine profiles were also different. Among cytokines with high diagnostic values (i.e., area under the curve > 0.7) with respect to distinguish patients with ESSIC type 2 IC/BPS from controls, regulated upon activation, normal T cell expressed and presumably secreted (RANTES), macrophage inflammatory protein (MIP)-1β, and IL-8 were of higher sensitivity, whereas macrophage chemoattractant protein (MCP)-1, chemokine (C-X-C motif) ligand 10 (CXCL10), and eotaxin-1 were of higher specificity. In multivariate logistic regression models controlling for age, sex, body mass index, and diabetes mellitus, the urine cytokines with high diagnostic values (MCP-1, RANTES, CXCL10, IL-7, and eotaxin-1) remained statistically significant in differentiating IC/BPS and controls. MCP-1, CXCL10, eotaxin-1, and RANTES were positively correlated with glomerulation grade and negatively correlated with maximal bladder capacity. In conclusion, patients with IC/BPS had urine cytokine profiles that clearly differed from those of controls. Urine cytokines might be useful as biomarkers for diagnosing IC/BPS and mapping its clinical characteristics.

Application of Adult and Pluripotent Stem Cells in Interstitial Cystitis/Bladder Pain Syndrome Therapy: Methods and Perspectives

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a multifactorial, chronic disease without definite etiology characterized by bladder-related pelvic pain. IC/BPS is associated with pain that negatively affects the quality of life. There are various therapeutic approaches against IC/BPS. However, no efficient therapeutic agent against IC/BPS has been discovered yet. Urothelium dysfunction is one of the key factors of IC/BPS-related pathogenicity. Stem cells, including adult stem cells (ASCs) and pluripotent stem cells (PSCs), such as embryonic stem cells (ESCs) and induced PSCs (iPSCs), possess the abilities of self-renewal, proliferation, and differentiation into various cell types, including urothelial and other bladder cells. Therefore, stem cells are considered robust candidates for bladder regeneration. This review provides a brief overview of the etiology, pathophysiology, diagnosis, and treatment of IC/BPS as well as a summary of ASCs and PSCs. The potential of ASCs and PSCs in bladder regeneration via differentiation into bladder cells or direct transplantation into the bladder and the possible applications in IC/BPS therapy are described in detail. A better understanding of current studies on stem cells and bladder regeneration will allow further improvement in the approaches of stem cell applications for highly efficient IC/BPS therapy.

BDNF promotes activation of astrocytes and microglia contributing to neuroinflammation and mechanical allodynia in cyclophosphamide-induced cystitis

BACKGROUND

Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) often grieve over a low quality of life brought about by chronic pain. In our previous studies, we determined that neuroinflammation of the spinal dorsal horn (SDH) was associated with mechanisms of interstitial cystitis. Moreover, it has been shown that brain-derived neurotrophic factor (BDNF) participates in the regulation of neuroinflammation and pathological pain through BDNF-TrkB signaling; however, whether it plays a role in cyclophosphamide (CYP)-induced cystitis remains unclear. This study aimed to confirm whether BDNF-TrkB signaling modulates neuroinflammation and mechanical allodynia in CYP-induced cystitis and determine how it occurs.

METHODS

Systemic intraperitoneal injection of CYP was performed to establish a rat cystitis model. BDNF-TrkB signaling was modulated by intraperitoneal injection of the TrkB receptor antagonist, ANA-12, or intrathecal injection of exogenous BDNF. Mechanical allodynia in the suprapubic region was assessed using the von Frey filaments test. The expression of BDNF, TrkB, p-TrkB, Iba1, GFAP, p-p38, p-JNK, IL-1β, and TNF-α in the L6-S1 SDH was measured by Western blotting and immunofluorescence analysis.

RESULTS

BDNF-TrkB signaling was upregulated significantly in the SDH after CYP was injected. Similarly, the expressions of Iba1, GFAP, p-p38, p-JNK, IL-1β, and TNF-α in the SDH were all upregulated. Treatment with ANA-12 could attenuate mechanical allodynia, restrain activation of astrocytes and microglia and alleviate neuroinflammation. Besides, the intrathecal injection of exogenous BDNF further decreased the mechanical withdrawal threshold, promoted activation of astrocytes and microglia, and increased the release of TNF-α and IL-1β in the SDH of our CYP-induced cystitis model.

CONCLUSIONS

In our CYP-induced cystitis model, BDNF promoted the activation of astrocytes and microglia to release TNF-α and IL-1β, aggravating neuroinflammation and leading to mechanical allodynia through BDNF-TrkB-p38/JNK signaling.

Therapeutic efficacy of mirabegron 25 mg monotherapy in patients with nocturia-predominant hypersensitive bladder

Objective:

The objective of this study was to evaluate the efficacy of mirabegron 25 mg daily in patients with nocturia-predominant hypersensitive bladder (HSB).

Materials and Methods:

This study prospectively investigated 219 consecutive patients with nocturia-predominant HSB and treated with mirabegron 25 mg daily from July 2015 to 2016. Patient with nocturia episode decreased by ≥1/night after treatment was considered successful. The subjective symptom score, such as International Prostate Symptom Score (IPSS), Quality of life index, Overactive Bladder Symptom Score (OABSS), Urgency Severity Scale, patient perception of bladder condition (PPBC), and nocturia episodes per night, was assessed before and 1 month after mirabegron treatment and between successful and failed groups.

Results:

A total of 219 patients, including 51 women and 168 men, were enrolled. The mean age of the population was 72.3 ± 11.0 years. Totally, 58 (26.5%) of the patients had improvement in nocturia at 1 month after treatment. Among them, 14 (27.5%) women and 44 (26.2%) men had improvement in nocturia episodes after treatment (P = 0.858). Compared the clinical data between successful and failed group, the baseline symptom scores were more severe in successful group, including IPSS-storage subscore (4.84 ± 2.09 vs. 4.11 ± 2.19, P = 0.031), OABSS (3.21 ± 0.67 vs. 2.91 ± 1.00, P = 0.037), and nocturia episodes (3.81 ± 0.95 vs. 3.095 ± 1.32, P = 0.000). Multivariate analysis revealed only a higher nocturia episodes (P = 0.046) predict a successful treatment result. Mirabegron 25 mg daily significantly improved PPBC score along the 3 months' follow-up (P < 0.05), and postvoid residual volume did not increase after mirabegron treatment in overall patients.

Conclusions:

Mirabegron 25 mg daily treatment showed a limited therapeutic effect on nocturia-predominant HSB patients. The patients with higher OAB symptoms predict a successful result.

[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

Urinary physiology and hypoxia: a pilot study of moderate-altitude trekking effects on urodynamic indexes

Exposure to high altitude is one of the most widely used models to study the adaptive response to hypoxia in humans. However, little is known about the related effects on micturition. The present study addresses the adaptive urinary responses in four healthy adult lowlanders, comparing urodynamic indexes at Kathmandu [1,450 m above sea level (a.s.l.); K1450] and during a sojourn in Namche Bazar (3,500 m a.s.l.; NB3500). The urodynamic testing consisted of cistomanometry and bladder pressure/flow measurements. Anthropometrics, electrocardiographic, and peripheral capillary oxygen saturation data were also collected. The main findings consisted of significant reductions in bladder power at maximum urine flow by ~30%, bladder contractility index by 13%, and infused volume both at first (by 57%) and urgency sensation (by 14%) to urinate, indicating a reduced cystometric capacity, at NB3500. In addition to the urinary changes, we found that oxygen saturation, body mass index, body surface area, and median RR time were all significantly reduced at altitude. We submit that the hypoxia-related parasympathetic inhibition could be the underlying mechanism of both urodynamic and heart rate adaptive responses to high-altitude exposure. Moreover, increased diuresis and faster bladder filling at altitude may trigger the anticipation of being able to void, a common cause of urgency. We believe that the present pilot study represents an original approach to the study of urinary physiology at altitude.

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

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

Variations in bladder pain syndrome/interstitial cystitis (IC) definitions, pathogenesis, diagnostics and treatment: a systematic review and evaluation of national and international guidelines

INTRODUCTION AND HYPOTHESIS

Interstitial cystitis (IC) and bladder pain syndrome (BPS) are challenging and encompassing hypersensitivity disorders of the lower urinary tract. A variety of national and international guidelines have been published including guidance on nomenclature, definitions, etiopathology, diagnostics and treatment. A lack of universally established clinical guidance is apparent. The aim of this review is to evaluate key guidelines on this area of practice, identify variations, compare their recommendations and grade them using AGREE II.

METHODS

Literature searches were performed using the PUBMED and CINAHL database from January 1, 1983, to December 1, 2018, referring to the search strategy of AUA. Ten national and international guidelines were included into the analysis. We assessed the guidelines with the updated AGREE II.

RESULTS

Symptoms congruent in all guidelines are: pain, pressure, discomfort and frequency, urgency and nocturia. Urinalysis is a prerequisite for diagnostics, cystoscopy for most and urodynamics not part of the routine assessment. Treatment options are recommended stepwise. The highest level of evidence and consensus was identified for oral therapies. Nine guidelines had an overall quality score ≥ 50% and three scored ≥ 70% (AUA, GG, RCOG).

CONCLUSIONS

The guidelines are congruent in symptom reporting, quite congruent in diagnostics and vary to a high degree on treatment recommendations. The complexity of BPS and emerging evidence indicate the need for regular updating of the guidelines and a wider consensus.

Bladder pain syndrome: Prevalence and routine clinical practice in women attending functional urology and urodynamics units in Spain

INTRODUCTION AND OBJECTIVES

Bladder pain syndrome (BPS) is classified as a rare chronic debilitating disease and its diagnosis presents a challenge because its symptoms overlap with those associated with overactive bladder syndrome. The aim of the routine study was to estimate the prevalence of BPS and discover to study the profile of symptoms and clinical practice for patients attending functional urology and urodynamics units.

MATERIAL AND METHODS

An epidemiological study in which 37 functional urology and urodynamics units in Spain participated. The prevalence was studied in both sexes. Clinical practice was evaluated for 319 women with BPS (new diagnosis or under review). Clinical and sociodemographic data were collected retrospectively. The results were studied of urine tests, cystoscopy, biopsy, physical examination, bladder diary, and those of the four available questionnaires: Patient Perception of Bladder Condition; Bladder Pain/Interstitial Cystitis Symptom Score; EuroQoL-5 Dimensions-5L and Patient Global Impression of Severity.

RESULTS

Five point four percent (503) of the patients who attended these units (9,312) had a diagnosis of BPS (90% [453] females). The tests that were performed most according to the clinical history and anamnesis were: urine test, bladder ultrasound and cystoscopy. The most common symptoms/comorbidities were: pain in the bladder region, increased urinary frequency, nocturia, anxiety and depression. Diagnostic assessment determined pain on hydrodistension (86.9%), positive biopsy (59.2%), myofascial pelvic pain (28.4%), urological phenotype (97.8%), and increased urinary frequency (88.7%). The questionnaires reflected how much the quality of life of these patients was affected.

CONCLUSIONS

The prevalence of BPS in functional urology and urodynamics units in Spain is low. No homogeneity was observed in terms of diagnosis between the different participating centres. Therefore, a common methodology is required for the management of patients with BPS in these units, with tools specific to this disorder.

Cystoscopic evaluation and clinical phenotyping in interstitial cystitis/bladder pain syndrome

Herein, we aimed to review, report, and discuss the role of cystoscopy and clinical phenotyping in interstitial cystitis/bladder pain syndrome (IC/BPS). For this purpose; a comprehensive nonsystematic review of the relevant literature was conducted. We reviewed articles published in English and indexed in the PubMed, Embase, and Google Scholar databases. Original manuscripts, review articles, case series, and case reports were taken into consideration. Data regarding the indications for, technique, and possible findings of cystoscopy with hydrodistension (HD) and biopsy, as well as clinical implications of cystoscopic information and the concept and use of clinical phenotyping within the context of IC/ BPS were extracted and discussed. IC/BPS is diagnosed based on symptomatic assessment and exclusion of confusable diseases. There is no universal agreement upon the evaluation and diagnostic algorithm of IC/BPS. The majority of the guidelines recommend cystoscopy with HD and biopsy as a diagnostic prerequisite. Various different techniques have been described for cystoscopy with HD. General or epidural anesthesia is more commonly preferred and advocated while assessing endoscopic alterations in patients suspected of having IC/BPS. Cystoscopy with HD and biopsy enables more objective exclusion of confusable diseases. It also provides the basis of the European Society for the Study of Interstitial Cystitis classification. Patients with IC/BPS who demonstrate positive cystoscopic (glomerulations and/or Hunner lesion) and histologic findings have a more severe symptomatology and may benefit from lesion-targeted endoscopic treatments. Clinical phenotyping has been implemented for IC/BPS and may be used for individualized assessment and treatment.

Guideline of guidelines: bladder pain syndrome

OBJECTIVES

Bladder pain syndrome (BPS) is a debilitating condition which can be difficult to diagnose and treat due to the lack of consensus on aetiology, definition, and management. The aim of this review is to summarise the findings from major national and international guidelines on the management of BPS, highlighting areas of disagreement and uncertainty.

METHODS

We performed a Medline/PubMed search from 1st January 2000 to 31st December 2017 in order to identify relevant guidelines addressing BPS/interstitial cystitis. We also manually searched the websites of major national and international societies. The following guidelines were included in this review: European Association of Urology, American Urological Association, International Society for the Study of BPS, International Consultation on Incontinence, International Continence Society, East Asian guideline, Royal College of Obstetricians and Gynaecologists/British Society of Urogynaecology, and the Canadian Urological Association.

RESULTS

There is disagreement between guidelines on the exact definition of BPS and the nomenclature to use to describe this condition. However, all agree that the diagnosis is dependent on the presence of pain, pressure, or discomfort, in addition to at least one urinary symptom, in the absence of other diseases that could cause pain. Exclusion of other pathology that could cause similar symptoms requires thorough evaluation, and is recommended in all guidelines. There is also disparity in the recommended diagnostic investigation of BPS, with hydrodistension and bladder biopsy either recommended, considered optional, or not recommended, by different guidelines. It is accepted that BPS can be diagnosed clinically, without invasive investigation, but cystoscopy and diagnostic hydrodistension aids sub-typing of patients and may help direct treatment strategies. Patients should be phenotyped in order to direct multimodal treatment (including behavioural, physical, emotional, and psychological therapy), and treatments should follow a stepwise approach starting with the most conservative. Although widely performed, hydrodistension as a therapeutic strategy has a limited evidence base and is unlikely to provide long-term resolution of symptoms CONCLUSION: There are multiple national and international guidelines for the diagnosis and management of BPS, and this review has highlighted the differences in nomenclature, definitions, and recommended diagnostic tests between guidelines. The overall evidence base for the majority of treatments for BPS/IC is of low-quality, and larger randomised trials are required to more accurately inform guideline recommendations and clinical management of this complex group of patients.

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

INTRODUCTION

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