Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms

OBJECTIVE

To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks.

RESULTS

Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother).

CONCLUSION

A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

The fundamentals of chronic pelvic pain assessment, based on international continence society recommendations

AIMS

Chronic pelvic pain (CPP) is defined as a noncyclical pain that has duration of at least 6 months and can lead to decreased quality of life and physical performance. The pain can be attributed to problems in the pelvic organs and/or problems in related systems, and possible psycho-social attributes may contribute to the manifestation. Due to the complex nature, CPP syndromes are multifactorial and the terminology needs to reflect the setting.

METHODS

The current review is a synthesis of key aspects of the recent International Continence Society Standardization for Terminology in CPP Syndromes.

RESULTS

Nine domains can be used for a detailed description of CPP. They include four domains specific to the pelvic organs (lower urinary tract, female genital, male genital, gastrointestinal), two related to other sources of pain which may be perceived in the pelvis (musculoskeletal, neurological) and three which may influence the response to the pain or its impact on the individual (psychological, sexual, and comorbidities). For an individual patient with CPP, each domain should be reviewed in terms of symptoms and signs, noting that positive findings could reflect either a primary cause or a secondary consequence. The findings will guide further evaluations and subsequent treatment.

CONCLUSION

We present a synthesis of the standard for terminology in CPP syndromes in women and men, which serves as a systematic framework to consider possible sources of pain (pelvic organs or other sources) and the individual responses and impact.

Gynecological associated disorders and management

BACKGROUND

Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management.

METHODS

An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed.

RESULTS

Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery.

CONCLUSION

Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.

Thermal and Mechanical Pain Thresholds of Women With Provoked Localized Vulvodynia: A Pilot Study

Context

Vulvodynia is a chronic pain condition defined as vulvar pain lasting at least 3 months in the absence of gross anatomic or neurologic findings. Provoked, localized vulvodynia (PLV), a subtype of vulvodynia, is characterized by vestibular pain in response to light touch. The cause of PLV remains largely unknown, and triggering events have yet to be determined.

Objective

To evaluate vestibular and peripheral experimental pain thresholds in patients with PLV to further define the somatosensory profile of these patients.

Methods

After informed consent was provided, eligible participants completed a questionnaire and underwent quantitative sensory testing at the forearm and posterior vestibule. Detection and pain thresholds to thermal (cold and heat) and mechanical (pressure) stimuli were measured.

Results

Seventeen participants with PLV and 16 control participants were included. Participants in the PLV group scored lower on the patient health questionnaire 9 (PHQ-9) compared with those in the control group (P<.05) and had higher ratings of self-reported genital pain with sex (P<.001) and daily activity (P<.05). Forearm pain thresholds to cold (P<.01) and heat (P<.01) stimuli were also lower in the PLV group compared with those in the control group. Vestibular pain thresholds to cold (P<.05) and pressure (P<.01) stimuli were also lower in the PLV group.

Conclusion

Lower scores on the PHQ-9 and higher self-reported genital pain ratings of patients with PLV highlight the significant impact of this poorly understood condition on quality of life. Quantitative sensory testing results demonstrated that vestibular cold allodynia may be a somatosensory feature of PLV. Reduced forearm pain thresholds in these patients suggest altered sensory processing at extrapelvic sites, although it is unclear whether these measurements are related to central sensitization.

The evaluation and management of female sexual dysfunction

Female sexual dysfunction has complex physiologic and psychological components that require a detailed screening, history, and physical examination. Our goal in this review is to provide family physicians with insights and practical advice to help screen, diagnose, and treat female sexual dysfunction, which can have a profound impact on patients' most intimate relationships.

A novel approach to mesh revision after sacrocolpopexy

Pelvic organ prolapse (POP) is the herniation of pelvic organs to or beyond the vaginal walls. POP affects 50% of parous women; of those women, 11% will need surgery based on bothersome symptoms. Transvaginal mesh has been used for vaginal augmentation since the 1990s. Complications from mesh use are now more prominent, and include chronic pelvic pain, dyspareunia, vaginal mesh erosion, and urinary and defecatory dysfunction. Presently, there is no consensus regarding treatment of these complications. Reported herein are two cases of women with defecatory dysfunction and pain after sacrocolpopexy who underwent mesh revision procedures performed with both urogynecologic and colorectal surgery.

A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society

AIMS

Terms used in the field of chronic pelvic pain (CPP) are poorly defined and often confusing. An International Continence Society (ICS) Standard for Terminology in chronic pelvic pain syndromes (CPPS) has been developed with the aim of improving diagnosis and treatment of patients affected by chronic pelvic pain syndromes. The standard aims to facilitate research, enhance therapy development and support healthcare delivery, for healthcare providers, and patients. This document looks at the whole person and all the domains (organ systems) in a systematic way.

METHODS

A dedicated working group (WG) was instituted by the ICS Standardisation Steering Committee according to published procedures. The WG extracted information from existing relevant guidelines, consensus documents, and scientific publications. Medline and other databases were searched in relation to each chronic pelvic pain domain from 1980 to 2014. Existing ICS Standards for terminology were utilized where appropriate to ensure transparency, accessibility, flexibility, and evolution. Consensus was based on majority agreement.

RESULTS

The multidisciplinary CPPS Standard reports updated consensus terminology in nine domains; lower urinary tract, female genital, male genital, gastrointestinal, musculoskeletal, neurological aspects, psychological aspects, sexual aspects, and comorbidities. Each is described in terms of symptoms, signs and further evaluation.

CONCLUSION

The document presents preferred terms and definitions for symptoms, signs, and evaluation (diagnostic work-up) of female and male patients with chronic pelvic pain syndromes, serving as a platform for ongoing development in this field. Neurourol. Urodynam. 36:984-1008, 2017. © 2016 Wiley Periodicals, Inc.

Complementary and alternative medical therapies for interstitial cystitis: an update from the United States

The diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) has shifted from organ-specific to a multifactorial, multidisciplinary and individualized approach. Patients with refractory and debilitating symptoms may respond to complementary and alternative medical treatments (CAM). Through CAM therapies, practitioners assist the patient to be at the center of their care, empowering them to be emotionally and physically involved. Multi-disciplinary care, including urology, gynecology, gastroenterology, neurology, psychology, physiotherapy and pain medicine, is also identified to be the crux of adequate management of patients with chronic pelvic pain because of its variable etiology. The purpose of this review is to emphasize these changes and discuss management strategies.

Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder pain syndrome: insights from a randomized, double-blind, placebo controlled study

PURPOSE

We compared the efficacy and safety of the currently recommended dose of pentosan polysulfate sodium with a third of the daily dose and with placebo.

MATERIALS AND METHODS

In this multicenter, double-blind, randomized, placebo controlled study 368 adults with interstitial cystitis/bladder pain syndrome, defined as an ICSI total score of 8 or greater and a score of greater than 0 on the 4 ICSI component items, received pentosan polysulfate sodium 100 mg once daily or 3 times daily, or matching placebo for 24 weeks. Study eligibility was not based on cystoscopy findings. ICSI was administered at baseline, and at weeks 4, 8, 12, 18 and 24. Unblinded interim analysis performed at 6 years with 54% of the target number of 645 patients enrolled resulted in early study termination.

RESULTS

There was no statistically significant difference between the pentosan polysulfate sodium group and the placebo group or between the 2 pentosan polysulfate sodium groups for the primary end point, defined as responder achieving a 30% or greater reduction from the baseline ICSI total score at study end. This primary end point was achieved by 48 of 118 patients (40.7%) in the placebo group, and by 51 of 128 (39.8%) and 52 of 122 (42.6%) in the pentosan polysulfate sodium 100 mg once daily and 3 times daily groups, respectively. Pentosan polysulfate sodium was well tolerated with a similar percent of patients (range 10.2% to 13.3%) across the groups discontinuing due to an adverse event.

CONCLUSIONS

Results of this study in a broad population of patients with symptoms consistent with interstitial cystitis revealed no treatment effect vs placebo for pentosan polysulfate sodium at the currently established dose or at a third of the daily dose.

The impact of neuropathic pain in the chronic pelvic pain population

PURPOSE

Patients with chronic pelvic pain disorders often present with neuropathic features. We examined a cohort of patients with a primary complaint of chronic pelvic pain for the presence of neuropathic pain symptoms.

MATERIALS AND METHODS

Patients with chronic pelvic pain disorders from 2 tertiary referral centers were prospectively evaluated. The validated S-LANSS (Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs) survey was used to examine pain symptoms of neuropathic origin. Patients completed SF-12v2™ to assess mental/physical health domains. The 2-tailed t test and chi-square analysis were used to compare physical and mental component summaries in patients with vs without neuropathic symptoms.

RESULTS

A total of 142 patients mean age of 45 years were included in analysis. Of the patients 72.5% with chronic pelvic pain carried more than 1 primary diagnosis. The S-LANSS survey identified symptoms suggestive of neuropathic pain in 44 patients (31%). A greater proportion of patients with a neuropathic component had altered sensation in the affected area (86.4% vs 24.5%). Patients with neuropathic pain scored 4.28 and 5.45 points lower on the physical and mental component summaries (p = 0.053 and 0.008, respectively).

CONCLUSIONS

A large proportion of patients with chronic pelvic pain present with neuropathic features and report decreased quality of life compared with the general population. Those with neuropathic symptoms have significantly lower quality of life than those without such symptoms. Clinicians can identify patients to use targeted therapies and use a multidisciplinary approach to care.

When to suspect interstitial cystitis

The symptom profile and comorbidities associated with this painful condition can make it difficult to diagnose--unless you know what to look for.

Depression, abuse and its relationship to interstitial cystitis

This study evaluated the prevalence of depression, sexual abuse, and physical abuse among women diagnosed with interstitial cystitis (IC). One hundred forty-one subjects completed the validated Beck's Depression Inventory II Questionnaire (BDI-II) and the validated Drossman Abuse Questionnaire. Ninety-seven (69%) subjects scored 14 or higher on the BDI-II, corresponding to depression. When compared to the US prevalence of 9%, this was significantly higher. Fifty-one subjects (36%) reported sexual abuse which is higher than the US average. The prevalence of childhood sexual abuse in the sample was not significantly different than the US average. The prevalence of physical abuse in the sample was not statistically different than the US average. Women with IC appear to have a higher prevalence of depression and sexual abuse than the general population. Women with IC should be screened for depression and abuse and referred to a mental health expert as necessary for treatment.

Bilateral S3 Stimulator in Patients with Interstitial Cystitis

OBJECTIVES

To show the value of placing bilateral sacral nerve stimulators in patients diagnosed with interstitial cystitis with the symptoms of frequency, urgency, and pain.

METHODS

A retrospective chart review was performed of patients who had had bilateral S3 stimulators placed during a 6-month period. At consultation immediately before undergoing the procedure and on subsequent postoperative visits, these patients completed the Urinary Distress Inventory short form and voiding diaries. Patients were excluded if sacroneuromodulation had been attempted to be placed previously, if patients had any identifiable neurologic deficits, or if they had any evidence of urinary retention.

RESULTS

The mean age of the 15 patients was 43.2 years, with a mean follow-up of 14.1 months. Student's t test was used to compare the preoperative and postoperative values. The mean decrease in frequency and nocturia was 10.4 voids (P <0.001) and 2.6 voids (P <0.001), respectively. The change in the Urinary Distress Inventory short form showed that patients had satisfaction postoperatively (P <0.001). Four patients also noted improvement in fecal incontinence after the procedure, with a mean decrease in episodes of 2.75 (P <0.01).

CONCLUSIONS

The results of this study have demonstrated that patients with bilateral stimulator placement have a significant decrease in frequency and nocturia with postoperative satisfaction. Also, evidence of possible improvement in the daily episodes of fecal incontinence was demonstrated.

Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction

OBJECTIVES

To evaluate the effectiveness of transvaginal manual therapy of the pelvic floor musculature (Thiele massage) in symptomatic female patients with interstitial cystitis and high-tone dysfunction of the pelvic floor.

METHODS

A total of 21 women with documented interstitial cystitis and high-tone pelvic floor dysfunction underwent transvaginal massage using the Thiele technique twice a week for 5 weeks. Symptoms were evaluated before massage, at protocol conclusion, and at a mean of 4.5 months after therapy completion (long-term follow-up). The response to treatment was evaluated through the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes, Likert Visual Analogue Scales for urgency and pain, and Short-Form 12-item (SF-12) Quality-of-Life Scale, and through changes in the physical examination findings using a 5-point modified Oxford Scale to document pelvic floor tenderness.

RESULTS

A statistically significant improvement was seen in the Symptom and Problem Indexes of the O'Leary-Sant Questionnaire (P = 0.015 and P = 0.039, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.001 and P = 0.005, respectively), the Physical and Mental Component Summary from the SF-12 Quality-of-Life Scale (P = 0.049 and P = 0.044, respectively), and the modified Oxford Scale (P <0.05) after protocol completion. At long-term follow-up, the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes (P = 0.049 and P = 0.02, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.004 and P = 0.005, respectively), and modified Oxford Scale for three of four muscles in the pelvic floor (P <0.05) remained significantly improved.

CONCLUSIONS

Thiele massage appears to be very helpful in improving irritative bladder symptoms in patients with interstitial cystitis and high-tone pelvic floor dysfunction in addition to decreasing pelvic floor muscle tone.

Intravesical resiniferatoxin for the treatment of interstitial cystitis: a randomized, double-blind, placebo controlled trial

PURPOSE

Interstitial cystitis is a painful bladder condition of unknown etiology and poorly understood pathophysiology. Current therapies have met with limited success. Vanilloid receptor agonists such as resiniferatoxin (RTX) desensitize C-fibers that transmit pain; it is hypothesized that such drugs will be effective in the treatment of interstitial cystitis and painful bladder syndrome by decreasing the pain that leads to urinary frequency and urgency.

MATERIALS AND METHODS

A randomized, double-blind, placebo controlled study was conducted in 163 patients with interstitial cystitis. Participants were randomly assigned to receive a single intravesical dose of 50 ml of either RTX 0.01 microM, 0.05 microM, 0.10 microM, or placebo. Safety and efficacy was evaluated over 12 weeks. The primary efficacy endpoint was the Global Response Assessment, a 7-point scale rating overall change in symptoms of interstitial cystitis after 4 weeks. Secondary efficacy endpoints included reduction in pain, urgency, frequency, nocturia, average void volume, and the O'Leary-Sant Symptom and Problem Indexes.

RESULTS

RTX did not improve overall symptoms, pain, urgency, frequency, nocturia, or average void volume during 12 weeks followup. RTX resulted in a dose-dependent increase in the incidence of instillation pain, but was otherwise generally well tolerated.

CONCLUSIONS

In the largest prospective, randomized clinical trial reported to date with intravesical vanilloid therapy, single administration of RTX at doses of 0.01 microM to 0.10 microM was not effective in patients with interstitial cystitis.

Capsaicin for the treatment of vulvar vestibulitis

OBJECTIVE

The purpose of this study was to evaluate the use of local capsaicin cream as an effective treatment for patients with documented vulvar vestibulitis syndrome.

STUDY DESIGN

A retrospective chart review was performed for patients who received a diagnosis of vulvar vestibulitis syndrome that was treated with capsaicin. Patients performed local application of capsaicin 0.025% cream for 20 minutes daily for 12 weeks. A comparison was made between the pre- and posttreatment Kaufman touch test to evaluate discomfort. The Marinoff dyspareunia scale was also used to assess pre- and posttreatment.

RESULTS

The sum of the Kaufman touch test scores before the treatment (13.2 +/- 4.9) compared with the scores after treatment (4.8 +/- 3.8) was statistically improved (P < .001). A significant improvement was also observed at each individual site (P < .001). The Marinoff dyspareunia scale also showed a significant improvement (P < .001).

CONCLUSION

Vulvar vestibulitis syndrome that is treated with capsaicin significantly decreases discomfort and allows for more frequent sexual relations.

Interstitial cystitis and pelvic floor dysfunction: a comprehensive review

Interstitial cystitis is a clinical condition occurring predominantly in women and is characterized by urinary frequency, urgency, and pain. Patient symptoms have the potential to significantly affect quality of life, posing a challenge to some to perform activities of daily living. This article comprehensively reviews the literature on the epidemiology, etiology, evaluation, and treatment of interstitial cystitis, and considers commonly associated pelvic floor dysfunction.

Sacral neuromodulation in patients with interstitial cystitis: a multicenter clinical trial

Female patients with interstitial cystitis (IC) unresponsive to standard oral and intravesical therapy were enrolled at three clinical sites for percutaneous sacral nerve root stimulation (PNS) in a prospective, observational pilot study. Evaluation was in the form of a 3-day voiding diary completed both prior to and following the commencement of sacral nerve root stimulation. Symptoms were also assessed by the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indices (ICSI and ICPI). Baseline and test stimulation values for voiding diary parameters and O'Leary-Sant scores were compared to determine treatment efficacy. A total of 33 patients were enrolled. Statistically significant improvements were seen in frequency, pain, average voided volume and maximum voided volume. Significant improvements were also seen in ICSI and ICPI scores. Subacute PNS appears to be effective in reducing symptom severity and increasing voided volumes in patients with IC previously unresponsive to standard therapy.

Current management of interstitial cystitis

The management of patients with IC remains a challenge because no single agent has proven universally effective. DMSO and PPS have been evaluated through early placebo-controlled trials, and these two agents are FDA approved treatments for IC. BCG is currently undergoing a large placebo-controlled trial, and hyaluronic acid is receiving similar clinical evaluation. Sacral nerve root stimulation shows promise with early favorable results. As with any treatment algorithm, it is reasonable to begin with conservative treatment using time-dependent milestones, allowing adequate trials of successive therapy while ensuring an appropriate pace for timely symptom resolution.

Complementary and alternative therapies as treatment approaches for interstitial cystitis

The management of interstitial cystitis (IC) is predominantly the reduction of the symptoms of frequency, urgency, and pain. Multimodal treatment approaches for IC are helpful in customizing therapy for individual patients. Complementary and alternative therapies are a quintessential addition to the therapeutic armamentarium and frequently include dietary modification, nutraceuticals, bladder training, neuromodulation, stress reduction, and sex therapy. Dietary modification involves elimination of bladder irritants, fluid regulation, and a bowel regimen. Nutraceuticals studied for the treatment of IC include calcium glycerophosphate, L-arginine, mucopolysaccharides, bioflavinoids, and Chinese herbs. Bladder training is effective after pain reduction. The neuromodulation of high-tone pelvic-floor muscle dysfunction is achieved with physical therapy and acupuncture. Stress reduction and sex therapy are best administered by a qualified stress manager and sex therapist. Multimodal, nonconventional management may add efficacy to the treatment of IC.

Lack of effect following repeated in vivo exposure of the rabbit urinary bladder to urine from interstitial cystitis patients at low infusion volumes

We reported previously that substances in interstitial cystitis urine, when infused into the rabbit bladder, induce changes that resemble bladders of interstitial cystitis (IC) patients. Here we report our investigation of the effect of additional molecular weight subfractions of IC urine and lower infusion volume in this rabbit bladder bioassay. Urine was pooled from symptomatic IC patients, asymptomatic IC patients (in remission), and normal volunteers. Two fractions of 20x concentrated urine were obtained for each of the 3 groups: a 10-100-kD fraction and a fraction > 100 kD but <0.22 microm. Six rabbits per group were infused twice per week with 6 ml of 1 of these 6 urine fractions or saline as a control. After 6 weeks, each rabbit was cystoscoped before and after hydrodistension, bladder capacity and urea permeability were determined, and the bladder was removed for histologic examination. A questionnaire revealed a significant difference (P < 0.01) regarding voiding symptom severity between symptomatic IC patients and both normal volunteers and IC patients in remission. There was no statistically significant difference among groups of rabbits in cystoscopic bladder appearance, bladder capacity, urea permeability, or bladder histology. If a urine-borne factor is in part responsible for IC symptoms, the rabbit bladder must be filled with urine to near capacity to be able to detect a difference between IC and normal urine in this rabbit bladder bioassay.

Hydrogel/silver ion-coated urinary catheter reduces nosocomial urinary tract infection rates in intensive care unit patients: a multicenter study

OBJECTIVES

Indwelling urinary catheters are the leading source of nosocomial urinary tract infections (NUTIs). The Bardex I.C. catheter is a hydrogel latex Foley catheter with a monolayer of silver metal applied to the inner and outer surfaces of the catheter. We investigated the Bardex I.C. catheter for its ability to decrease the NUTI rate in critical care units.

METHODS

Five hospitals participated in a blind prospective study, exchanging the standard latex Foley catheter for the Bardex I.C. Foley catheter. The device use rate and NUTI rate were monitored. Data were collected and analyzed using Wilcoxon rank sum test and four-way analysis of variance. A cost analysis was also performed.

RESULTS

The baseline period, intervention period, and number of device days was similar for both periods. The unadjusted catheter-associated infection rate during the baseline and intervention periods was 7.1 and 4.5 infections per 1000 catheter days, respectively (P <0.01). The adjusted catheter-associated infection rate during the baseline and intervention periods was 8.1 and 4.9 infections per 1000 catheter days, respectively. This was not statistically significant (P = 0. 13).

CONCLUSIONS

A trend toward a reduction in NUTIs with the use of the hydrogel/silver-coated catheter was noted in all intensive care units at each institution as shown by the unadjusted and adjusted catheter-associated infection rates. One hospital demonstrated a statistically significant reduction in NUTIs. However, statistical significance was not met when the results were adjusted. The cost analysis at one institution demonstrated cost savings with the use of the silver-coated catheter. Future analysis may require a double-blind, prospective-controlled study of longer duration to reach statistical significance.

Antiproliferative activity is present in bladder but not renal pelvic urine from interstitial cystitis patients

PURPOSE

To determine whether an antiproliferative urine factor that we previously discovered to be specific for urine from interstitial cystitis (IC) patients originated in the lower urinary tract or a more proximal site.

MATERIALS AND METHODS

Sequential catheterized urine specimens were collected under sterile conditions from the bladder and renal pelvis of 20 IC patients and one control patient (with stress incontinence). Antiproliferative activity was determined by 3H-thymidine incorporation of primary normal adult bladder epithelial cells cultured with pH- and osmolality-corrected bladder or ureteral urine specimens; significant inhibition was defined as a change in 3H-thymidine incorporation greater than 2 standard deviations from the mean of control cells.

RESULTS

Bladder urine specimens from 19 of 20 IC patients significantly inhibited 3H-thymidine incorporation as compared to cell medium alone (mean change for bladder specimens = -68.7+/-7.5%), while a renal pelvic specimen from only 1 of 20 IC patients inhibited proliferation significantly (mean change for renal pelvic specimens = 3.2+/-3.4%) (p<.001 by Fisher's exact test). The one inhibitory IC renal pelvic specimen inhibited by 31% while a bladder specimen obtained during the same procedure inhibited by 94%. In comparison, neither bladder nor renal pelvic urine from the control patient had inhibitory activity.

CONCLUSIONS

The antiproliferative factor previously found in the urine of IC patients appears to be made and/or activated in the distal ureter or urinary bladder.

The interstitial cystitis symptom index and problem index

OBJECTIVES

To develop 2 brief self-administered indices for measuring lower urinary tract symptoms and their impact in patients with interstitial cystitis (IC).

METHODS

An initial set of questions was developed and evaluated in focus groups. The index was revised, shortened, and validated with patients diagnosed in 3 large urologic practices with experience in interstitial cystitis (N = 45). Controls were recruited from a group of healthy volunteers in a gynecology clinic (N = 67). Internal consistency, construct validity, and test-retest reliability were evaluated.

RESULTS

The IC symptom index and the IC problem index measure urinary and pain symptoms and assesses how problematic symptoms are for patients with interstitial cystitis. Psychometric performance of both instruments is good, with the symptom index demonstrating excellent ability to discriminate characteristics between patients and controls.

CONCLUSION

Both indices should be useful in the evaluation and management of patients with IC and should be particularly useful in clinical trials of new therapies for this condition, where reliable, validated, and reproducible outcome measures are critically important.

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial

OBJECTIVE

Our purpose was to determine the efficacy of transvaginal electrical stimulation in treating genuine stress incontinence.

STUDY DESIGN

This was a multicenter, prospective, randomized, double-blind, placebo-controlled 15-week trial comparing the use of an active pelvic floor stimulator with a sham device. Thirty-five women used an active unit and 17 control subjects used sham devices. Weekly and daily voiding diaries were recorded throughout the trial. Urodynamic testing, including pad test and subtracted cystometry, was done before and at the end of device use. Pelvic muscle strength was measured at baseline and at the end of the trial. Patients scored their symptoms on visual analog scales and completed quality-of-life questionnaires before and after therapy.

RESULTS

Significant improvements from baseline were found in patients using active devices but not in controls. Comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = 0.009) and daily (p = 0.04) leakage episodes, pad testing (p = 0.005), and vaginal muscle strength (p = 0.02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = 0.007) and stress incontinence (p = 0.02), as well as for subjective reporting of frequency of urine loss (p = 0.002), and urine loss with sneezing, coughing, or laughing (p = 0.02), when compared with controls. Pad testing showed that stress incontinence was improved by at least 50% in 62% of patients using an active device compared with only 19% of patients using sham devices (p = 0.01). Voiding diaries showed at least 50% improvement in 48% of active-device patients compared with 13% of women using the sham device (p = 0.02). No irreversible adverse effects were noted in either group.

CONCLUSIONS

Transvaginal pelvic floor electrical stimulation was found to be a safe and effective therapy for genuine stress incontinence.

Self-care regimens for patients with interstitial cystitis

For those who suffer from interstitial cystitis, living with the condition is a challenge that requires creativity, patience, determination, and a sound set of coping mechanisms. Because of the high percentage of gynecologic and systemic manifestations of interstitial cystitis, a customized treatment regimen is often necessary to achieve the therapeutic goal of a remission in symptoms. Treatment philosophies should be based on the proposed causative mechanisms, and a multimodality approach to therapy is usually successful. Self-care regimens give the patient a sense of control by active participation in treatment, which often improves coping mechanisms. Treatment of the sequelae of chronic pain (anxiety and depression) often improves response to overall therapy. Remission is the goal, coping is the key, and creativity opens the door to treating this most perplexing of conditions.

Effect of repeated instillation of interstitial cystitis urine on the rabbit urinary bladder

One theory for the etiology of interstitial cystitis (IC) proposes toxic substances in the urine. This hypothesis was tested in our laboratory by infusing urine into the bladders of rabbits twice weekly for six weeks. For the first study rabbits were treated by one-hour biweekly intravesical exposure to urine from a symptomatic interstitial cystitis patient, a normal volunteer, or physiologic saline. For the second study, animals were exposed to both a high and a low molecular weight fraction of urine pooled from 7 interstitial cystitis patients, 7 normal female volunteers, and physiologic saline. At the end of six weeks the animals were cystoscoped and the bladder was removed the following day for histologic and contractile studies. Post-distention glomerulations were observed in 3 of the 4 whole IC urine-treated animals and an ulcer identical to the classic "Hunner's ulcer" was seen in one of these animals. Post-distention petechial hemorrhages were also noted in all 5 of the high molecular weight IC urine-treated animals but in none of the others, suggesting a difference between IC and normal urine. These IC urine-treated groups also showed the greatest degree of histologic changes including edema and plasma cell infiltrates in the lamina propria, submucosa and perivascular tissue. However, there was no statistically significant difference in bladder capacity, micturition patterns, or contractile response of bladder strips. These results indicate that there are substances with nominal molecular weight greater than 10 kD in interstitial cystitis urine that induce changes in the rabbit bladder that resemble bladders of interstitial cystitis patients.

Traumatic rupture of the corpus cavernosum: evaluation and management

Rupture of the corpus cavernosum is a rare but probably under-reported entity. It truly represents a urological emergency and current recommendations are for early surgical intervention. We review 5 cases with evaluation, treatment and followup. Delays in treatment lead to long-term complications, such as erectile dysfunction and penile curvature.

Bladder purinergic receptors

In rabbits the contractile response of the urinary bladder is only partially due to cholinergic innervation since atropine does not completely block neuronally mediated contractions. In the human bladder this atropine resistance is controversial with some reporting atropine resistance in vitro while others have stated that the atropine resistance is also tetrodotoxin resistant. Results of the present investigation demonstrate that an atropine resistant, tetrodotoxin sensitive contraction can be evoked in some, but not all human bladder strips. Evidence accumulated over the past few decades indicates that this atropine resistant contraction may be mediated by ATP or a related purine compound. Studies presented herein are designed to develop a radioligand assay for this purinergic receptor. Initial studies indicated that the hydrolysis resistant ATP analog beta, gamma methylene ATP offers several advantages over ATP as a potential radioligand. It is only slowly hydrolyzed by endogenous ATPase and does not inhibit the hydrolysis of ATP indicating that it probably does not bind to the active sites of endogenous ATP hydrolyzing enzymes. In addition beta, gamma methylene ATP is 10-100 fold more potent than ATP itself in stimulating contractions of the urinary bladder in-vitro. The radioligand binding assay herein described can be used to quantitate the density of purinergic receptors, an essential step for determining the role of this system in urinary bladder function and dysfunction. Application of this assay could form the foundation for development of a new class of therapeutic agents for the treatment of urinary bladder dysfunction based on modulation of the purinergic nervous system.

Masson's tumor of the kidney: a new renal lesion

Intravascular papillary endothelial hyperplasia (Masson's tumor) is a rare benign reactive lesion usually found in thrombosed subcutaneous blood vessels. We report a case of Masson's tumor of the kidney, and discuss the relevant clinical, radiographical and pathological aspects.

Functional and biochemical alterations in the rabbit urinary bladder following ileocystoplasty

Although the use of ileocystoplasty has increased significantly in recent years, very little is known concerning the smooth muscle properties of the implanted bowel segment. In a previous study, preliminary evidence was presented which indicated that the pharmacological response of the cytoplastic ileal segment to autonomic agonists changed toward that of the bladder. The present study extends and expands these preliminary observations on the physiology and pharmacology of augmentation cystoplasty. Augmentation cystoplasty with detubularized ileum was carried out in 16 rabbits. In vivo and in vitro physiological and pharmacological studies were carried out one and three months after surgery. The results can be summarized as follows: 1) in-vivo CMG at one month was similar to that of the preoperative bladder, but at three months there was a 24% increase in capacity, with the presence of multiple phasic contractions beginning at a volume of approximately 65% of capacity. 2) The frequency and magnitude of spontaneous activity in the cystoplastic ileum did not significantly alter from that of the normal ileum. 3) Cystoplastic ileum responded to muscarinic stimulation differently from the normal ileum. The bladder responded with an increase in the tension whereas the ileum responded with an increase in the frequency and amplitude of phasic contractions. The cystoplastic ileum responded with a pronounced sustained contraction with phasic contractions superimposed. The tonic contraction at three months was of a significantly greater magnitude than that at one month. 4) The qualitative and quantitative response to field stimulation of the cystoplastic ileum was altered from that of the ileum towards that of the bladder. 5) The normal bladder contains greater amount of creatine phosphate and lesser amounts of creatine than the normal ileum. Cystoplasty, after three months induced a change in the ileal segment towards the bladder (increased creatine phosphate and decreased creatine). 6) The normal ileum was found to have greater number of muscarinic receptors than the normal bladder whereas the cystoplastic ileum at three months was intermediate.

Xanthogranulomatous pyelonephritis and amyloidosis: a rare association

The coincidence of systemic amyloidosis and xanthogranulomatous pyelonephritis has been reported previously only once. Clinical findings, such as the nephrotic syndrome, cardiac and autonomic nervous system dysfunction, and adrenal insufficiency, are suggestive and a thorough investigation to rule out other causes of secondary amyloidosis is warranted. We report a case of xanthogranulomatous pyelonephritis associated with secondary systemic amyloidosis and the nephrotic syndrome. Treatment consisted of nephrectomy and intensive supportive care. The unique clinical, radiographic and pathological aspects of this case are discussed.

Office urodynamics

Each urologist can best form his or her own set of indications for and techniques of urodynamic evaluation or referral. Thus, what constitutes "office urodynamics" in one practice does not in another. The practicing urologist should at least have access to filling cystometry, flowmetry, residual urine determination, and voiding cystourethrography. All but the last named are certainly compatible with any office practice.

Bladder calculi in women after urethrovesical suspension

There have been a number of reports recently on vesical calculi in women with a history of gynecological procedures. Within 1 year we encountered 2 patients with vesical calculi after vesicourethral suspension performed with concomitant hysterectomy. These calculi formed on a retained intravesical suture and a monofilament knitted polypropylene pledget, and they produced interesting pathological and radiographic findings.

Vascular integrity of the distal ureter following combined tapering and cross trigonal reimplantation

Massive unilateral hydroureteronephrosis was created in 20 female dogs by ligating the urographically normal prevesical ureter. Over a 14-day period the obstructed ureter dilated to an average of 15.3 mm. A ureteral tapering procedure was performed by lateral darting and posterior folding of the resultant flap, followed by a cross-trigonal reimplantation. One anastomotic stricture resulted; in the remaining 19 animals, ureteral peristalsis was restored, the ureteral diameter was reduced 61.9 per cent and hydronephrosis was resolved. Histological studies on the tapered segments of these 19 animals showed that the subadventitial blood supply was preserved with fibrotic occlusion of the folded flaps. These results demonstrate that no significant vascular compromise after ureteral tapering and cross-trigonal reimplantation occurs. Success rates comparable to those of conventional ureteral tailoring can be achieved by this technically simplified form of reconstructive surgery.

Murine hybridoma antibodies against human transitional carcinoma-associated antigens

Spleen cells from mice immunized with the human urinary bladder transitional cell carcinoma cell line 647V have been fused with a syngeneic myeloma cell line to produce hybridomas. Screening of supernatants from 40 hybridomas which reacted with the immunizing cell line identified antibodies recognizing a variety of common, shared and tumor-associated antigens as well as newborn calf serum dependent antigens. Three hybridoma antibodies, 9A7 , 2E1 and 2A6 , recognize antigens found on all the human transitional cell carcinoma cell lines and tissue preparations tested, but the antigens were not found on normal human tissue (including urothelium), thus demonstrating the capability of the antibodies to distinguish normal from malignant bladder transitional epithelium. These antibodies, however, otherwise differ in their patterns of reactivity, with 1 recognizing an antigen which is also expressed on highly anaplastic malignant non-transitional cell carcinoma cell lines and tumors, while the other 2 demonstrate reactivities which are far more restricted to transitional cell carcinoma.