Interstitielle Zystitis

Zusammenfassung Die interstitielle Zystitis (IC) ist eine chronisches, heterogenes Syndrom, das mit den klassischen Symptomen Nykturie, Pollakisurie und Blasenschmerzen einhergeht. Populationsstudien zeigen ansteigende Prävalenz- und Inzidenzraten. Von den unterschiedlichen Hypothesen zur Pathogenese und Ätiologie werden die der epithelialen Dysfunktion und der neurourothelialen Wechselwirkung am häufigsten zur Erklärung genutzt. Es empfiehlt sich eine individuelle und flexible Anwendung der offiziellen Diagnosekriterien des NIDDK (National Institute of Diabetes, Digestive and Kidney Disease), um gut therapierbare Frühformen nicht zu übersehen. Da ein pathognomonischer Marker noch fehlt, beruht die Diagnose v. a. auf klinischen Befunden und dem Ausschluss von Differenzialdiagnosen. Blasenspiegelung und Probebiopsie sind nicht beweisend, machen die Diagnose jedoch wahrscheinlicher und können wichtige Informationen über den Ausprägungsgrad, auch in Hinblick auf eine angepasste Therapie, liefern. Die elektromotorische Medikamentenapplikation (EMDA) in der Instillationstherapie hat in den letzten Jahren die Erfolgsraten der konservativen Therapie deutlich verbessert.     

Interstitielle Zystitis: Aspekte aus dem Blickwinkel Evidenz-Basierter Medizin

Ohne Zusammenfassung     

Epidemiologie der interstitiellen Zystitis

Available data on the epidemiology of interstitial cystitis (IC) are heterogeneous. Its prevalence ranges between 16 and 510 females/100,000 inhabitants and the incidence at 1.2-2.6/100,000 females with a mean age of 42-52 years. The disease tends to affect women (female:male ratio 9-10:1) and Caucasians (> 90%). The quality of life of patients suffering from IC is reduced to a significant degree in almost every aspect (work, social events, leisure activities). Financial expenses (medical as well as economical) associated with the disease are considerable. There is an enormous need to promote IC education and research in order to support affected patients effectively in the future.     

Epidemiologie der interstitiellen Zystitis

Die vorliegenden Daten zur Epidemiologie der interstitiellen Zystitis sind sehr heterogen. Die Pr?valenz betr?gt 16–510 Frauen/100.000 Einwohner, die Inzidenz liegt zwischen 1,2–2,6 /100.000 Frauen mit einem mittleren Alter bei Diagnosestellung von 42–52 Jahren. Die Geschlechterverteilung bevorzugt das weibliche im Verh?ltnis zum m?nnlichen Geschlecht (9–10 Frauen/1 Mann) mit einer ethnischen Bevorzugung der Kaukasier (>90%).     

Emphysematöse Zystitis

We present a rare case of cystitis emphysematosa in an 85-year-old female patient in whom the typical risk factors were present: diabetes of long standing, neurogenic bladder and urinary infection with E.coli. Thanks to early diagnosis by cystoscopy and abdominal CT, after antibiotic treatment, appropriate insulin therapy and continuous bladder drainage the course was uneventful. The patient was fit to leave hospital after 14 days.     

Diagnostik der interstitiellen Zystitis

Interstitial cystitis (IC) represents a rare and complex inflammatory bladder condition in which diagnostics can be challenging. Strict NIH criteria for its diagnosis were designed for research purposes. Their routine application would miss large proportions of IC patients. When IC is suspected, history and physical exam are followed by an evaluation of long-term voiding diaries. Large voided volumes (functional capacity > 250 cc) or longer micturition intervals (> 2 h.), absence of nocturia or symptom-free periods reduce the likelihood of IC. Further exclusion diagnostics include urine tests (infection), cytology (in-situ carcinoma), ultrasound (calculi, bulks, anomalies) and urodynamics in selected cases. Bladder capacity measurements under sedoanalgesia are of limited value, since functional low-volume bladders can be mechanically extendable. Cystoscopy under general anesthesia represents the diagnostic standard procedure for IC during which 90% of IC-patients present with characteristic mucosal glomerulations after bladder distension. Biopsies are recommended for exclusion of malignancy. Potassium-leak testing plays no relevant role in routine diagnostics due to its poor sensitivity. Similarly, complex determinations of novel IC markers (histamine, tryptase, cytokines, growth factors, substance P, nitric oxide) are of no relevance in clinical settings and should be restricted to research projects.     

Offen-chirurgische Therapie der interstitiellen Zystitis

Die Behandlung der interstitiellen Zystitis (IC) stellt eine der schwierigsten therapeutischen Herausforderungen in der Urologie dar. Zahlreiche Urologen sind der Ansicht, dass ein konservativer Therapieansatz bei den leidenden Patienten nicht l?nger hinausgez?gert werden sollte, da effektive chirurgische Alternativen zur Verfügung stehen, die eine schnelle und anhaltende Linderung zu erzielen verm?gen.     

Endourologische Operationstechniken bei interstitieller Zystitis

Endourological surgical procedures (transurethral resection and fulguration, Nd-YAG-laser application) for the treatment of interstitial cystitis (IC) have been evaluated only in a few studies. Theoretically, they could be the next step in a therapeutic concept after conservative measures have failed and before open surgery is performed as an ultima ratio. However, our review of the literature suggests that to date there is no scientific evidence to support endourological techniques in the treatment of IC.     

Endourologische Operationstechniken bei interstitieller Zystitis

Endourologische Operationstechniken (transurethrale Resektion und Koagulation, Nd-YAG-Laser) zur Behandlung der interstitiellen Zystitis (IC) wurden nur in wenigen Studien wissenschaftlich untersucht. Nach Aussch?pfen konservativer Behandlungsstrategien stellen sie theoretisch den n?chsten Schritt im Therapiekonzept dar, bevor offen chirurgische Behandlungsans?tze als Ultima ratio zum Einsatz kommen.     

Offen-chirurgische Therapie der interstitiellen Zystitis

Treatment of IC is one of the most difficult therapeutic challenges in urology, frequently resulting in frustration for both patient and therapist. Many urologists believe that conservative treatment should not be unnecessarily prolonged in severe cases with low bladder capacity, since cystectomy may provide immediate and permanent relief for the suffering patient. However, it remains unclear which surgical approach and technique is the most suitable. Generally three different techniques are performed: supratrigonal cystectomy; radical cystectomy, saving only the bladder neck; and, finally, radical cystectomy combined with excision of the urethra. All three techniques require substitution of the excised bladder tissue with bowel segments.     

Intravesikale Therapie bei interstitieller Zystitis

Die intravesikale Instillationstherapie hat den Vorteil einer hohen Wirkkonzentration in der Blase bei geringen systemischen Nebenwirkungen. Pentosanpolysulfat wird relativ h?ufig zur Blaseninstillation eingesetzt und senkt signifikant die Nykturiefrequenz, w?hrend die Miktionsfrequnz tagsüber in einer kontrollierten Studie unver?ndert blieb. Auch Heparin senkte die Nykturiefrequenz in einer offenen prospektiven Studie. Der maximale Wirkungseintritt wird bei Heparin oft erst nach 4–6 Monaten bemerkt. Sowohl Heparin als auch Pentosanpolysulfat sind praktisch nebenwirkungsfrei.     

Orale Therapie der interstitiellen Zystitis

Up to now there is no specific treatment targeting the ultimate cause of interstitial cystitis (IC), since its pathogenesis and etiology are still unknown. Most studies focussing on oral medication have not been randomized, double-blinded or placebo-controlled. Numerous case reports and intent-to-treat trials are lacking a systematic approach and do not meet evidence-based medicine criteria. Consequently there is as yet no standard oral therapy available for the treatment of IC. However, only a few oral substances have shown a potential to improve symptoms such as frequency and pain. The best results were obtained from monotherapeutic use of pentosanpolysulfate, amitriptylin and hydroxycin. The true benefit of these substances alone should be compared to analgesics and anticholinergics in the course of controlled clinical trials.     

Intravesikale Therapie bei interstitieller Zystitis

Intravesically applied medications have the benefit of establishing high concentrations of a therapeutic agent at the intended target tissue along with a low risk for systemic side effects. Pentosanpolysulfate is frequently applied for this purpose and was shown to significantly reduce nycturia while frequency during the day remained unaffected in a controlled study. Heparin reduced nycturia in an open prospective protocol as well. For heparin the maximal onset of a therapeutic effect is often observed as late as 4-6 months after initiation of treatment. Heparin as well as pentosanpolysulfate cause practically no side effects. Dimethylsulfoxide (DMSO), when instilled intravesically, decreases symptoms up to 50-70% for an effective period of 1-2 months. An irritating but harmless side effect of DMSO is the development of a striking garlic-like odor. BCG improved symptoms in 10 of 15 patients after 8 months and in 8 of 15 patients after 24 months. No patient with an initial bladder capacity below 175 cc benefited from BCG instillations. Discomfort in the bladder region was noted as a frequent side effect. Instillations of clorpactin WCS 90 are painful and can thus only be applied under anesthesia. Success rates range between 50-70% and last for 6-12 months.     

Interstitielle Pankreatitis bei experimentellem Gallenwegsverschluß

Zusammenfassung Bei weißen Ratten wurde experimentell ein Verschluß des Ductus choledochus herbeigeführt, was teilweise mit und teilweise ohne gleichzeitige Obstruktion des Bauchspeichelabflusses erfolgte. In beiden Fällen ließ sich am Pankreas das Auftreten einer Sekretstase mit interstitieller Entzündung beobachten.Die Pathogenese der interstitiellen Pankreatitis wird an Hand der Versuchsergebnisse diskutiert. Für die Klinik ergibt sich aus den Tierexperimenten die Folgerung, daß bei Gallengangsverschlüssen—auch ohne zusätzliche Verlegung der Abflußwege des Bauchspeichels—häufiger Veränderungen des Pankreas vorkommen können, als allgemein angenommen wird.Mit 6 Textabbildungen     

Alternative und additive Therapieverfahren bei interstitieller Zystitis

Alternative therapies are gaining more and more popularity. Mostly, these methods are demanded by patients who are not effectively relieved by allopathy. This review points out alternative and additive methods that have been repeatedly described as effective as additional supportive treatments of interstitial cystitis.     

Die Versorgungssituation von Patienten mit interstitieller Zystitis in Deutschland

Background

Using a comprehensive questionnaire the care situation of 270 patients with interstitial cystitis (IC) and bladder pain syndrome in Germany was recorded. Despite comprehensive literature on IC (62,000 citations in PubMed) almost nothing is known of the everyday care and quality of patient care in Germany.

Results

In total 94?% of the patients were women and 6?% men, the average age of women was 53.5 years and that of men 67 years and 47.77?% of the patients felt that they were well or very well informed about the disease whereby the internet was the source of information in many cases. The exchange of information among patients will increase further through social networks. The diagnosis of IC was made most frequently (62.22?%) by biopsy and histological examination followed by urodynamics, potassium test, hydrodistension and cystoscopy. The average duration of the diagnosis was 9 years, 46.67?% of the patients consulted a doctor more than 20 times before the diagnosis was made and 51.84?% had to pass water more than 14 times per day. Frequency, nocturia and pain were the leading symptoms and 25?% of the patients complained of urge incontinence. Among oral medications, analgesics were taken most frequently (61.7?%) followed by pentosan polysulphate, antidepressants, antiepileptic drugs, antispasmodics and remedies for urinary urgency. In the self-assessment of the success of treatment with oral medications (helped very well and well), pentosan polysulphate, analgesics, antidepressants and antiepileptic drugs were considered to be the best. Medications that restore the glucosamine lining of the bladder were used predominantly for instillation into the bladder included hyaluronic acid, chondroitin sulphate and a combination of both and pentosan polysulphate. In the self-assessment of the success of treatment with instillation therapy (helped very well or well) the order was: chondroitin sulphate (62.69?%), hyaluronic acid (55.77?%), a combination of both (53.66?%) and pentosan polysulphate (46.30?%). The electromotive drug administration (EMDA) procedure with the use of direct current to introduce medications into the bladder wall was mentioned surprisingly often, namely, in 119 patients. In the self-assessment success (helped very well or well) was considered the best for intravesical procedures with 61.34?%.

Conclusions

Compared with all drug procedures instillation of medications into the bladder was mentioned 368 times and was assessed by the patients as having helped very well and noticeably by 53.53?%, followed by special invasive procedures at 50.56?%/271 mentions, alternative therapies at 41.11?%/287 mentions and oral medication at 39.75?%/1,024 mentions. Hyaluronic acid and chondroitin sulphate products, the combination of both and pentosan polysulphate (oral and intravesical) are not reimbursed by the statutory health insurance. Over 40?% of patients treated with these therefore discontinued the treatment for reasons of cost.