TREATMENT OF INTERSTITIAL CYSTITIS: COMPARISON OF SUBTRIGONAL AND SUPRATRIGONAL CYSTECTOMY COMBINED WITH ORTHOTOPIC BLADDER SUBSTITUTION

Purpose

We retrospectively evaluate the outcome of interstitial cystitis treated with subtrigonal or supratrigonal cystectomy and orthotopic bladder substitution.

Materials and Methods

Of 22 women and 1 man a mean of 51 years old with interstitial cystitis refractory to conservative therapy 17 were treated with subtrigonal cystectomy and ureteral reimplantation (group 1), and 6 were treated with supratrigonal cystectomy directly above the ureteral orifices (group 2). Both groups underwent orthotopic bladder substitution with an ileocecal pouch (Mainz pouch I).

Results

Postoperatively functional capacity significantly increased from a mean plus or minus standard error of mean 46 +/− 5 to 346 +/− 57 ml. in group 1 and 34 +/− 61 to 319 +/− 29 ml. in group 2 (p <0.001). Daytime and nighttime urinary frequency significantly decreased from 24 +/− 2 to 8 +/− 1 and 7 +/− 1 to 2 +/− 1 ml., respectively, in group 1 and 28 +/− 2 to 6 +/− 1 to 1 +/− 1 ml., respectively, in group 2 (p <0.001). At a mean followup of 93.9 months 14 patients in group 1 (82%) are completely symptom-free, and 1 has tolerable residual urinary urgency and suprapubic pain. At a mean followup of 31.5 months all group 2 patients are symptom-free and void spontaneously, whereas 41% of the group 1 patients require self-catheterization after subtrigonal cystectomy.

Conclusions

For interstitial cystitis refractory to conservative treatment subtotal cystectomy with orthotopic bladder substitution with the ileocecal pouch (Mainz pouch I) is a valid therapeutic option. In this series supratrigonal and subtrigonal cystectomy resulted in similar relief of symptoms but the former appears to provide better functional bladder rehabilitation.     

Supratrigonal cystectomy and ileocystoplasty in management of interstitial cystitis

BACKGROUND: Interstitial cystitis is a chronic non-infectious inflammatory disease of the bladder of unknown aetiology which is characterized by irritative voiding symptoms and suprapubic pain related to bladder filling. Surgical treatment is indicated in severely symptomatic patients when medical therapies have failed, usually after a period of several years. The authors' experience with a modified technique of ileocystoplasty following supratrigonal cystectomy performed in five patients with interstitial cystitis is presented here. METHODS: A modified technique of bladder augmentation using ileum following supratrigonal bladder resection is described. RESULTS: All patients experienced relief from their symptoms. No patient had residual bladder pain and urinary frequency settled down in all. Bladder capacity was increased significantly. Three patients voided spontaneously postoperatively and two required clean intermittent self-catheterization. CONCLUSIONS: Supratrigonal cystectomy and ileocystoplasty can be a satisfactory option in refractory cases of interstitial cystitis. A simplified technique of ileal bladder construction that provides satisfactory bladder capacity is presented. Most urologists are familiar with ileal surgery, having used the ileum as a conduit after cystectomy for urinary diversion.     

Discrimination Between the Ulcerous and the Nonulcerous Forms of Interstitial Cystitis by Noninvasive Findings

Purpose

We determined whether the classification of interstitial cystitis cases into ulcer and nonulcer categories from cystoscopic findings could be corroborated with epidemiological data relating to demographics, risk factors, symptoms, pain and psychosocial factors.

Materials and Methods

We surveyed 565 interstitial cystitis patients (111 with and 454 without ulcer), and from univariate analyses we found 10 noninvasive variables to be significantly associated with the presence of Hunner's ulcers. The 3 multivariate statistical methodologies of discriminant analysis, logistic regression and recursive partitioning were used to classify ulcer versus nonulcer cases from these variables. The retrospective and prospective performances from each methodology were also analyzed.

Results

Retrospectively, resubstitution error rates of all 3 methodologies were small, with overall misclassification rates of 19.1 percent with linear discriminant, 14.7 percent with logistic regression and 8.0 percent with recursive partitioning. Prospectively, the overall misclassification rates increased slightly to 20.0 percent with linear discriminant, 15.8 percent with logistic regression, and 15.9 percent with recursive partitioning.

Conclusions

The classification of interstitial cystitis into distinct categories of Hunner's ulcer (classic interstitial cystitis) and nonulcer based on cystoscopic findings can be corroborated with epidemiological evidence. The 2 categories may represent different manifestations of the underlying disease pathophysiology.     

INCREASED URINARY HYALURONIC ACID AND INTERSTITIAL CYSTITIS

Purpose

We compared urinary levels of hyaluronic acid in patients who met the National Institute for Diabetes, and Digestive and Kidney Diseases criteria for interstitial cystitis and in age matched healthy female controls.

Materials and Methods

Urinary hyaluronic acid was measured by solid phase radiometric assay using hyaluronic acid binding protein. Hyaluronic acid and symptom scores were compared in interstitial cystitis patients who gave multiple urine samples during treatment. Since hyaluronic acid changed with treatment in some patients, 17 samples from untreated interstitial cystitis patients were selected and compared with 17 control samples.

Results

Mean plus or minus standard deviation urinary hyaluronic acid concentrations were similar in the 2 groups (interstitial cystitis group 574 ± 496, controls 512 ± 324 ng./ml., p = 0.77). When normalized to creatinine urinary hyaluronic acid was significantly higher in interstitial cystitis patients (interstitial cystitis group 674 ± 220, controls 446 ± 220 ng./mg. creatinine, p = 0.0019). Urinary creatinine concentrations did not differ significantly (interstitial cystitis group 842 ± 715, controls 1,162 ± 516 mg./l., p = 0.12).

Conclusions

Urinary hyaluronic acid was higher in interstitial cystitis patients than healthy controls. Since bladder hyaluronic acid is below the epithelium, this finding may indicate leakage across the epithelium into the urine in interstitial cystitis patients.     

The role of reconstructive surgery in patients with end-stage interstitial cystitis/bladder pain syndrome: is cystectomy necessary?

Introduction

Interstitial cystitis is a debilitating condition that has a profound effect on quality of life. Although many approaches to treatment have been explored, no consistently effective treatment has been identified. Reconstructive surgery is offered to patients with refractory IC/BPS; however, expert opinion is divided as to whether simultaneous cystectomy is necessary to achieve symptomatic cure. The aim of this study was to report our experience in the surgical management of IC/BPS in a university teaching hospital.

Methods

The hospital inpatient enquiry (HIPE) system was used to identify patients with IC/BPS who underwent surgery between 1997 and 2013. Medical records were examined and patients were invited to complete three symptom-based questionnaires.

Results

Twelve patients were identified (8 female, 4 male). Reconstructive procedures included urinary diversion without cystectomy (9) and augmentation ileocystoplasty (4). One patient failed to have a sustained improvement in symptoms following ileocystoplasty and later underwent successful urinary diversion. All other patients noted a “marked improvement” in overall symptoms on global response assessment (GRA) and the resolution of bladder pain on a visual analogue sale (VAS). There were no persistent symptoms or complications related to the retained bladder following diversion.

Conclusion

Our study adds to the existing evidence that cystectomy is not necessary to provide symptomatic cure in patients with end-stage IC/BPS. Urinary diversion without cystectomy is a highly effective operation and a successful outcome was achieved in all patients. Ileocystoplasty may be offered in carefully selected cases.

     

Urinary Chondroitin Sulfates, Heparan Sulfate and Total Sulfated Glycosaminoglycans in Interstitial Cystitis

Purpose

We compared urinary glycosaminoglycan levels in patients with interstitial cystitis and healthy controls.

Materials and Methods

Total sulfated glycosaminoglycans assayed by dimethylmethylene blue binding and individual glycosaminoglycans analyzed by cellulose acetate electrophoresis were compared in patients with interstitial cystitis and healthy controls. Also, multiple urine samples were obtained from healthy female controls for 2 months to assess the relationship of urinary glycosaminoglycan and creatinine concentrations, and to determine whether glycosaminoglycan excretion changes during the menstrual cycle.

Results

Total sulfated glycosaminoglycan and creatinine concentrations correlated well in random voided samples. Menstrual cycle day did not affect total sulfated glycosaminoglycan levels. Cellulose acetate electrophoresis revealed 3 bands corresponding to chondroitin sulfates, heparan sulfate and acidic glycoprotein. Patients with interstitial cystitis had decreased urinary concentrations of each of these individual components and total sulfated glycosaminoglycans. However, glycosaminoglycan-to-creatinine ratios were similar in interstitial cystitis and control urine.

Conclusions

Using these assays total and individual urinary glycosaminoglycan levels normalized to creatinine were not altered in interstitial cystitis.     

Urinary Epitectin (MUC-1 Glycoprotein) in the Menstrual Cycle and Interstitial Cystitis

Purpose

We compared interstitial cystitis and control urine specimens for epitectin (MUC-1 glycoprotein), an epithelial mucin.

Materials and Methods

Urinary epitectin was measured in 28 patients with interstitial cystitis and 26 healthy controls. Ten controls provided multiple urine samples to determine whether urinary epitectin changes with the menstrual cycle.

Results

Epitectin levels were stable throughout the menstrual cycle. Interstitial cystitis cases had decreased urinary epitectin-to-creatinine ratios (mean 3.89 versus 6.38 microgram/mg. creatinine for controls, p = 0.0035) and epitectin concentrations (mean 1.96 versus 4.30 microgram/ml., respectively, p = 0.0005).

Conclusions

Decreased mean urinary epitectin levels may reflect a cause (epithelial mucin deficiency) or a consequence of interstitial cystitis.     

EFFECT OF LONG-TERM ORAL L-ARGININE ON THE NITRIC OXIDE SYNTHASE PATHWAY IN THE URINE FROM PATIENTS WITH INTERSTITIAL CYSTITIS

Purpose

We attempted to determine whether oral L-arginine, the substrate for nitric oxide synthase, increases nitric oxide synthase activity and cyclic guanosine monophosphate (cGMP) levels in the urine from interstitial cystitis patients. Nitric oxide and cGMP are decreased in urine from interstitial cystitis patients and both induce smooth muscle relaxation and immunological responses. Increasing urinary nitric oxide and cGMP may ameliorate interstitial cystitis symptoms.

Materials and Methods

Eight patients with interstitial cystitis were given L-arginine (1,500 mg. a day) orally for 6 months. Before and during treatment nitric oxide synthase activity and inducible nitric oxide synthase protein, cGMP, nitrate plus nitrite and interleukin 8 (IL-8) levels were measured in urine.

Results

After 2 weeks to 1 month of oral L-arginine treatment, urinary levels of nitric oxide synthase related enzymes and products increased significantly, while levels of the cytokine IL-8 were not changed significantly. IL-8 was significantly elevated in interstitial cystitis patients with leukocyte esterase positive urine.

Conclusions

Long-term oral administration of L-arginine increases nitric oxide related enzymes and metabolites in the urine of patients with interstitial cystitis, which is associated with a decrease in interstitial cystitis related symptoms.     

THE ROLE OF URINARY POTASSIUM IN THE PATHOGENESIS AND DIAGNOSIS OF INTERSTITIAL CYSTITIS

Purpose

We determined whether intravesical potassium absorption in normal bladders correlates with increased sensory urgency, and corroborated the hypothesis that mucus is important in the regulation of epithelial permeability. We compared sensory nerve provocative ability of sodium versus potassium, and determined whether intravesical potassium sensitivity discriminates patients with interstitial cystitis from normal subjects and those with other sensory disorders of the bladder.

Materials and Methods

A total of 231 patients with interstitial cystitis and 41 normal subjects underwent intravesical challenge with 40 ml. water and then 40 ml. of 40 mEq./100 ml. potassium chloride. Subjective responses of urgency or pain stimulation were recorded on a scale of 0 to 5. In 19 normal subjects potassium absorption was measured at baseline, after injury of the bladder mucus with protamine, after heparin treatment to reverse mucus damage and then for a final time. These subjects simultaneously recorded the symptoms of sensory urgency and pain at baseline, after protamine and after heparin. Another group of normal volunteers underwent a challenge with sodium versus potassium to determine which cation was more provocative. Patients with bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), detrusor instability, and acute and chronic urinary tract infection but no current infection were also evaluated for potassium sensitivity.

Results

Neither normal subjects nor patients with interstitial cystitis reacted to water administered intravesically. There was marked sensitivity to intravesical potassium in 75% of patients with interstitial cystitis versus 4% of controls (p <0.01). Only 1 patient with BPH responded to potassium and none of the 5 with chronic urinary tract infection responded. All 4 patients (100%) with a current acute urinary tract infection reacted positively to the potassium challenge. Of 16 patients with detrusor instability 25% responded. Normal subjects had minimal sensitivity to potassium before (11%) and markedly increased sensitivity after (79%) protamine treatment, and these symptoms were reversed by heparin in 42%. Potassium absorption directly correlated with symptoms (0.4, 3.0 and 1.3 mEq. before and after protamine, and after heparin reversal, respectively). In regard to sodium versus potassium provocation, potassium was far more provocative for causing urgency after protamine (10 versus 90%). Neither group underwent provocation before protamine.

Conclusions

Chronic diffusion of urinary potassium into the bladder interstitium may induce sensory symptoms, damage tissue and be a major toxic factor in the pathogenesis of interstitial cystitis. Intravesical potassium sensitivity is a reliable method for detecting abnormal epithelial permeability. It discriminates between patients with interstitial cystitis and normal subjects with intact epithelial function, and it is a useful diagnostic test for interstitial cystitis. Potassium sensitivity correlates with increased potassium absorption in normal subjects, and potassium is far more provocative than sodium. Potassium sensitivity is also present in acute urinary tract infection and occasionally detrusor instability but not in BPH or chronic urinary tract infections.     

ANTERIOR ENTEROCELE FOLLOWING CYSTECTOMY FOR INTRACTABLE INTERSTITIAL CYSTITIS

Purpose

We clinically define the development of an anterior vaginal wall hernia following cystectomy for the management of intractable interstitial cystitis and establish surgical technique for its correction.

Materials and Methods

Of 27 women who underwent simple cystectomy and urethrectomy for intractable interstitial cystitis an anterior vaginal wall hernia developed in 3 (71, 56 and 61 years old) at 8, 14 and 16 months, respectively, postoperatively. Clinical appearance was similar to a midline cystocele but it contained bowel contents in the form of an anterior enterocele. Anterior enterocele was associated with vaginal vault prolapse in 1 patient who was treated with transvaginal sacro-spinous colpopexy. Patients with isolated anterior enterocele required a transabdominal approach with mobilization of the intestinal hernia contents and obliteration of the intervaginal abdominal wall space.

Results

At 12, 19 and 33 months following reconstruction prolapse has not recurred, and sexual function was restored in 1 patient.

Conclusions

These cases suggest that an extended simple cystectomy performed on women with intractable interstitial cystitis may result in a weakening of the anterior vaginal wall with resultant anterior enterocele formation. When it is associated with vaginal vault prolapse a transvaginal technique may be considered but we prefer a transabdominal approach for an isolated anterior enterocele. Prevention of this entity may be warranted at the time of cystectomy.     

LOCAL MICROWAVE HYPERTHERMIA AND INTRAVESICAL CHEMOTHERAPY AS BLADDER SPARING TREATMENT FOR SELECT MULTIFOCAL AND UNRESECTABLE SUPERFICIAL BLADDER TUMORS

Purpose

The role of a combined regimen of local hyperthermia and topical chemotherapy in patients with multifocal and recurrent superficial bladder tumors not curable by transurethral resection was evaluated in a neodjuvant organ sparing clinical study.

Materials and Methods

A total of 19 patients with multifocal, superficial grades 1 to 3 bladder tumors that recurred after intravesical chemoprophylaxis or immunoprophylaxis underwent local combined administration of microwave induced hyperthermia and intravesical chemotherapy as a debulking approach. Due to extensive superficial involvement of the bladder walls complete transurethral resection of all tumors seemed technically unfeasible in all cases and radical cystectomy was considered the treatment of choice. Endovesical hyperthermia at 42.5 to 46C was delivered using the SB-TS 101 system,* based on a microwave transurethral applicator that irradiates the bladder filled with a circulating solution of mitomycin C. Patients underwent 8 weekly 1-hour sessions on an outpatient basis without anesthesia. When possible, after treatment patients underwent transurethral resection of residual tumors and all suspicious areas.*Boston Scientific Corp., Natick, Massachusetts.

Results

After treatment transurethral resection appeared to be feasible and curative in 16 patients (84%). Histological study revealed complete and partial responses in 9 (47%) and 7 (37%) cases, respectively. Due to extensive residual tumors radical cystectomy was performed in 3 patients (16%). At a median 33-month followup 8 superficial transitional tumor recurrences were documented and easily eradicated by transurethral resection or laser therapy in patients in whom the bladder had been saved.

Conclusions

Microwave induced hyperthermia combined with intravesical mitomycin C seems to be a feasible, safe and elective approach for conservative treatment of multifocal and recurrent superficial bladder tumors when other treatment strategies have failed.     

THE INCIDENCE OF HELICOBACTER PYLORI IN PATIENTS WITH INTERSTITIAL CYSTITIS

Purpose

The cause of interstitial cystitis is unknown. We evaluated the incidence of Helicobacter pylori antibodies in patients with interstitial cystitis to determine whether such infection may be a causative factor.

Materials and Methods

We obtained serum samples from 23 patients with interstitial cystitis and 23 control subjects. Samples were analyzed for the presence of H. pylori IgG antibodies.

Results

The incidence of positive tests for H. pylori antibodies was 22% in the interstitial cystitis group and 35% in controls.

Conclusions

The incidence of infection with H. pylori is not increased in interstitial cystitis, and so it is unlikely to be a causative factor.     

Increased Urinary Levels Of Tamm-Horsfall Glycoprotein Suggest A Systemic Etiology of Interstitial Cystitis

Purpose

We investigated the role of Tamm-Horsfall protein in interstitial cystitis.

Materials and Methods

Urinary Tamm-Horsfall protein excretion was analyzed in interstitial cystitis patients and controls, and bladder biopsy specimens were stained immunohistochemically for Tamm-Horsfall protein.

Results

Urinary Tamm-Horsfall protein levels in 28 women with interstitial cystitis were statistically significantly greater than those in 25 female controls. No positive staining for Tamm-Horsfall protein was demonstrated in the bladder tissue from 10 interstitial cystitis cases.

Conclusions

The results support the notion that interstitial cystitis may have a systemic etiology. In addition, this assay might have clinical value in the diagnosis of interstitial cystitis.     

Intravesical bacillus Calmette-Guerin and dimethyl sulfoxide for treatment of classic and nonulcer interstitial cystitis: a prospective, randomized double-blind study

PURPOSE: We conducted a prospective, double-blind study with a crossover design of intravesical bacillus Calmette-Guerin (BCG) and dimethyl sulfoxide to determine whether patients with classic and nonulcer interstitial cystitis, respectively, might benefit from either regimen. MATERIALS AND METHODS: A total of 21 patients, including 11 with classic and 10 with nonulcer interstitial cystitis, randomly underwent treatments with intravesical BCG or dimethyl sulfoxide and, if not improved, were treated with the other substance after a washout period. All 21 patients were evaluated with symptom questionnaires, including a visual analog pain scale and voiding diaries. RESULTS: Regardless of regimen, there was no improvement in maximal functional capacity. There was a reduction in urinary frequency following dimethyl sulfoxide treatment but only in the classic subtype (p <0.05), whereas no reduction was seen following BCG in either subtype. A substantial pain decrease was noted in classic (p <0.05) as well as nonulcer (p <0.05) interstitial cystitis following dimethyl sulfoxide. CONCLUSIONS: Intravesical BCG has been presented as a promising new option for treatment of interstitial cystitis. We failed to demonstrate benefit from this treatment. Dimethyl sulfoxide had no positive effect on maximal functional capacity but resulted in a significant reduction in pain and urinary frequency, although only in patients with classic interstitial cystitis.     

Subtotal cystectomy with ileocystoplasty for severe hemorrhagic cystitis after bone marrow transplantation

In a retrospective analysis of hemorrhagic cystitis subsequent to allogeneic bone marrow transplantation, we focused on patients who underwent subtotal cystectomy with ileocystoplasty because stepwise use of conservative treatments had failed. Severe lasting hemorrhagic cystitis (more than 40 days) led to urinary tract obstruction and sepsis that required subtotal cystectomy in 3 of 1300 bone graft patients. Hematuria did not recur after surgery with a satisfactory functional result (follow-up 10 months to 17 years). Subtotal cystectomy with detubularized ileocystoplasty can be used to control life-threatening hemorrhagic cystitis.     

Primary adenocarcinoma of the urinary bladder: a single site analysis of 21 cases

Purpose

To investigate whether there is a difference between urachal and non-urachal adenocarcinomas in terms of patient survival and to determine the significant prognostic factors.

Methods

Thirty-four patients with histologically proven adenocarcinoma of the urinary bladder were treated at Huashan hospital between 1999 and 2010. 13 cases were excluded, including 12 patients with metastatic involvement from gastrointestinal or reproductive tracts and one without follow-up data after the initial consultation. Life tables, Kaplan–Meier, Cox regression analysis and log-rank test were used.

Results

The difference between patients with urachal adenocarcinoma and patients with non-urachal adenocarcinoma was not statistically significant using the Kaplan–Meier estimates (P = 0.0763). Clinical stage had a significant influence on survival (P = 0.0320, Fig. 2). Patients with surgical resection including partial and radical cystectomy did not have a better prognosis (P = 0.7992, Fig. 3). However, the difference is statistically significant between patients who received partial cystectomy and patients who received radical cystectomy (P = 0.0123, Fig. 4).

Conclusion

Survival of Patients with adenocarcinoma is correlated with clinical stage. Patients with urachal adenocarcinoma and non-urachal adenocarcinoma may have similar survival outcome. Tumor stage was a highly significant predictor of outcome (P = 0.0320). Surgical resection seems to be more important than chemotherapy in the cases of adenocarcinoma of the urinary bladder. We are in favor of radical cystectomy for all patients.     

Combined Modified Rectus Fascial Sling and Augmentation Ileocystoplasty for Neurogenic Incontinence in Women

Purpose

We assessed results of a combined modified rectus fascial sling procedure and augmentation ileocystoplasty in women with neurogenic urinary incontinence.

Materials and Methods

We prospectively evaluated 21 patients (mean followup 28.6 months).

Results

A total of 20 patients (95.2%) was dry during the day on intermittent catheterization and none had difficulty with catheterization. Subsequently surgery was necessary in 1 case for perforation of the augmented bladder.

Conclusions

A combined modified rectus fascial sling procedure and augmentation ileocystoplasty are safe and effective when all available pharmacological treatments and clean intermittent catheterization have failed.     

Vaginal repair of supratrigonal vesicovaginal fistulae—a 10-year review

Introduction and hypothesis

A 10-year retrospective study was done to determine the outcome of vaginal repair for supratrigonal vesicovaginal fistulae (VVF).

Methods

One hundred thirty-two urinary fistulae were managed from 2001 to 2011 which include 34 ureterovaginal and 98 lower urinary tract fistulae. Fifty-three out of 98 were supratrigonal VVF, 49 were of benign etiology and 4 were malignancy induced. Further analysis of 49 supratrigonal VVF of benign etiology revealed that 38 (77.5%) were of gynecological origin and 11 (22.5%) obstetric. Forty-three were primary and six were recurrent VVF. Thirty (61.2%) supratrigonal VVF were repaired vaginally and 19 (38.8 %) abdominally. Mean follow-up period was 51.7?months.

Results

The successful outcome for vaginal and abdominal repair was 86.7% and 100%, respectively (p value?=?0.26). Overall, 91.8% supratrigonal VVF were cured at our first attempt.

Conclusions

Majority of supratrigonal VVF can be approached vaginally with success rate comparable to abdominal approach.     

Early Identification of Interstitial Cystitis May Avoid Unnecessary Hysterectomy

Background:

Interstitial cystitis is a clinical syndrome characterized by symptoms of pelvic pain, urinary urgency and frequency, and nocturia. It can be difficult to accurately identify interstitial cystitis because the symptoms overlap many other common gynecologic and urologic conditions. Patients with undiagnosed interstitial cystitis may undergo unnecessary procedures, including hysterectomy.

Methods:

A PubMed literature search for articles dating back to 1990 was conducted on the topics of interstitial cystitis and hysterectomy. Further references were identified by cross-referencing the bibliographies in articles of interest.

Results:

The literature review found that hysterectomy is performed more often in patients with undiagnosed interstitial cystitis than in patients with a confirmed diagnosis. Interstitial cystitis often coexists with conditions like endometriosis, for which hysterectomy is indicated. Many patients subsequently diagnosed with interstitial cystitis continue to experience persistent pelvic pain despite having had a hysterectomy for chronic pelvic pain. Careful history and physical examination can identify the majority of interstitial cystitis cases.

Conclusion:

Interstitial cystitis should be considered prior to hysterectomy in women who present with pelvic pain or who experience pelvic pain after a hysterectomy. If interstitial cystitis is diagnosed, appropriate therapy may eliminate the need for hysterectomy.     

THE EFFICACY OF INTRAVESICAL BACILLUS CALMETTE-GUERIN IN THE TREATMENT OF INTERSTITIAL CYSTITIS: LONG-TERM FOLLOWUP

Purpose

Interstitial cystitis is a severe debilitating bladder disease characterized by unrelenting pelvic pain and urinary frequency. A prospective, double-blind, placebo controlled study of the use of intravesical bacillus Calmette-Guerin (BCG) in the treatment of interstitial cystitis was recently completed with a mean followup of 8 months. Results demonstrated a 60% BCG response rate, compared to a 27% placebo response rate. We now report the long-term followup results of those patients who received intravesical BCG.

Materials and Methods

Subjects randomized to receive BCG were followed at routine intervals with questionnaires and voiding diaries identical to those in the blinded study. Adverse events were closely monitored in the treatment and followup phases of the study. Subject baseline values were compared to followup data.

Results

Of the BCG responders mean followup was 27 months (range 24 to 33), and 8 of 9 (89%) continue to have an excellent response in all parameters measured. The global interstitial cystitis survey improved 70%, daily voids decreased 31%, nocturia improved 54%, mean voided volume increased 61%, pelvic pain decreased 81%, vaginal pain decreased 71%, urgency decreased 71% and dysuria decreased 82%. Overall well-being improved 54% and the Rand-36 quality of life survey overall improved 64%. In 86% of the patients (6 of 7) dyspareunia resolved. Of the initial BCG nonresponders there was no significant difference in interstitial cystitis symptomatology from baseline to last followup, suggesting that BCG does not worsen interstitial cystitis symptoms. No long-term adverse events from BCG were noted.

Conclusions

Intravesical Tice^* BCG is safe, effective and durable in the treatment of interstitial cystitis. Of those patients who received only 6 weekly treatments and responded favorably 89% continue to have an excellent response with followup ranging from 24 to 33 months.