Minimum 6-year outcomes for interstitial cystitis treated with sacral neuromodulation

Introduction and hypothesis  

Interstitial cystitis is a multifaceted medical condition consisting of pelvic pain, urgency, and frequency. Can sacral neuromodulation be successfully utilized for the medium term of ≥6 years in interstitial cystitis patients for whom standard drug therapies have failed?     

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.     

Prevalence of painful bladder syndrome/interstitial cystitis-like symptoms in women: a population-based study in Korea

Objective  

Despite growing clinical interest in painful bladder syndrome/interstitial cystitis (PBS/IC, also known as bladder pain syndrome), estimating its prevalence is difficult because of its variable presentation and the lack of clear diagnostic criteria. In this study, we estimated the prevalence of PBS/IC-like urinary symptoms in adult women in the general population of South Korea.     

THE TREATMENT OF INTERSTITIAL CYSTITIS WITH SUPRATRIGONAL CYSTECTOMY AND ILEOCYSTOPLASTY: DIFFERENCE IN OUTCOME BETWEEN CLASSIC AND NONULCER DISEASE

Purpose

Interstitial cystitis is a chronic debilitating condition that mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer type seems to respond less favorably to various conservative treatments than the classic type. Supratrigonal cystectomy with ileocystoplasty is established treatment for interstitial cystitis refractory to conservative treatment. We evaluate whether classic interstitial cystitis responds differently than nonulcer disease to subtotal bladder resection and ileocystoplasty.

Materials and Methods

We evaluated 13 patients 27 to 79 years old with interstitial cystitis who underwent supratrigonal cystectomy and ileocystoplasty due to failure to respond to conservative treatment.

Results

In all 10 patients with classic interstitial cystitis symptoms were relieved after ileocystoplasty. In the 3 patients with nonulcer interstitial cystitis pain remained, while the frequency of voiding somewhat decreased. In these patients trigonal resection and urinary diversion with a Kock pouch resolved the symptoms.

Conclusions

Our study confirms that supratrigonal cystectomy with ileocystoplasty results in a good outcome in classic interstitial cystitis. However, this method seems to be unsuitable for nonulcer disease. Identification of the relevant subtype of interstitial cystitis is of crucial importance for selecting the appropriate method of lower urinary tract reconstruction.     

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis

Introduction and hypothesis  

The objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires.     

Long-term results of intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis

Introduction and hypothesis  

While the short-term efficacy of intravesical hyaluronan for bladder pain syndrome/interstitial cystitis (BPS/IC) has been demonstrated, no data exist on the long-term outcome of this therapy.     

Decreased nanobacteria levels and symptoms of nanobacteria-associated interstitial cystitis/painful bladder syndrome after tetracycline treatment

Introduction and hypothesis  

This study was designed to detect whether nanobacteria (NB) reside in urine and bladder tissue samples of patients with interstitial cystitis/painful bladder syndrome (IC/PBS) and whether antibiotic therapy targeting these organisms is effective in reducing NB levels and IC/PBS symptoms.     

Intravesical botulinum toxin A injections in the treatment of painful bladder syndrome/interstitial cystitis: a systematic review

Introduction and hypothesis  

Intravesical botulinum toxin A (BTX-A) is emerging as a potential new treatment for refractory interstitial cystitis (IC). However, there has been conflicting evidence on this treatment's effectiveness. The aim of our systematic review was to assess the effectiveness and adverse effects of intravesical BTX-A in IC.     

Treatment choice, duration, and cost in patients with interstitial cystitis and painful bladder syndrome

Introduction and hypothesis  

In order to better understand provider treatment patterns for interstitial cystitis (IC)/painful bladder syndrome, we sought to document the therapies utilized and their associated expenditures using a national dataset.     

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.     

Efecto apoptótico como biomarcador de enfermedad,severidad y seguimiento en la cistitis intersticial

Objective

To determine whether the apoptotic effect test could serve as a biomarker of severity in bladder pain syndrome/interstitial cystitis.

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.     

Anterior vaginal wall tenderness (AVWT) as a physical symptom in chronic pelvic pain

Background and Objectives:

Chronic pelvic pain is often difficult to diagnose and treat properly. Physicians called on to treat this problem may not be able to give a specific diagnosis. The aim of this study was to see whether the physical presence of anterior vaginal wall tenderness could help narrow down and elucidate diagnoses in a practice focusing on diagnosis and treatment of chronic pelvic pain.

Methods:

The study cohort comprised 284 patients with chronic pelvic pain limited to gynecologic and lower urinary problems. Histories, physical examinations, and endoscopic procedures were performed on each patient. An analysis of this information was conducted.

Results:

Of the chronic pelvic pain patients, 78% had endometriosis, 81% had interstitial cystitis, and 61% had both concurrently. The sensitivity of anterior vaginal wall tenderness (AVWT) in patients with interstitial cystitis was 95%, and in those with only endometriosis and no interstitial cystitis, the sensitivity was 17%. The positive predictive value for interstitial cystitis was 85%, and for endometriosis it was 67%.

Conclusions:

Examination of the anterior vaginal wall with an empty bladder at the initial examination can lead one to suspect interstitial cystitis and possibly either concomitant or singular endometriosis and allow the physician to approach the workup accordingly.     

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.     

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.     

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 Efficacy of Intravesical Tice Strain Bacillus Calmette-Guerin in the Treatment of Interstitial Cystitis: A Double-Blind, Prospective, Placebo Controlled Trial

Purpose

Interstitial cystitis is a debilitating bladder disease of unknown etiology with no cure. A recent report suggested that bacillus Calmette-Guerin (BCG) may be effective in the treatment of interstitial cystitis. A randomized, prospective, double-blind, placebo controlled trial to evaluate the safety and efficacy of intravesical BCG in treating interstitial cystitis was done.

Materials and Methods

Patients meeting the National Institute of Arthritis, Diabetes and Digestive and Kidney Diseases criteria for interstitial cystitis received 6 weekly instillations of Tice strain BCG or placebo. Periodic questionnaires, voiding diaries and cystometrograms were obtained. A total of 30 evaluable subjects was enrolled in the study with a mean followup of 8 months (range 6 to 13). Based on an exit questionnaire a responder was defined as one who rated the interstitial cystitis symptoms as moderately improved or better.

Results

A 60% BCG response rate was noted, compared to a 27% placebo response rate. Minimum voided volume and quality of life improved in the BCG group compared to placebo. Adverse events were similar in each group, mostly irritative in nature, and no significant systemic events were noted.

Conclusions

Intravesical Tice strain BCG appears to be safe and efficacious in the treatment of interstitial cystitis. Additional studies must be performed to confirm the results of this pilot study.     

Cyclosporine in Severe Interstitial Cystitis

Purpose

Cyclosporine is a widely used immunosuppressive drug in organ transplantation and recently it has been used in several autoimmune disorders with good results. Because interstitial cystitis may have an autoimmune etiology, we wished to determine whether cyclosporine has any effect on symptoms in patients with severe interstitial cystitis.

Materials and Methods

A total of 11 patients, who fulfilled the criteria for interstitial cystitis according to an international accrual form, received cyclosporine for 3 to 6 months at an initial dose of 2.5 to 5 mg./kg. daily and a maintenance dose of 1.5 to 3 mg./kg. daily. Blood pressure, serum creatinine and cyclosporine concentrations were monitored regularly. The patients completed frequency-volume charts at 2-week intervals.

Results

The frequency-volume charts showed favorable effects. Micturition frequency decreased (p less than 0.01), and mean and maximum voided volumes increased significantly (p less than 0.001 and p less than 0.01, respectively). Bladder pain decreased or disappeared in 10 patients, allowing for storage of larger urine volumes. Serum creatinine did not change with the dosages used. Mild hypertension occurred in 2 patients and resolved after the cyclosporine dose was lowered. After cessation of treatment symptoms recurred in the majority of patients.

Conclusions

The findings revive the concept of interstitial cystitis as an autoimmune disease.     

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.     

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.