Interstitial cystitis/painful bladder syndrome: diagnostic evaluation and therapeutic response in a private urogynecology unit

Background

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a spectrum of pelvic, bladder or urethral pain, as well as irritative voiding symptoms. The term interstitial cystitis (IC) is reserved for patients with typical cystoscopic features. Diagnosis and management of this syndrome may be difficult. The aim of this study was to describe endoscopic features and our experience on the treatment of this syndrome in Urodifem de Occidente S.C., a private urogynecology unit.

Methods

Observational, retrospective analytic study of 25 treated patients from 33 with diagnosis of IC/PBS between January 2001 and March 2015. The diagnosis was done by clinical, cystoscopic and urodynamic approach. Treatment was based on bladder instillation of dymetilsulfoxido (DMSO), dexamethasone and heparin. Oral pentosan polysulphate was prescribed for at least 1 year.

Results

Cystoscopic findings showed petechial hemorrhages in 32%, Hunner’s lesions in 28%, glomerulations in 28% and bladder pain in absence of lesions in 12%. The basic treatment included one instillation once a week for 6 weeks, twice a month for 2 months and four monthly instillations. Three cases had complete remission of their symptoms, 21 had significant improvement and we have only one failure.

Conclusions

We recommend the combined use of DMSO instillation and pentosan polysulphate (PPS) in cases of IC/PBS.     

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.     

Significance of Random Bladder Biopsies in Non-Muscle Invasive Bladder Cancer

Background/Aims

To evaluate retrospectively the clinical outcome of random bladder biopsies in patients with non-muscle invasive bladder cancer (NMIBC) undergoing transurethral resection (TUR).

Patients and Method

This study included 234 consecutive patients with NMIBC who underwent random biopsies from normal-appearing urothelium of the bladder, including the anterior wall, posterior wall, right wall, left wall, dome, trigone and/or prostatic urethra, during TUR.

Result

Thirty-seven patients (15.8%) were diagnosed by random biopsies as having urothelial cancer. Among several factors available prior to TUR, preoperative urinary cytology appeared to be independently related to the detection of urothelial cancer in random biopsies on multivariate analysis. Urinary cytology prior to TUR gave 50.0% sensitivity, 91.7% specificity, 56.8% positive predictive value and 89.3% negative predictive value for predicting the findings of the random biopsies.

Conclusion

Biopsies of normal-appearing urothelium resulted in the additional detection of urothelial cancer in a definite proportion of NMIBC patients, and it remains difficult to find a reliable alternative to random biopsies. Collectively, these findings suggest that it would be beneficial to perform random biopsies as part of the routine management of NMIBC.Key Words: Non-muscle invasive bladder cancer, Random biopsy, Urinary cytology     

膀胱水扩张联合灌注透明质酸钠治疗问质性膀胱炎的临床分析

目的探讨膀胱水扩张加透明质酸钠灌注治疗间质性膀胱炎的临床有效性及安全性。方法。2006年7月至2009年5月,采用美国国立。肾病、消化病和糖尿病研究所（NIDDK）制定的标准诊断间质性膀胱炎27例,所有患者均在麻醉下行膀胱镜检查加水扩张,第2天用无菌透明质酸钠液40mg／50ml膀胱灌注,1次,周,连续12次为一疗程。观察指标：钾离子敏感试验（PST）评分,O’Leary—Sant间质性膀胱炎症状评分（ICSI）,膀胱容量测定和生活质量（QOL）评分。结果27例患者均完成治疗,随访6-15个月,平均9个月,24例患者症状缓解或消失,PST评分、ICSI评分、膀胱容量、QOL评分明显改善,3例患者效果较差。PST评分由4．09±0．51分下降至1．05±0．27分（P〈0．05）,ICSI评分由13．80±2．74分下降至7．34±2．47分（P〈0．05）;膀胱容量由97±17ml增加为268±62ml（P〈O．05）,QOL评分由22．5±4．5增加为43．8±7．0。治疗前后比较差异有显著性意义（10〈0．05）。结论膀胱水扩张联合灌注透明质酸钠液是治疗间质性膀胱炎有效方法,可以明显缓解临床症状和提高生活质量。     

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.     

Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The "Evil Twins" syndrome.

OBJECTIVE: To determine the prevalence of interstitial cystitis and endometriosis in patients with chronic pelvic pain. METHODS: A prospective analysis was conducted in 178 women with CPP who presented with bladder base/anterior vaginal wall and/or uterine tenderness, with or without irritative voiding symptoms. The Potassium Sensitivity Test was used to assess bladder epithelial dysfunction. Patients were evaluated with concurrent laparoscopy and cystoscopy with hydrodistention. RESULTS: Laparoscopic findings among the 178 patients with chronic pelvic pain supported a diagnosis of endometriosis in 134 (75%) patients, and cystoscopy confirmed a diagnosis of interstitial cystitis in 159 (89%) patients. Both interstitial cystitis and endometriosis were diagnosed in 115 patients (65%). The Potassium Sensitivity Test was positive in 146 (82%) patients, with 140 (96%) of these patients diagnosed with interstitial cystitis and 105 (72%) with endometriosis. CONCLUSIONS: Results of this prospective study show that interstitial cystitis and endometriosis may frequently coexist in patients with chronic pelvic pain. A positive Potassium Sensitivity Test accurately predicted the presence of interstitial cystitis in 96% of these patients with chronic pelvic pain, as confirmed by cystoscopic hydrodistention. It is necessary to consider the diagnosis of endometriosis and interstitial cystitis concurrently in the evaluation of patients with chronic pelvic pain to avoid unnecessary delay in identifying either condition.     

Bladder necrosis following hydrodistention in patients with interstitial cystitis

PURPOSE: Bladder hydrodistention is used to diagnose and treat patients with interstitial cystitis. This procedure has been shown to have minimal morbidity and provide symptomatic relief in a subset of patients with interstitial cystitis. We report our experience with almost total bladder necrosis after hydrodistention at 2 institutions. To our knowledge this rare complication has not been previously reported in the literature. We also reviewed the literature regarding complications of hydrodistention and discuss their possible etiology. MATERIALS AND METHODS: We report 3 cases of bladder necrosis after therapeutic hydrodistention for interstitial cystitis at 2 institutions. All records were reviewed, and the clinical presentation, findings and treatments are discussed. A literature review was performed to evaluate the effectiveness and complications of hydrodistention for interstitial cystitis. RESULTS: There were 2 female and 1 male patient between ages 29 and 46. All patients had a previous diagnosis of interstitial cystitis and had been previously treated with hydrodistention. All patients presented with severe abdominal pain and had necrosis of the entire bladder wall with sparing of the trigone. Two patients were treated with supratrigonal cystectomy. A review of the literature revealed little data on the effectiveness of hydrodistention for interstitial cystitis. CONCLUSIONS: Vesical necrosis is a rare but devastating complication of hydrodistention. It can occur in young patients in the absence of a contracted bladder and it usually presents as severe postoperative abdominal pain. At exploration bladder necrosis with sparing of the trigone was observed. All patients required enterocystoplasty.     

Bladder stretch alters urinary heparin-binding epidermal growth factor and antiproliferative factor in patients with interstitial cystitis

PURPOSE: The etiology of interstitial cystitis is unknown. Urine from patients with interstitial cystitis has been shown to inhibit urothelial proliferation through a putative antiproliferative factor and to contain decreased levels of heparin-binding epidermal growth factor-like growth factor (HB-EGF) compared to controls. Stretch of detrusor smooth muscle cells is known to stimulate HB-EGF production. Because bladder hydrodistention sometimes alleviates the symptoms of interstitial cystitis, we determined whether the stretch stimulus of hydrodistention alters antiproliferative factor activity and/or HB-EGF in interstitial cystitis urine specimens. MATERIALS AND METHODS: Urine was collected immediately before, and 2 to 4 hours and 2 weeks after hydrodistention from 15 patients with symptoms and cystoscopic findings compatible with interstitial cystitis and 13 controls. Hydrodistention was performed with the subject under general or regional anesthesia and bladders were distended to 80 cm. water 3 times. Urinary HB-EGF was measured by enzyme-linked immunosorbent assay and urinary antiproliferative factor activity was determined by measuring 3H-thymidine uptake by normal human bladder urothelial cells. RESULTS: Hydrodistention significantly increased urinary HB-EGF in patients with interstitial cystitis toward normal control values (before distention p = 0.003, 2 weeks after distention p = 0.67). Urine antiproliferative factor activity decreased significantly after hydrodistention in patients with interstitial cystitis. However, antiproliferative factor activity in interstitial cystitis and control specimens was still statistically different 2 weeks after distention (before distention p = 0.0000004, 2 weeks after distention p = 0.04). CONCLUSIONS: Bladder stretch increased HB-EGF and conversely reduced antiproliferative factor activity in urine from patients with interstitial cystitis but not controls up to 2 weeks after distention. These results provide additional evidence for the possible role of antiproliferative factor and decreased HB-EGF in the pathophysiology of interstitial cystitis. To our knowledge this is also the first human study to show that in vivo bladder stretch can alter urinary factors that regulate cell growth.     

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.     

Endoscopic ablation of Hunner’s lesions in interstitial cystitis patients

Introduction:

We report our experience with endoscopic ablation of Hunner’s lesions in women with interstitial cystitis (IC).

Methods:

A chart review was performed on 14 patients with IC symptoms who were identified to have bladder lesions and underwent endoscopic ablation. A Hunner’s lesion was identified as an area of erythema that reproduced the patients’ pain when touched by the cystoscope. Pathology reports were reviewed and improvement in pain was used as the main outcome measure.

Results:

Of the 14 patients, 12 had more than 50% symptomatic improvement and 8 patients reported 100% improvement. Mean improvement was 76%. In all patients who improved, the biopsy specimen showed inflammatory cystitis, often with epithelial denudation. Four patients had symptomatic recurrence, but all had improvement after repeat ablation.

Conclusion:

Endoscopic ablation of Hunner’s lesions improves symptoms in IC patients. Recurrence of symptoms should prompt repeat cystoscopy to identify recurrent lesions, as repeat ablation offers symptomatic improvement.     

Interstitial cystitis in persistent posthysterectomy chronic pelvic pain.

OBJECTIVES: Hysterectomies may be performed unnecessarily in women with chronic pelvic pain if the diagnosis of interstitial cystitis is not considered. The objectives of this study were to investigate the prevalence of interstitial cystitis in patients with posthysterectomy chronic pelvic pain and to evaluate the efficacy of various therapies for interstitial cystitis. METHODS: A study was performed of 111 patients with chronic pelvic pain whose pain persisted after hysterectomy. Patients were screened with the Pelvic Pain and Urgency/Frequency symptom scale, and underwent Potassium Sensitivity Testing. Patients were treated with dietary changes alone or in combination with cystoscopic hydrodistention or oral pentosan polysulfate, or both of these, for 3 to 6 months. RESULTS: Of the 111 patients enrolled, 79% (n=88) were diagnosed with bladder dysfunction consistent with interstitial cystitis. For patients treated with dietary modification alone (n=33), the mean score on the Pelvic Pain and Urgency/Frequency questionnaire improved 15.4%, from 13.18 at baseline to 11.15 at follow-up. For patients treated with pentosan polysulfate or cystoscopic hydrodistention, or both, plus diet changes (n=78), Pelvic Pain and Urgency/Frequency scores improved 34.2%, from 15.01 to 9.87. CONCLUSION: In this study, nonsurgical treatment for interstitial cystitis resulted in a marked improvement in symptoms that had not improved with surgery. Without determining the origin of bladder pain, gynecologists should not proceed to hysterectomy in patients with chronic pelvic pain.     

Comparison of cystoscopic and histological findings in patients with suspected interstitial cystitis

PURPOSE: Although the exact etiology of interstitial cystitis remains elusive, bladder inflammation appears to be common in many patients. The National Institutes of Health (NIH) have established diagnostic criteria for interstitial cystitis based on the presence of irritative voiding symptoms in the absence of other identifiable pathology. Cystoscopic examination with hydrodistention performed in patients under anesthesia is part of the NIH diagnostic criteria. We determine if the severity of cystoscopic findings correlated with histological evidence of inflammation in patients with suspected interstitial cystitis. MATERIALS AND METHODS: A total of 69 patients who met NIH symptom criteria for interstitial cystitis and underwent cystoscopy, hydrodistention and bladder biopsy under anesthesia were reviewed. There were 2 investigators blinded to the histological data who independently reviewed operative reports. A urological pathologist blinded to the clinical data reviewed biopsies for inflammation severity. Cystoscopic and histological findings were then converted to a numeric scale. Numeric data were analyzed using the Pearson correlation coefficient. RESULTS: Cystoscopic examination revealed no evidence of interstitial cystitis in 6 patients (9%), mild changes in 27 (39%), moderate changes in 23 (33%) and severe changes in 13 (19%). Histological examination revealed no inflammation in 21 patients (30%), mild inflammation in 28 (41%), moderate inflammation in 11 (16%) and severe inflammation in 9 (13%). Histological scores correlated poorly with total and scaled cystoscopic severity scores (r = 0.295 and 0.349, respectively). CONCLUSIONS: Severity of cystoscopic findings observed during hydrodistention with anesthesia does not appear to correlate with the degree of inflammation identified histologically in patients with suspected interstitial cystitis.     

Urological vignette: Satellite lesion in the bladder from urachal enteric adenocarcinoma

INTRODUCTION

We present, to the best of our knowledge, the first published case report of a satellite lesion within the bladder from enteric type urachal adenocarcinoma (UA).

PRESENTATION OF CASE

Our case report involves a 38-year-old man from the Solomon Islands who underwent open partial cystectomy for UA. However, resection margins were positive due to the novel finding of a satellite lesion on histopathological assessment. Salvage cystectomy was subsequently performed and the patient had an uncomplicated post-operative recovery.

DISCUSSION

This case highlights the importance of achieving negative soft tissue and bladder margins on initial resection of UA, as the consequences of incomplete resection can place significant additional morbidity on the patient.

CONCLUSION

We aim to highlight the possibility of satellite lesions within the bladder in UA and suggest that further studies looking at this phenomenon are required to establish its incidence and overall impact on management of UA.     

Electrical Stimulation of the Urethra Evokes Bladder Contractions in a Woman With Spinal Cord Injury

Objective:

Electrical stimulation of pudendal urethral afferents generates coordinated micturition in animals and bladder contractions in men after spinal cord injury (SCI), but there is no evidence of an analogous excitatory urethra-spinal-bladder reflex in women. The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions in a woman with SCI.

Case Report:

A 38-year-old woman with a C6 ASIA A SCI who managed her bladder with clean intermittent catheterization and oxybutynin demonstrated neurogenic detrusor overactivity on urodynamics. Oxybutynin was discontinued 2 days prior to urodynamic testing with a custom 12F balloon catheter mounted with ring-shaped electrodes located in the bladder neck, mid urethra, and distal urethra. The inflated balloon was placed against the bladder neck to stabilize the catheter electrodes in place along the urethra. However, the balloon limited emptying during contractions. Urodynamics were performed at a filling rate of 25 mL/minute until a distention-evoked bladder contraction was observed. The urethra was stimulated over a range of bladder volumes and stimulus parameters to determine whether electrical stimulation could evoke a bladder contraction.

Findings:

Electrical stimulation via urethral electrodes evoked bladder contractions that were dependent on bladder volume (>70% capacity) and the intensity of stimulation.

Conclusions:

This is the first report of an excitatory urethra-spinal-bladder reflex in a woman with SCI. Future studies will determine whether this reflex can produce bladder emptying.     

Diagnostic and Prognostic Significance of Serum and Tissue Galectin 3 Expression in Patients with Carcinoma of the Bladder

Background

Galectins are group of proteins found in the cytoplasm, nucleus, cell surface and extracellular matrix. Galectin 3 (Gal-3) displays pathological expression in a variety of processes such as tumorigenesis.

Patients and Method

70 patients classified into the control group, cystitis group, transitional cell carcinoma group, and squamous cell carcinoma group were enrolled in this study which aimed to detect the serum level and the intensity of tissue expression of Gal-3.

Results

Both serum level and tissue expression of Gal-3 were statistically higher in bladder cancer patients compared to the other groups. Gal-3 level expression increased from low to high grade urothelial tumors, with a statistically significant increase of its level and expression between muscle invasive and non-muscle invasive Ta urothelial tumors.

Conclusion

The serum Gal-3 level is sensitive and specific for the diagnosis of bladder cancer. The prognostic significance of tissue expression is to be confirmed.Key Words: Galectin 3, Bladder cancer, Transitional cell carcinoma, Squamous cell carcinoma, Schistosomiasis     

Aggressive bladder carcinoma in an HIV-positive man with tetraplegia and neurogenic bladder

Background/objective

Patients with neurogenic bladder secondary to spinal cord injury who are managed long term with an indwelling catheter are known to be at increased risk for transitional cell carcinoma of the bladder. Immunosuppression is a known risk factor for malignancies that often are more aggressive than those seen in normal populations.

Method

Case report and discussion of management recommendations.

Results

We summarize the case of a 44-year-old HIV-positive C5–C6 incomplete tetraplegic male (date of injury 1980), who was diagnosed with transitional cell carcinoma of the bladder and succumbed to disease within 6 months of diagnosis. The patient was a non-smoker who was never managed with an indwelling catheter. There has been no such case reported in the literature.

Conclusions

HIV infection in the presence of a neurogenic bladder may carry an increased risk of aggressive bladder malignancy. More studies are warranted to determine whether routine annual screening with cystoscopy in all patients with HIV and neurogenic bladder is indicated.     

Radical cystectomy for the treatment of T1 bladder cancer: the Canadian Bladder Cancer Network experience

Background:

Radical cystectomy may provide optimal survival outcomes in the management of clinical T1 bladder cancer. We present our data from a large, multi-institutional, contemporary Canadian series of patients who underwent radical cystectomy for clinical T1 bladder cancer in a single-payer health care system.

Methods:

We collected a pooled database of 2287 patients who underwent radical cystectomy between 1993 and 2008 in 8 different centres across Canada; 306 of these patients had clinical T1 bladder cancer. Survival data were analyzed using Kaplan-Meier method and Cox regression analysis.

Results:

The median age of patients was 67 years with a mean follow-up time of 35 months. The 5-year overall, disease-specific and disease-free survival was 71%, 77% and 59%, respectively. The 10-year overall and disease-specific survival were 60% and 67%, respectively. Pathologic stage distribution was p0: 32 (11%), pT1: 78 (26%), pT2: 55 (19%), pT3: 60 (20%), pT4: 27 (9%), pTa: 16 (5%), pTis: 28 (10%), pN0: 215 (74%) and pN1-3: 78 (26%). Only 12% of patients were given adjuvant chemotherapy. On multivariate analysis, only margin status and pN stage were independently associated with overall, disease-specific and disease-free survival.

Interpretation:

These results indicate that clinical T1 bladder cancer may be significantly understaged. Identifying factors associated with understaged and/or disease destined to progress (despite any prior intravesical or repeat transurethral therapies prior to radical cystectomy) will be critical to improve survival outcomes without over-treating clinical T1 disease that can be successfully managed with bladder preservation strategies.     

Possible mechanisms inducing glomerulations in interstitial cystitis: relationship between endoscopic findings and expression of angiogenic growth factors

PURPOSE: Glomerulation has been one of the requisite criteria for the diagnosis of interstitial cystitis (IC) but the mechanisms for glomerulation remain unclear. Therefore, we investigated the relationship between the cystoscopic findings of vascular events and the expression of angiogenic growth factors in IC bladders to identify the possible mechanisms inducing glomerulations in IC. MATERIALS AND METHODS: In 45 patients suspected of having IC continuous, fixed point cystoscopic observation was performed during hydrodistention using spinal anesthesia. Bladder biopsies were performed in these cases and in an additional 5 asymptomatic cases. Thereafter, the expression of platelet derived endothelial cell growth factor/thymidine phosphorylase (PDECGF/TP) was measured by enzyme-linked immunosorbent assay. Immunohistochemical staining for PDECGF/TP and vascular endothelial growth factor was also performed. RESULTS: Of 45 symptomatic patients 38 had glomerulations during cystoscopic examination. In these patients during hydrodistention the blood flow in bladder wall vessels was interrupted by whitish fibrous bundles. Thereafter petechial bleeding began from capillaries distal to obstructed vessels during bladder emptying. PDECGF/TP expression in patients with glomerulation was significantly higher than in symptomatic patients without glomerulation or asymptomatic patients (p < 0.001). In patients with glomerulations a high positive rate for PDECGF/TP (97.4%) and vascular endothelial growth factor (68.4%) staining was observed, while no positive staining was found in asymptomatic patients. CONCLUSIONS: Glomerulations during hydrodistention are highly associated with the over expression of angiogenic growth factors in the bladder. Thus, it seems likely that neovascularization promoted by angiogenic growth factors has an important role in the pathogenesis of IC, inducing glomerulations during hydrodistension.     

Non-Invasive Evaluation of Bladder Outlet Obstruction in Men Suspected of Benign Prostatic Hyperplasia: Usefulness of the D Index

Objective

To compare a new index of voiding dysfunction (D) based purely on free uroflow vs. Abrams-Griffiths (A-G) number obtained from intubated flow, for classification of bladder outlet obstruction in men.

Patients and Methods

Urodynamic tracings of 60 non-neurological patients (30 before transurethral resection of the prostate and of 30 men suspected of benign prostatic hyperplasia included in a medical therapy trial) were retrospectively analyzed. The Valentini-Besson-Nelson model was used to evaluate the value of the D index. A-G was obtained from intubated flows. Obstruction was defined as D > 32.5 cm H₂O (translation of A-G criterion).

Results

D showed 82.05% sensitivity with 66.66% specificity; the positive predictive value was 82.05% and the negative predictive value 66.66% for the whole population, 83.3 vs. 80.9% sensitivity with 58.3 vs. 77.7% specificity for pre- transurethral resection of the prostate vs. medical therapy group.

Conclusion

D index which can be obtained from a free uroflow appears as a valuable alternative to invasive urodynamic investigations when the diagnosis of bladder outlet obstruction needs to be more solidly established before a treatment decision or in men suspected of benign prostatic hyperplasia who elect for watchful waiting.Key Words: Bladder outlet obstruction, Benign prostatic hyperplasia, Voiding dysfunction index, Free uroflow, Non invasive testing     

The Intravesical Potassium Sensitivity Test and Urodynamics: Implications in a Large Cohort of Patients with Lower Urinary Tract Symptoms

PURPOSE: Bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH) is the most common diagnosis in older men with lower urinary tract symptoms. However, these symptoms also can occur with interstitial cystitis. We determine whether the potassium sensitivity test is useful for distinguishing BPH from possible intersitial cystitis in patients with lower urinary tract symptoms. We also test the hypothesis that patients with these symptoms who have a positive test will have urodynamic findings consistent with the diagnosis of interstitial cystitis. MATERIALS AND METHODS: The potassium sensitivity test was performed in 526 (95%) males and 25 (5%) females with lower urinary tract symptoms undergoing urodynamic testing. Urodynamic parameters in the positive and negative potassium sensitivity test groups were compared. %Results: Of the patients 16% (89 of 551) had a positive potassium sensitivity test. Compared with patients who had a negative test, those who had a positive test were younger (61 versus 64 years, p = 0.03), had urgency at significantly lower volumes (108 versus 182 cc, p <0.0001), lower bladder capacity (343 versus 436 cc, p <0.0001) and lower post-void residual (49 versus 95 cc, respectively, p <0.001). Urodynamic parameters in the 24% (6 of 25) of women who had a positive potassium sensitivity test were similar to those in men who also had a positive test. CONCLUSIONS: Urodynamic findings in patients with lower urinary tract symptoms who have a positive potassium sensitivity test are significantly different from those in patients who have a negative test, and are similar to those findings characteristic of interstitial cystitis. Interstitial cystitis should be considered in patients with lower urinary tract symptoms who have a positive test. The potassium sensitivity and urodynamic tests may be a useful combination for screening men with lower urinary tract symptoms to identify those symptoms that may be due to interstitial cystitis versus BPH.