Treatment of painful bladder syndrome/interstitial cystitis with botulinum toxin A: why isn’t it effective in all patients?

Botulinum toxin A (BTA) is currently used to treat a variety of painful disorders, including painful bladder syndrome/interstitial cystitis (PBS/IC). However, BTA is not consistently effective in all patients. This may be due to the disparity of causes of pain, but this may also relate to the processes by which BTA exerts anti-nociceptive effects. This review discusses mechanisms by which BTA may inhibit pain and studies of the use of BTA in PSB/IC patients. It is doubtful that any single treatment will effectively control pain in PBS/IC patients, and it is highly probable that multiple strategies will be required, both within individual patients and across the population of PBS/IC patients. The purpose of this review is to discuss those mechanisms by which BTA acts, with the intent that alternative strategies exploiting these mechanism, or work through alternative pathways, can be identified to more effectively treat pain in PBS/IC patients in the future.     

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.     

Voiding urges perceived by patients with interstitial cystitis/painful bladder syndrome

AIMS: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a symptom-based diagnosis. We studied the IC/PBS symptom commonly referred to as "urgency" and its relationship to IC/PBS pain in a group of women with recent onset of the disease. METHODS: As part of a case control study to identify risk factors for IC, cases completed a questionnaire including two statements regarding the perceived cause of their urge to void. One was related to fear of incontinence and the other was linked with relief of pain. A Likert scale indicating level of agreement/disagreement comprised the response options. RESULTS: Most respondents (65%) agreed with the statement linking urge with pain relief. A minority (21%) concurred with the fear of incontinence statement. Disagreement for both was found in 19%. A substantial proportion (46%) agreed with pain relief but also disagreed that urge is related to fear of incontinence. Those who reported urge to relieve pain were significantly more likely to report worsened pain with bladder filling and/or improved pain with voiding. There were no such associations with urge to prevent incontinence. Overactive bladder or diabetes prior to IC onset did not confound these results. CONCLUSIONS: At least two distinct experiences of urge to urinate are evident in this population. For most, urge is linked with pain relief and is associated with bladder filling/emptying. About 1/5 reported urge to prevent incontinence. A similar portion did not agree with either urge, indicating that they may experience something altogether different, which requires further inquiry.     

A multidisciplinary approach to the evaluation and management of interstitial cystitis/bladder pain syndrome: an ideal model of care

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a complex syndrome that has long been treated with bladder directed therapies, which often fail to address the multiple underlying etiologies that can contribute to this disease process. This disease often involves symptoms that extend beyond the bladder and involve the pelvic floor making it crucial for clinicians to approach the patient using a multidisciplinary team. This article will discuss the underlying etiologies for IC/BPS and describe the multidisciplinary approach which we have found to be extremely successful in managing this patient population.     

膀胱疼痛综合征相关症状的鉴别诊断及临床意义

目的探讨鉴别诊断在女性膀胱疼痛综合征／间质性膀胱炎诊断中的重要意义。方法回顾2005年至2011年间42例转诊到广州医科大学附属广州市第一人民医院的膀胱疼痛综合征／间质性膀胱炎（IC）女性患者的临床资料。患者平均年龄49（26～69）岁,IC病程14（6～24）个月。通过详细分析病史及辅助检查（如尿动力学检查、尿道膀胱镜检、排尿期膀胱尿道造影、尿流率、剩余尿量测定、磁共振等）来探讨这些Ic病例是否存在其他泌尿系疾病,以及这些新发现的其他疾病经治疗后IC症状的改善情况。站栗尿动力学检查发现10例（24％）存在膀胱出口梗阻;排尿期膀胱尿道造影联合尿流率和剩余尿量发现16例（38％）存在远端尿道狭窄;核磁共振发现5例（12％）存在尿道憩室;尿道膀胱镜检发现21例（50％）膀胱三角区严重黏膜充血、滤泡增生明显,部分黏膜下可见弥漫脓包形成,5例（12％）存在尿道外口狭窄。42例患者根据新发现的病变进行相应的治疗,如膀胱出口梗阻或尿道外口狭窄接受尿道扩张、尿道松解术或者尿道外口成形术;膀胱炎接受经尿道膀胱黏膜电灼术;尿道憩室接受尿道憩室切除术等。42个患者中,26例（62％）的症状明显改善或完全消失,16例（38％）症状元改善。平均随访时间18（6～36）个月。结论膀胱疼痛综合征／间质性膀胱炎因与泌尿系统其他疾病的症状相似而容易被混淆。只有做好缜密的鉴别诊断才能避免误诊。     

Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management

Interstitial cystitis/bladder pain syndrome (IC/BPS) and vulvodynia are chronic pain syndromes that appear to be intertwined from the perspectives of embryology, pathology and epidemiology. These associations may account for similar responses to various therapies.     

Assessing UK specialists’ knowledge of the diagnostic criteria for painful bladder syndrome/interstitial cystitis

The aim of this study was to assess UK clinicians’ knowledge of the National Institute of Diabetes, Digestive and Kidney diseases (NIDDK) criteria for painful bladder syndrome (PBS)/interstitial cystitis (IC). A questionnaire survey was distributed nationally to 100 gynaecologists and urologists. The main outcome measure was to determine whether respondents knew the NIDDK diagnostic criteria for PBS/IC. All respondents cared for women with lower urinary tract dysfunction in their daily practice; 40% had a special interest in urogynaecology. Most (83%) knew that urgency, frequency and pain are required to diagnose PBS/IC; however, few were aware of exclusion/inclusion criteria. The minority perform double fill at cystoscopy, and only 56% were aware that glomerulations and/or Hunner’s ulcers are required to diagnose IC. Urologists with a special interest in female urology answered nearly 75% of the questionnaire correctly in contrast to less than 40% of general gynaecologists. The findings suggest misdiagnosis of PBS/IC may be widespread in the UK. The NIDDK criteria are complex and appear to be of little relevance in clinical practice highlighting the need for more clearly defined diagnostic criteria.     

Mast cell activation syndrome

In 1984, interstitial cystitis (IC) was considered a rare psychosomatic disorder in post-menopausal women. In 2014, the Interstitial Cystitis Association of America (ICA) celebrated its 30^th anniversary. We’ve come a long way since 1984 and great progress has been made. IC is now recognized as a condition that afflicts both men and women of all ages, including children and teenagers. It is not a psychiatric disorder. Though it was once thought to be an orphan disease (defined as affecting less than 200,000 people), we now know that there are millions of women and men who suffer from IC/BPS (bladder pain syndrome). In looking back over this period, there were seven key reasons why the ICA became so successful: an extremely dedicated ICA staff, Board of Directors and volunteers; a very strong Medical Advisory Board and participation of many other urologists from across the country and around the world; cooperation of the media; epidemiological studies; the ICA’s Pilot Research Program; our representation in Congress; and a strong working partnership with the National Institutes of Health (NIH). Our history may prove useful to other advocacy groups.     

Test-retest reliability and discriminant validity for the Brazilian version of “The Interstitial Cystitis Symptom Index and Problem Index” and “Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale” instruments

Background

The purpose is to evaluate the psychometric properties of reliability and discriminant validity of the Brazilian Portuguese versions of two instruments used in the diagnosis of interstitial cystitis (IC): “The Interstitial Cystitis Symptom Index and Problem Index” (The O’Leary-Sant), and “Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale”.

Methods

Three groups of patients were examined: a study group (subjects with IC), control group 1 (individuals with at least one IC symptom), and control group 2 (subjects without IC symptoms). Test-retest stability was evaluated at intervals of 3 to 7 days in the study group. Discriminant validity was examined in all three groups.

Results

The intraclass correlation coefficient (ICC) [95% confidence interval (CI)] results were 0.56 (range, 0.21-0.78) for The O’Leary-Sant Symptom Index, 0.48 (range, 0.10-0.73) for The O’Leary-Sant Problem Index, and 0.49 (range, 0.12-0.74) for the PUF. To analyze discriminant validity between groups, we used Fisher’s exact test and odd ratio (OR) to identify differences. We obtained a P value<0.0001, which indicated that the null hypothesis was rejected; in other words, there was evidence that at least two different groups were compared to the proportion of patients with IC.

Conclusions

The analyzed instruments did not reach appropriate values for reliability. Future studies are needed to analyze the psychometric measures of these instruments on a larger sample of patients with IC.     

A real-life multicentre clinical practice study to evaluate the efficacy and safety of intravesical chondroitin sulphate for the treatment of interstitial cystitis

OBJECTIVE

To report a multicentre, community based open‐label study designed to assess the efficacy and safety of intravesical sodium chondroitin sulphate in the treatment of patients with the clinical diagnosis of interstitial cystitis (IC). Chondroitin sulphate is a naturally occurring glycosaminoglycan (GAG) in the bladder mucus layer and changes in this GAG have been implicated in the pathogenesis of IC, and small single‐centre studies have suggested that intravesical chondroitin sulphate may have efficacy in IC.

PATIENTS AND METHODS

Patients with IC were treated with sodium chondroitin sulphate (Uracyst®, Stellar Pharmaceuticals Inc., London ON, Canada) solution 2.0% via urinary catheter weekly for 6 weeks and then monthly for 16 weeks for a total of 10 treatments. The primary efficacy endpoint was the percentage of responders to treatment as indicated by a marked or moderate improvement on a seven‐point patient Global Response Assessment (GRA) scale at week 10 (4 weeks after the initial six treatments) compared with baseline. A major secondary efficacy endpoint (durability) was the percentage of responders on the GRA scale after 10 treatments. Additional secondary efficacy objectives were differences from baseline in Patient Symptom/Problem Index scores over the course of the treatment compared with baseline.

RESULTS

In all, 47% of the 53 enrolled patients with long standing moderately severe IC (mean [sd , range] diagnosis of IC 3.0 [3.4, 0.1–16] years; duration of symptoms 9.2 [9.2, 1–39] years; baseline symptom score 14.2 [3.2]) were responders at week 10. At 24 weeks, 60% were responders. There was a statistically and clinically significant decrease in the mean (sd ) symptom and bother scores from baseline at 10 weeks and 24 weeks, at 9.0 (4.3) and 8.1 (5.0), respectively (P < 0.001). There were no significant safety issues during the study.

CONCLUSIONS

This multicentre community based real‐life clinical practice study suggests that intravesical chondroitin sulphate may have an important role in the treatment of IC and validates the rationale for a randomized placebo‐controlled trial.     

Increased bladder permeability in interstitial cystitis/painful bladder syndrome

The definition of interstitial cystitis (IC) has evolved over the years from being a well-defined entity characterized by diagnostic lesion (Hunner’s ulcer) in the urothelium to a clinical diagnosis by exclusion [painful bladder syndrome (PBS)]. Although the etiology is unknown, a central theme has been an association with increased permeability of the bladder. This article reviews the evidence for increased permeability being important to the symptoms of interstitial cystitis/painful bladder syndrome (IC/PBS) and in treating the disorder. Recent work showing cross-communication among visceral organs is also reviewed to provide a basis for understanding IC/PBS as a systemic disorder of a complex, interconnected system consisting of the bladder, bowel and other organs, nerves, cytokine-responding cells and the nervous system.     

Potassium sensitivity test (PST) as a measurement of treatment efficacy of painful bladder syndrome/interstitial cystitis: a prospective study with cyclosporine A and pentosan polysulfate sodium

AIMS: Potassium sensitivity test (PST) has been used as an optional tool in diagnosing painful bladder syndrome/interstitial cystitis (PBS/IC). The role of PST in the follow-up of patients with PBS/IC is elusive. We performed PST before and after treatment of PBS/IC with cyclosporine A (CyA) or pentosan polysulfate sodium (PPS), to test whether the result of repeated PST correlates with alleviation of PBS/IC-related symptoms. MATERIALS AND METHODS: Sixty-four patients who participated in a randomized clinical study comparing CyA and PPS in the treatment of PBS/IC were recruited to the present study. Patients underwent 0.4 M PST before and after 6 months of treatment. The primary end point was a change from positive PST to negative among patients who responded to both treatments determined by global response assessment (GRA). RESULTS: Potassium sensitivity test (PST) was more likely to change from positive to negative among patients who responded to their treatment according to GRA (P < 0.001). The PST change follows the clinical course (ICSI score, voiding frequency, VAS score), which was more beneficial in the CyA-treated patients. CONCLUSIONS: Potassium sensitivity test (PST) reflects symptom severity of PBS/IC patients. Change of pre-treatment positive PST to negative correlates well with clinical alleviation of PBS/IC-related symptoms. In patients with persistent symptoms it may be painful and does not offer additional information. Thus, we do not recommend PST to be used as a routine clinical test in monitoring of PBS/IC treatment efficacy.     

Comparison of intravesical botulinum toxin type A injections plus hydrodistention with hydrodistention alone for the treatment of refractory interstitial cystitis/painful bladder syndrome

OBJECTIVE

To compare the clinical effectiveness of botulinum toxin type A (BoNT‐A) injections followed by hydrodistention (HD) with HD alone in patients with interstitial cystitis/painful bladder syndrome (IC/PBS).

PATIENTS AND METHODS

A prospective, randomized study was performed in a urological referral centre. In all, 67 patients with IC/PBS who had failed conventional treatments were enrolled. Of these, 44 patients received suburothelial injection with 200 U (15) or 100 U (29) of BoNT‐A followed by cystoscopic HD 2 weeks later (BoNT‐A groups). The control group (23 patients) received the identical HD procedure with no BoNT‐A injection. All patients remained on baseline medications of pentosan polysulphate throughout the study. Bladder pain visual analogue scale (VAS), O’Leary‐Sant symptom and problem indexes, functional bladder capacity (FBC) and urodynamic variables were measured at baseline and after treatment. Global response assessment was used to evaluate successful treatment response.

RESULTS

The IC/PBS symptom score significantly decreased in all three groups, but VAS reduction, FBC and cystometric bladder capacity increases were significant only in the BoNT‐A groups at 3 months. Of the 44 patients in the BoNT‐A group 31 (71%) had a successful result at 6 months. A successful result at 12 and 24 months was reported in 24 (55%) and 13 (30%) patients in BoNT‐A group, respectively, compared with only six (26%) and four (17%) in the control group (P = 0.002).

CONCLUSION

Intravesical injections of BoNT‐A followed by HD produced significantly better clinical results than HD alone in patients with IC/PBS.     

The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Bladder pain syndrome (BPS) is a chronic debilitating disease. A recently done survey estimates the prevalence of the BPS symptoms among adult females in the U.S. to be 7%. Conservative management is the first line of therapy but at least 10% of the patients show poor response. Sacral neuromodulation is a minimal invasive technique with good long‐term outcomes in these patients. It should be considered before any invasive surgical intervention is planned. However, the revision rate is high and patients need lifelong follow‐up.

OBJECTIVE

? To evaluate the long‐term success and tolerability of sacral neuromodulation (SNM) in the control of the symptoms of bladder pain syndrome (BPS).

METHODS

? This was a retrospective study of all patients with BPS who underwent peripheral nerve evaluation and then SNM in our department of urology by a single surgeon from 1994 till 2008. The global response assessment scale was used to evaluate the outcome of the SNM.

RESULTS

? A total of 78 patients fulfilled the International Consultation on Incontinence clinical criteria for BPS and showed cystoscopic evidence of glomerulation or ulcer as recommended by the European Society for the Study of Interstitial Cystitis/Painful Bladder Syndrome. All patients failed conservative management before considering SNM. ? Permanent SNM implant was performed in patients who showed at least 50% improvement in their symptoms with a temporary peripheral nerve evaluation test. Median follow up was 61.5 months (sd ± 27.7). Good long‐term success of the SNM was seen in 72% of the patients. ? Presence of urgency was a positive predictor of the long‐term success of the implant. The explantation rate was 28%. The commonest reason for explantation was poor outcome (54% of the failed patients). The revision rate was 50%. ? The most common indication for revision was lack of stimulation sensation and worsening of symptoms. The average durability of the pulse generator battery was 93 months.

CONCLUSION

? SNM is an effective treatment to control the symptoms of BPS. It should be considered before any major invasive surgical intervention if conservative measures have failed. It is a minimally invasive, safe procedure with good long‐term outcome. However, the revision rate is high and patients require lifelong follow‐up.     

Hydrodistension under local anesthesia for patients with suspected painful bladder syndrome/interstitial cystitis: Safety,diagnostic potential and therapeutic efficacy

Objectives: To evaluate the safety, diagnostic potential and therapeutic efficacy of cystoscopy with hydrodistension under local anesthesia in patients with suspected painful bladder syndrome/interstitial cystitis (PBS/IC). Methods: Thirty‐six patients with frequency, urgency or bladder pain for ≥6 months and an average voided volume of <200 mL were enrolled in the study. Hydrodistension was carried out 10 min after instillation of 10 mL of 4% lidocaine. The instilled saline volume for hydrodistension was determined based on each patient's level of tolerance of urinary sensation and symptoms. Results: Overall, 30 patients (median age 54 years, range 25–76) were evaluated. The median instilled saline volume was 450 mL (250 to 580 mL). No patients were admitted to hospital due to adverse events associated with hydrodistension. Glomerulation was found in 23 patients and two had Hunner's ulcers. Therapeutic efficacy at one month after hydrodistension was shown in 21/30 patients (71%). A median efficacy period of 20 ± 3.7 weeks was determined by Kaplan–Meier analysis. Factors with an independent influence on therapeutic efficacy of hydrodistension were not identified, but patients with an instilled volume greater than the median volume had significantly longer efficacy periods (P < 0.022). Conclusions: Cystoscopy with hydrodistension under local anesthesia provides a simple and safe method for differential diagnosis and has some therapeutic efficacy in patients with suspected PBS/IC.     

Patient-centred standardization in interstitial cystitis/bladder pain syndrome—a PLEA

Standardization has an impact on all links in the healthcare chain and directly affects patients with regard to diagnosis, treatment, eligibility for reimbursement, social benefits and care. Furthermore, patients are also affected if research goes down inappropriate pathways due to inaccurate terminology and definitions. Complex healthcare coding and electronic medical record systems and global reliance on the internet and search machines mean that new terminology or changes now need in some way to be designed to last or to be updated in a way that will cause least disruption, while still allowing for evolution, since changes have far more ramifications today than they ever did in the past. Official recognition of a condition is vital, so coding must be correct and uniform across all authorities. Potential problems must be anticipated at an early stage in the process. In order to achieve global consensus, stakeholders from all parts of the world need to communicate and collaborate with all viewpoints taken into consideration. Patients and their advocacy groups should be involved in standardization processes to ensure that all aspects of a condition are covered, that no patients or symptoms are excluded and that there is no adverse impact on the patient in practical terms following implementation. The trend today is for patients to be more involved in healthcare and decision-making. We must ensure that standardisation and guidelines do not get left behind in this process of development either now or in the future. However, it is necessary to find some way of training patient representatives to enable them to participate fully in standardization and guidelines and also to encourage them to do so.     

Cystoscopic findings in women with minimal and maximal lower urinary tract symptoms

BackgroundGlomerulations are not specific for interstitial cystitis/bladder pain syndrome (IC/BPS). Controversy exists about whether cystoscopic findings differ between patients with and without lower urinary tract symptoms. We sought to compare the prevalence of cystoscopic findings in women with “no or minimal” urinary symptoms to those with a “high” symptom burden.MethodsThis is a secondary analysis of a prospective cohort study performed at a University Educational Facility. Participants in this study were part of a larger prospective study, in which female patients scheduled to undergo routine gynecologic procedures were all consented for cystoscopy with hydrodistension (CWHD). We defined the “minimally symptomatic group” as those with ≤1 on each of the O’Leary/Sant Interstitial Cystitis Symptom Index (ICSI) subscores and without history of IC/BPS. The “highly symptomatic” cohort of women had composite ICSI score ≥12 and a Burning/Pain subscore of 4 or 5. All were non-smokers.ResultsA total of 84 women underwent CWHD, with 33 having minimal symptoms and 51 being highly symptomatic. The two groups were not statistically different when assessing for ‘any glomerulations’ compared to ‘no glomerulations.’ However, minimally symptomatic women had an eight-fold lower prevalence of significant glomerulations than highly symptomatic women (3.0% minimally symptomatic vs. 23.5% highly symptomatic, P<0.05.)ConclusionsExtensive glomerulations (≥10 in 3 or 4 quadrants) are rare in women with minimal urinary symptoms. These findings contrast with prior limited prospective data which quoted similar incidence of glomerulations in IC/BPS patients and asymptomatic patients. This study highlights the importance of evaluating objective evidence on CWHD and merits further investigation as part of the ongoing conversation regarding the definition of bladder health and pathology     

Phenotyping of interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome is a chronic, potentially debilitating condition characterized by pain perceived to be related to the bladder in conjunction with lower urinary tract symptoms, and includes a wide variety of clinical phenotypes with diverse etiologies. Currently the only clinically relevant proven phenotype of interstitial cystitis/bladder pain syndrome is the Hunner lesion. Whether the presence of Hunner lesions is a hallmark of a distinct disease cohort or a potentially transient feature of non‐Hunner lesion phenotype has been debated but remains controversial. There are few documented examples of a patient converting between the two forms. Growing clinical and basic evidence supports eliminating the Hunner lesion phenotype from the bladder pain syndrome umbrella and considering it a distinct disease. The Hunner lesion phenotype is characterized by distinct bladder histology, including subepithelial chronic inflammatory changes and epithelial denudation, and specific clinical characteristics (older onset age, severe bladder‐centric symptoms, reduced bladder capacity, and favorable response to the lesion‐targeted therapies). To define the Hunner lesion phenotype, it is necessary to develop an atlas of standardized images of cystoscopic (and, if possible, pathological) appearances of Hunner lesions. A true potential and clinically relevant phenotype of interstitial cystitis/bladder pain syndrome may be patients with non‐bladder‐centric symptoms, characterized by the affect dysregulation and somatic symptoms, and a greater bladder capacity in absence of Hunner lesions. In the present workshop, we concluded that the Hunner lesion is a valid phenotype and can reasonably be considered a disease in its own right. Assessment of bladder capacity and the extent of symptoms (bladder beyond or bladder centric) may help phenotyping of interstitial cystitis/bladder pain syndrome. Proper phenotyping is essential for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome, and for facilitating research.     

A survey on clinical practice of interstitial cystitis in Japan

Background

To explore the real-life practice of clinical management of interstitial cystitis (IC) in Japan.

Methods

A questionnaire on the number of IC patients, cystoscopic findings, diagnostic methods, and the treatment modalities was sent via e-mail to 114 medical institutions belonging to the Society of Interstitial Cystitis of Japan (SICJ).

Results

Completed questionnaires were returned from 62 institutions (20 university hospitals, 26 general hospitals and 16 clinics), with a response rate of 54%. The median of patient number per institution was 20 and the national number of IC patients was counted as 4,531 in Japan. The number of new patients in 2013 was 7 (median) per institution and calculated as 1,214 in total. The case volume per institution distributed broadly and skewed to a lower volume. The patients were categorized according to cystoscopic findings as either Hunner type IC with Hunner lesions (n=2,066, 45%), non-Hunner type IC with glomerulations on hydrodistension (n=1,720, 38%) or hypersensitive bladder without endoscopic abnormalities (n=304, 7%), excluding unknown (n=441, 10%). The proportion of Hunner type IC was highly variable among the institutions, ranging from 0% to 100% with a median of 29%. As for evaluation, symptom and quality of life (QOL) assessment by questionnaires, frequency volume chart, urinalysis, urine cytology, urine culture, post-void residual measurement, uroflowmetry, ultrasound and cystoscopy were widely adapted. Administration of oral medicines and intravesical instillation therapy were undertaken at 98% and 63% of institutions, respectively. Hydrodistension was commonly performed, totaling in 812 procedures at 53 institutions, while only five cystectomies were reported from four institutions.

Conclusions

The survey estimated about 4,500 IC patients and 2,000 Hunner type IC patients in Japan. It also revealed a wide range of case volume, acceptable adherence to clinical guidelines, and high variability in the proportion of Hunner type IC. The variable proportions of Hunner type IC despite a high performing rate of endoscopy suggest inconsistency in diagnostic criteria for the Hunner lesion.     

A combined intravesical therapy with hyaluronic acid and chondroitin for refractory painful bladder syndrome/interstitial cystitis

The aims of this study were to evaluate the efficacy and tolerability of intravesical instillations of high-molecular-weight hyaluronic acid (HA) 1.6% and chondroitin sulfate (CS) 2.0% in patients with refractory painful bladder syndrome/interstitial cystitis (PBS/IC) and to observe their impact on Quality of Life. Twenty-three women were enrolled. They received bladder instillations with HA and CS weekly for 20 weeks and then monthly for 3 months. Mean follow-up after completion of therapy was 5 months. We observed a significant improvement in urinary symptoms on voiding diaries and Visual Analogue Scale for frequency (p = 0.045), urgency (p = 0.005), and pain (p = 0.001). The O'Leary-Sant Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index resulted in a significant improvement in both scores (p = 0.004 and 0.01, respectively). The Pelvic Pain and Urgency/Frequency Symptom Scale only showed significant improvement in the symptom score (p = 0.001). This promising experience seems to offer an additional therapeutic option in patients with refractory PBS/IC.