Urodynamic testing and interstitial cystitis/painful bladder syndrome

Introduction and hypothesis

The objective of this study is to evaluate the relationship between symptom severity in interstitial cystitis/painful bladder syndrome, urodynamic testing (UDT), and cystoscopy.

Methods

Charts of subjects who underwent cystoscopy and bladder overdistention (BOD) from January 2006 to July 2007 were reviewed for data points, questionnaires, UDT, and BOD findings. The independent T test and Mann–Whitney U test were performed between questionnaires, urodynamic data, and cystoscopic findings.

Results

Significantly lower volumes on all UDT parameters and higher scores on the interstitial cystitis problem index and pain Likert scale were found in subjects who felt pain with filling on UDT. Significantly lower median volumes for certain urodynamic parameters were found in subjects with high pain Likert scores and O'leary–Sant indices and those with grade 3 glomerulations and anesthetic bladder capacities of less than 600 mL on BOD.

Conclusion

UDT may be a useful adjunctive test in the evaluation of patients with irritative voiding symptoms.     

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.     

Hyaluronan treatment of interstitial cystitis/painful bladder syndrome

The aim of this study is to evaluate the efficacy of intravesical hyaluronan therapy in interstitial cystitis/painful bladder syndrome (IC/PBS). One hundred twenty-six patients with IC/PBS and an average disease duration of 6.1 years were treated with weekly instillations of a 50-cm³ phosphate-buffered saline solution containing 40 mg sodium hyaluronate. To be eligible for hyaluronan treatment, a positive modified potassium test was requested as a sign of a urine–tissue barrier disorder. Data were obtained by a visual analogue scale (VAS) questionnaire rating from 0 to 10 that asked for global bladder symptoms before and after therapy. Additional questions evaluated the therapeutic impact on quality of life. A positive and durable impact of hyaluronan therapy on IC/PBS symptoms was observed—103 (85%) of the patients reported symptom improvement (≥2 VAS units). The mean initial VAS score of 8.5 decreased to 3.5 after therapy (p < 0.0001). Out of 121 patients, 67 (55%) remained with no or minimal bladder symptoms after therapy (VAS 0–2). The majority (101, 84%) reported significant improvement of their quality of life. Intravesical therapy had to be initiated again with good success in 43 patients (34.5%) as symptoms recurred after discontinuation of treatment, while the rest stayed free of symptoms for up to 5 years. In general, hyaluronan therapy was well tolerated and, with the exception of mild irritative symptoms, no adverse reactions were reported for a total of 1,521 instillations. Timely hyaluronan instillation therapy may lead to complete symptom remission or even cure in part of the IC/PBS patients, while some responders need continuous intravesical therapy. The present results suggest that selection of patients for hyaluronan therapy by potassium testing improves the outcome of intravesical therapy with a response rate of >80%.     

膀胱疼痛综合症／间质性膀胱炎研究进展

膀胱疼痛综合症／间质性膀胱炎（painful bladder syndrome／interstitial cystitis,PBS／IC）是一种基于尿频、尿急、膀胱或盆底疼痛的的慢性疼痛综合症。1836年美国费城外科医生JOSEPH PARRISH报告了3例病因不明的有严重下尿路症状的患者并将此疾病命名为“膀胱三叉神经痛”。     

Morbidity rate and medical utilization in interstitial cystitis/painful bladder syndrome

Introduction and hypothesis

The objective was to calculate the morbidity rate and medical utilization of interstitial cystitis/painful bladder syndrome (IC/PBS) over 12 years using a nationwide database of Taiwan.

Methods

This was a cohort study of the Longitudinal Health Insurance Database 2010 with new diagnoses of IC/PBS from 2002 through 2013. The morbidity rate was adjusted for age, sex, and calendar date using density methods. Moreover, medical utilization during the study period was measured.

Results

It was observed that the incidence of IC/PBS was 21.8/100,000 in 2002 and 21.1/100,000 in 2013. The prevalence of IC/PBS was 21.8/100,000 in 2002 and 40.2/100,000 in 2013. In 2003, the incidence and prevalence of women was 28.6/100,000 and 63.5/100,000 respectively. The incidence and prevalence of men was 12.3/100,000 and 19.4/100,000 respectively. In 2002, the incidence was 45.5/100,000, 32.4/100,000, and 9/100,000 in the age groups above 65, 40–65, and under 40 years respectively. The prevalence in 2003 was 86.3/100,000, 63.1/100,000, and 16.4/100,000 in age groups above 65, 40–65, and under 40 years respectively. This pattern was similar until 2013. The mean outpatient and inpatient visit time was 4.8 and 1.8 times per year respectively. The mean surgical fee (US$ 246.6?±?304.5) was 23.6% of the total fee.

Conclusions

The morbidity rate of IC/PBS showed a higher incidence and prevalence in women and older patients. A new drug for the treatment of IC/PBS may be a factor of the peak in the morbidity rate. The increase in medical utilization could be explained by the awareness of physicians and patients seeking medical help.

     

The relationship between sexual abuse and interstitial cystitis/painful bladder syndrome

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic syndrome characterized by irritative voiding symptoms and pelvic pain or discomfort. IC/PBS represents localized bladder pathophysiologic changes and central nervous system upregulation. Patients exhibit bladder hyperalgesia and allodynia. Childhood sexual abuse occurs in up to 27% of females in the United States. Adults with a prior history of abuse or traumatization demonstrate hypothalamic-pituitary-adrenal (HPA) axis abnormalities, similar to IC/PBS patients. Childhood sexual abuse and physical traumatization are associated with subsequent lifelong risks of chronic pain syndromes. IC/PBS patients have increased rates of sexual abuse or physical traumatization histories compared with controls. IC/PBS patients with abuse histories tend to have greater pain intensity and lesser irritative voiding symptoms compared with nonabused IC/PBS patients. This article reviews the relationship between sexual abuse, HPA axis abnormalities, IC/PBS pathophysiology, and the role of sexual abuse on subsequent IC/PBS.     

Symptom profile variability of interstitial cystitis/painful bladder syndrome by age

Study Type – Diagnostic (symptom prevalence) Level of Evidence 2b What's known on the subject? and What does the study add? Symptom variability is profound in the population of patients diagnosed with interstitial cystitis and painful bladder syndrome because these diagnoses represent a very heterogeneous patient population. Recently, younger patients are being diagnosed with these pain syndromes, without any specific investigation into the symptoms they experience. We identified that patients diagnosed with interstitial cystitis and painful bladder syndrome have variable clinical symptom profiles depending on the age at the time of their diagnosis. Dyspareunia, external genitalia pain, urgency, frequency and dysuria were more common in younger patients whereas nocturia, urinary incontinence and the presence of Hunner's ulcers were more common in older patients. Better defining symptom profiles for patients at the time of evaluation may potentially aid in more accurate and expedited diagnosis of these conditions, particularly in the youngest patient population which is being recognized more commonly in recent times.

OBJECTIVE

• ? To investigate the clinical profile differences among patients with interstitial cystitis/painful bladder syndrome (IC/PBS) based upon age at the time of diagnosis from childhood into the geriatric age group.

METHODS

• ? An analysis of 268 patients with IC/PBS seen between 1990 and 2008 was performed.
• ? Three age cohorts were analysed: <30 years, ≥30 years but <60 years, and ≥60 years of age at time of diagnosis.
• ? Patient demographics, disease characteristics and IC/PBS‐associated symptoms were compared across the three groups.

RESULTS

• ? Of the 268 patients, 60 were <30 years of age at the time of IC diagnosis (median 22, range 11–29), 105 were ≥30 but <60 years (median 48, range 30–59) and 103 patients were ≥60 years of age (median 69, range 60–88).
• ? Of the patients in the youngest, middle and oldest age cohorts: 12.0, 42.0 and 39.8% had Hunner's ulcers, respectively (P < 0.001).
• ? Dyspareunia and external genitalia pain were more common in the youngest age cohort, P < 0.001 and P = 0.001, respectively.
• ? Urinary urgency (P = 0.033), frequency (P = 0.006) and dysuria (P < 0.001) were also more common in patients diagnosed before 30 years of age.
• ? The reported rate of nocturia and urinary incontinence increased with age, P = 0.002 and P < 0.001, respectively.

CONCLUSIONS

• ? Patients with IC/PBS analysed across a wide spectrum of ages at time of diagnosis portrayed a unique symptom profile pattern.
• ? Patients diagnosed at the youngest ages experienced significantly more urinary urgency, frequency, dysuria, dyspareunia and pain in their external genitalia.
• ? Older patients had higher rates of nocturia, urinary incontinence and Hunner's ulcer disease.

     

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.     

Status of international consensus on interstitial cystitis/bladder pain syndrome/painful bladder syndrome: 2008 snapshot

Over the last 6 years there have been ongoing efforts around the world to standardize nomenclature, definition, and evaluation of interstitial cystitis/bladder pain syndrome/painful bladder syndrome. The convergence this year of several new projects stimulated an effort to bring together thought leaders from around the world to give a snapshot of current thinking with regard to this disorder. The Society for Urodynamics and Female Urology brought together thought leaders from Europe, Asia, and the United States to Miami, and a broad, structured discussion ensued which is the subject of this report. The most appropriate name of the disease remains an area of contention. A final “definition” of BPS/IC did garner substantial agreement among participants: An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes. It seems that the world is moving to a presumptive diagnosis based on history and physical examination, and relying on invasive procedures for more complex cases, although this is by no means a universal opinion, being more prevalent in the United States and Asia than in Europe. It is hoped that the conference proceedings can serve as a basis for future efforts to develop formal definitions, guidelines, and best practice policies to further advancement of the field. Neurourol. Urodynam. 28:274–286, 2009. © 2009 Wiley‐Liss, Inc.     

Intravesical treatment for interstitial cystitis/painful bladder syndrome: a network meta-analysis

Introduction and hypothesis

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic inflammatory condition of the submucosal and muscular layers of the bladder. So far, there is no effective and targeted treatment strategy for IC/PBS. This study aimed to assess the efficacy and safety of intravesical instillation treatment in IC/PBS patients.

Methods

We searched various databases up to October 2015. A network meta-analysis was performed to compare global response assessment (GRA) for different treatment strategies, including botulinum toxin A (BoNTA), bacillus Calmette–Guerin (BCG), resiniferatoxin (RTX), lidocaine, chondroitin sulfate (CS), oxybutynin, and pentosan polysulfate (PPS). A traditional meta-analysis was also performed.

Results

Sixteen trials evaluating 905 patients were included. Network meta-analysis indicated that BoNTA had the highest probability of being the best treatment course according to GRA assessment results (probability 81.7 %). BCG or BoNTA therapy yielded significant improvement in GRA incidence according to traditional meta-analysis. Patients who received PPS showed higher urinary frequency results compared with the placebo groups. BCG- and PPS-treated patients had elevated urinary urgency treatment effects compared with placebo groups. Bladder capacity restoration results also showed significant improvements in patients who received BoNTA compared with placebo-treated individuals.

Conclusions

These findings indicate that BoNTA therapy has the highest probability of being the best therapy according to GRA, and significantly improves bladder capacity in IC/PBS patients. BCG treatment also significantly increases the incidence of GRA and improves the symptoms of urinary urgency. PPS can significantly improve urinary frequency and urgency symptoms in IC/PBS patients.