Painful Bladder Syndrome Interstitial Cystitis

							Painful Bladder Syndrome /
Interstitial Cystitis

          Philip Hanno
   Hospital of the University of
          Pennsylvania
The Aunt Minnie Definition

 We have all met, at one time or another, patients who
  suffer chronically from their bladder; and we mean
  the ones who are distressed, not only periodically but
  constantly, having to urinate often, at all moments of
  the day and of the night, and suffering pains every
  time they void. We all know how these miserable
  patients are unhappy, and how those distressing
  symptoms get finally to influence their general state
  of health, physically and then mentally. Bourke, 1951
Definition: Where are we?
 Clinical syndrome defined by symptoms
 of urgency, frequency, and/or pain in
 the absence of any other reasonable
 causation.
 An exaggeration of normal sensations
 of urge to void, and discomfort
 necessitating a trip to the bathroom
We really have no accepted definition!
International Continence Society/
European Association of Urology


  Bladder Pain Syndrome:

     Suprapubic pain related to bladder filling,
     accompanied by other symptoms such as
     increased daytime and night-time
     frequency, in the absence of proven urinary
     infection or other obvious pathology

  Am J. Obstet Gynecol 2002; 187:116-126
Presumptive Diagnosis
 History
 Physical examination
 Appropriate cultures
 Local cystoscopy (especially with
 hematuria)
 Cytology in smokers and patients
 >40yrs
When Diagnosis is in doubt
 Urodynamics
 Consider Videourodynamics in men
 Cystoscopy under anesthesia with
 hydrodistention (potentially therapeutic)
 Bladder biopsy if endoscopic findings
 abnormal
Typical Hunner’s Ulcer
Modern era begins
   Anthony Walsh coins
   term glomerulations

   Messing and Stamey
   make glomerulations
   in a symptomatic
   patient hallmark of
   diagnosis
Urology, 12:381, 1978
  Pathology



                                    Nerve hypertrophy
Nonulcerative IC   Hunner’s ulcer   Detrusor mastocytosis

    Excludes tissue specific diagnoses only,
    no pathognomonic findings
KCl Test
 Intravesical sensitivity to 0.4M
 potassium solution
 80% of IC patients test positive
 20% false negative rate
 4% false positive rate in normals
 25% false positive rate in detrusor
 instability
 100% false positive rate with UTI
Laparoscopy

Indicated if gynecologist believes there
is a significant likelihood of gynecologic
problem (endometriosis) causing the
symptom complex
Not a part of the routine evaluation for
IC
      Disparity in Prevalence Data
          Oravisto:
          10/100,000                          Leppilahti:300/100,000*

          Held: 30/100,000                         Curhan:35/100,00*
          Jones:                                   Roberts: 1.2/100,000
          510/100,000

          Bade: 7/100,000*

          Ito: 1.2/100,000
* Figure based on estimated female to male ratio of 9:1
     Prevalence Rates: ICA Study
     Group vs General Population
30
      25                 24.6
25                                               22.4
                                                        18.8 18
20
                  15
15                              12.8
           10.9
10

5                                      3.2

0
      Vulvodynia         Fibromyalgia              Migraines

      Symptoms         Diagnosed             General Population
 Prevalence Rates: ICA Study
 Group vs General Population
9        8.2
8               7.3
7
6
5
4
3                                    2.3
                                           1.7
2
1
0
      Colitis/Crohn's Disease              SLE

       Symptoms         Diagnosed      General Population

SLE = systemic lupus erythematosus
                 Proposed pathogenesis of IC

                            Bladder insult


                        Epithelial layer damage
  Failure to repair
  Antiproliferative
  Factor secreted by
                          Potassium leak into
  Epithelial cells
  Keay                        interstitium


Immunogenic and        Mast cell activation and   Activation of C-fibers and
allergic responses       histamine release         release of substance P

                                                         Naoki Yoshimura

                             More injury
General Considerations
   Treatments are empiric as cause is
   unknown
   Symptoms can be controlled with one
   or variety of treatments in majority of
   patients
   Little evidence that treatment does
   more than influence symptomatic
   expression of IC
   50% incidence of remission (8 month
   duration) unrelated to specific
   treatment
More Cautions
 Patients can be victims of unorthodox
 providers, untested therapies, unproven
 surgical procedures
 Few treatments have been subjected to
 placebo-controlled trial
 Need for skepticism
After Initial Diagnosis
 Watchful waiting if symptoms not
 severe
 Therapy = tradeoff: inconvenience +
 treatment chronicity + side effects
 + cost vs. benefit
 PERFECT IS THE ENEMY OF GOOD
Conservative Rx
 Patient education and empowerment
   Support groups, Internet-based support
 Reassurance
 Timed voiding, voiding diary, behavioral
 therapy where frequency primary
 symptom
 Stress reduction
 Biofeedback, pelvic massage
Dietary Restrictions
 Supporting studies lacking
 No reason for strict IC diet
 Avoid foods that aggravate “your”
 symptoms
 ??citrus juices, tomato-based products,
 caffeinated beverages, alcohol, hot and
 spicy foods??
 Nguan: urine pH may not affect
 symptoms         AUA abstract 2004
Tricyclic Antidepressants
Antihistamines
 Simmons (1961) postulated that
 intravesical histamine release may
 cause IC symptoms
 Theoharides popularized hydroxyzine,
 piperazine H1-receptor antagonist that
 blocks neuronal activation of mast cells
 Uncontrolled studies showed mild-
 moderate efficacy at 50-75mg daily
 Sedation main side effect
Pentosanpolysulfate
 Heparin analogue, oral formulation
 Usage based on theory of epithelial
 permeability barrier in IC patients
 Trade name: Elmiron
 100mg TID
 Most studied oral drug used in IC
Analgesics
 Critical part of IC treatment: a chronic pain
 syndrome
 Nonopiod analgesics:
    Acetaminophen
    Nonsteroidal anti-inflammatory agents
    Aspirin
    Gabapentin
  Nonopioids all reach a ceiling of
    maximum analgesic effect
Intravesical Therapy
Nerve Stimulation
Direct Sacral Nerve
Stimulation
                                New treatment
 Percutaneous trial
                                for refractory IC
 followed by permanent
 implantation or staged
 procedure
 S3 electrode wire
 placement
 Initial studies suggest
 40% intent to treat
 success, higher in
 recent studies
       Comiter, AUA abstract 2004
Surgical Therapy
Major Surgery Indicated In
Less Than 10% of IC Patients
Cutting The Gordian Knot
 Cystourethrectomy is the ultimate
 surgical answer to the dilemma of
 interstitial cystitis
   Do you feel lucky?




You’ve got to ask yourself the
question, “Do you feel lucky?”
Interstitial Cystitis Association

         Patients, Researchers, Caregivers ~
         Putting the Pieces Together


    110 North Washington Street, Suite 340,
          Rockville, MD 20850, USA

           1-301-610-5300
           Website: www.ichelp.org
          Email: ICAmail@ichelp.org