Long-term outcomes of intravesical dimethyl sulfoxide/heparin/hydrocortisone therapy for interstitial cystitis/bladder pain syndrome

The Efficacy and Safety of Dimethyl Sulfoxide Into the Bladder for the Treatment of Interstitial Cystitis/Bladder Pain Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the efficacy and safety of intravesical DMSO instillation for the treatment of interstitial cystitis/bladder pain syndrome.

METHOD

The following databases were searched for relevant studies: PubMed, EMBASE, MEDLINE, Cochrane Library, and Web of Science (updated August 10, 2024). All studies on intravesical DMSO met the inclusion criteria and were evaluated using various quality assessment methods based on the type of study. Data were then analyzed using Review Manager 5.4 (Cochrane Collaboration software). The primary outcomes and indicators included the Interstitial Cystitis Symptom Index, the Interstitial Cystitis Problem Index, and Pain Scores. The secondary outcomes were bladder diary metrics and Pelvic Pain and Urgency/Frequency Symptom Scale (PUF).

RESULTS

This systematic review and meta-analysis included 5 randomized controlled trials and 9 single-arm or cohort studies, involving 554 patients. The combined statistics indicated an average pretreatment Interstitial Cystitis Symptom Index score was 14.27, an average Interstitial Cystitis Problem Index Score was 12.72, and an average Pain Score was 7.06. Compared to pretreatment values, the results indicated that the Interstitial Cystitis Symptom Index score decreased by 5.59 (95% CI: -6.68 to -4.50, p < 0.00001), the Interstitial Cystitis Problem Index score decreased by 5.14 (95% CI: -6.45 to -3.83, p < 0.00001), and the Pain Score decreased by 3.27 (95% CI: -3.95 to -2.60, p < 0.00001). Additionally, the overall incidence rate of adverse events in patients was 37.6%. Although 37% of cases had adverse events, the majority were considered mild and acceptable.

CONCLUSION

Evidence-based statistical analysis of the literature on intravesical DMSO treatment for interstitial cystitis/bladder pain syndrome indicates that this therapy is both effective and safe. Therefore, intravesical DMSO instillation can be considered a standard treatment method for interstitial cystitis/bladder pain syndrome.

Interstitial Cystitis Chatter: A Qualitative Evaluation of Bladder Instillation Online

OBJECTIVE

To qualitatively assess the perception and experiences of bladder instillation for interstitial cystitis among women on Reddit, a widely used anonymous social media platform.

METHODS

"r/interstitialcystitis," a Subreddit with >27,000 subscribers, was queried for bladder instillation among women with interstitial cystitis in November 2023. Posts were analyzed qualitatively by 3 independent researchers. Grounded theory principles were applied to derive preliminary themes. These themes were then used to develop emergent themes.

RESULTS

Sixty-three posts with 637 responses published between 2022-2023 were analyzed. Qualitative analysis yielded 4 themes: (1) IC/BPS anxiety and depression, (2) limited treatment options for IC/BPS pain, (3) exhausting all IC/BPS treatment options before bladder instillation, (4) bladder instillation ineffectiveness for IC/BPS pain. Three emergent concepts were derived: (1) a prevailing sense of desperation for relief among women with IC/BPS, (2) women are fearful and apprehensive about bladder instillation, (3) a perception of bladder instillation as the final recourse for women suffering from IC/BPS.

CONCLUSION

This study represents the first evaluation of bladder instillation as a therapeutic from a social media community focused exclusively on IC/BPS. These results capture patient's experiences with nonurological associated syndromes and indicate a role for physicians to address mental health concerns in patients with IC/BPS, in addition to opportunities to improve patient education on bladder instillations.

Bladder Pain Syndrome (BPS): A Comprehensive Review of Treatment Strategies and Management Approaches

Bladder pain Syndrome presents a multifaceted challenge in contemporary urological practice, marked by LUTS, negative behavioural, sexual, or emotional experiences, and the potential for sexual dysfunction. We meticulously explored the existing literature of conservative, non-invasive and invasive interventions, aiming to provide clinicians with a nuanced understanding of available options for comprehensive BPS management. We delve into the effectiveness and safety profiles from behavioural approaches through lifestyle changes and physical therapy, to oral or intravesical medications, until the definitive surgical treatment. The best option evaluated is the involvement of a multidisciplinary team, including urologists, urotherapists, gynaecologists, pain specialists, primary care physicians and psychologists, educating those patients regarding the condition and its chronic course and tailoring the perfect treatment for each person. Despite this, BPS remains a challenge for urologists. Indeed, our objective is to contribute to the evolving landscape of BPS management, fostering informed decision-making and personalized care for individuals grappling with this challenging condition.

The Pathomechanism and Current Treatments for Chronic Interstitial Cystitis and Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and debilitating condition characterized by symptoms such as bladder pain, frequent urination, and nocturia. Pain is typically perceived in the lower abdomen, pelvic floor, or urethra, causing significant discomfort and impacting quality of life. Due to the similarity of its symptoms with those of overactive bladder and acute bacterial cystitis, patients often face misdiagnosis and delayed appropriate treatment. Hunner's (HIC) and non-Hunner's IC (NHIC), each with distinct clinical presentations, urothelial dysfunction, chronic inflammation, and central sensitization and thus multimodal symptomatic treatment approaches, may be the most common pathogeneses of IC/BPS. Treatment of IC/BPS should involve identifying the different clinical phenotypes and underlying pathophysiology causing clinical symptoms and developing strategies tailored to the patient's needs. This review discusses the roles of urine biomarkers, bladder inflammation, and glycosaminoglycans in the pathogenesis of IC/BPS. Various bladder treatment modalities are explored, including glycosaminoglycan replenishment, botulinum toxin A injection, platelet-rich plasma injection, low-energy shock waves, immunosuppression, and low-dose oral prednisolone. Pelvic floor muscle physiotherapy and bladder therapy combined with psychiatric consultation can help alleviate psychological stress and enhance the quality of life of patients with IC/BPS. Elucidating the pathological mechanisms and exploring diverse treatment options would help advance the care of individuals suffering from this challenging bladder condition.

Efficacy and safety of intravesical dimethyl sulfoxide treatment for patients with refractory Hunner-type interstitial cystitis: Real-world data postofficial approval in Japan

OBJECTIVES

To examine real-world data regarding intravesical dimethyl sulfoxide (DMSO) therapy after official approval as a treatment for Hunner-type interstitial cystitis (HIC) in Japan.

METHODS

This single institution, retrospective observational study was conducted between 2021 and 2022 to evaluate the outcomes of 30 patients with refractory HIC who received intravesical DMSO therapy according to the approved standardized regimen: administration of DMSO every 2 weeks for a total of 12 weeks. Treatment outcomes were evaluated using a 7-graded global response assessment scale, O'Leary and Sant's symptom and problem indices (OSSI/OSPI), the overactive bladder symptom score (OABSS), an 11-point pain intensity numerical rating scale, quality of life (QOL) score, and frequency volume chart variables. Related complications were also documented.

RESULTS

The response rates at 2, 4, 6, 8, 10, and 12 weeks were 36.7%, 43.3%, 53.3%, 60.0%, 70.0%, and 70.0%, respectively. Compared with baseline, OSSI/OSPI, pain intensity, urinary frequency, and the QOL score improved significantly from 4 weeks of treatment. The OABSS score and functional bladder capacity also showed a tendency toward moderate improvement, but the difference was not significant. The mean duration of symptom relapse after termination of treatment was 6.4 ± 3.9 months. No patients discontinued treatment due to adverse events, although acute bladder irritation during infusion was noted in 21 patients (70%), which disappeared within 3 days.

CONCLUSIONS

This study verifies the safety, moderately durable efficacy, and tolerability of the standard intravesical treatment with DMSO for HIC in Japan.

Salvage of Nipple-Areolar Complex Ischemia With Dimethyl Sulfoxide: A Case Series

BACKGROUND

Nipple-areolar complex (NAC) necrosis is a known risk of breast surgery, particularly mastectomy. Disruption of the underlying blood supply to the NAC can lead to ischemia and subsequent necrosis. Nitroglycerin paste is currently used to combat NAC ischemia but has limited efficacy and an unfavorable side effect profile. Topical dimethyl sulfoxide (DMSO) has been shown to increase tissue perfusion in microsurgery and various skin flaps, but its role in the treatment and prevention of NAC ischemia has not been reported. Through a prospective case series, this study aims to introduce DMSO as a safe treatment for NAC ischemia after breast surgery.

METHODS

Patients treated by 2 breast surgeons and a single plastic surgeon who underwent nipple-sparing mastectomy or breast reduction and developed NAC ischemia were identified via a prospectively maintained database. Ischemic changes were diagnosed, and treatment to the affected NAC with DMSO was initiated at the conclusion of the procedure, or postoperative day 1 in most cases, and continued 4 times daily until ischemic changes had resolved clinically. Collected demographic, surgical, and outcome variables were analyzed using descriptive statistics.

RESULTS

Eleven patients with a mean age of 47.8 ± 9.5 years (range, 35-61 years) and mean body mass index of 26.0 ± 4.4 kg/m2 (range, 20.7-33.4 kg/m2) were identified. The mean duration of time between surgery and the clinical diagnosis of NAC ischemia was 1.3 ± 2.8 days (range, 0-7 days). The average length of time from DMSO initiation to clinical improvement or resolution of NAC ischemia was 7.5 ± 2.5 days (range, 5-12 days). All patients demonstrated significant improvement or complete resolution of NAC ischemia following serial topical DMSO application.

CONCLUSIONS

This study demonstrates DMSO is a safe treatment for threatened NACs. All patients in this series showed either dramatic improvement or resolution of NAC ischemia after DMSO application, and threatened NACs of all 11 patients were successfully salvaged. These promising results set the basis for ongoing randomized controlled studies to determine the efficacy of DMSO treatment for NAC ischemia.

Emerging molecular mechanisms and genetic targets for developing novel therapeutic strategies for treating bladder diseases

Bladder diseases affect millions of patients worldwide and compromise their quality of life with a substantial economic impact. The not fully understood aetiologies of bladder diseases limit the current diagnosis and therapeutic options to primarily symptomatic treatment. In addition, bladder targeted drug delivery is challenging due to its unique anatomical features and its natural physiological function of urine storage and frequent voiding. Therefore, current treatment options often fail to provide a highly effective, precisely targeted and long-lasting treatment. With the growing maturity of gene therapy, comprehensive studies are needed to provide a better understanding of the molecular mechanisms underpinning bladder diseases and help to identify novel gene therapeutic targets and biomarkers for treating bladder diseases. In this review, molecular mechanisms involved in pathology of bladder cancer, interstitial cystitis and overactive bladder syndrome are reviewed, with focus on establishing potential novel treatment options. Proposed novel therapies, including gene therapy combined with nanotechnology, localised drug delivery by nanoparticles, and probiotics, are discussed in regard to their safety profiles, efficacy, treatment lenght, precise targeting, and in comparison to conventional treatment methods.

[EARLY EXPERIENCE OF INTRAVESICAL INSTILLATION OF DIMETHYL SULFOXIDE 50% SOLUTION FOR HUNNER TYPE INTERSTITIAL CYSTITIS IN A CLINIC]

(Objectives) To analyze the early observations in intravesical instillation of dimethyl sulfoxide (DMSO) 50% solution for Hunner-type interstitial cystitis (HIC) in our clinic and discuss possible factors affecting outcomes and future tasks. (Materials and methods) Seven patients who received DMSO therapy upon HIC relapse after transurethral resection of Hunner lesions with hydrodistension were enrolled for this study. For DMSO, 50 mL of 50% intravesical solution was administered six times every two weeks. Treatment evaluation was conducted using O'Leary & Sant Interstitial Cystitis Symptom and Problem Indexes (ICSI and ICPI), numerical rating scale (NRS) for bladder pain (0-10 points), and the post-treatment variations for which the pre-treatment values of the 24-hour urinary frequency, the average voided volume, and the maximum voided volume were used. The patient satisfaction survey was conducted with a questionnaire, and cystoscopy was conducted for all cases before and after treatment. (Results) All the patients were females with an average age of 58.3 years old. According to the Society of Interstitial cystitis of Japan Severity Criteria, 5 of the 7 cases showed a moderate level. No severe side effects were observed, and all the patients achieved six times administration. Changes in the points from the pre-treatment baseline values to the post-treatment values were -6.1, -9.1, and -10.0 for Pain NRS, ICSI, and ICPI, respectively. In addition, the 24-hour urinary frequency decreased by 5.34 times, while the average voided volume and the maximum voided volume increased to 60.3 mL and 75.7 mL, respectively. Subjective symptoms of all the patients improved, and cystoscopy revealed the disappearance or remission of Hunner lesions. (Conclusions) If Hunner lesions can be diagnosed, DMSO therapy could be used effectively and safely for HIC. The therapy is also promising for use as a future initial therapy. Therefore, the accurate diagnosis of Hunner lesions will be more important in the future.

Bladder Instillations With Triamcinolone Acetonide for Interstitial Cystitis-Bladder Pain Syndrome: A Randomized Controlled Trial

OBJECTIVE

To evaluate the utility of adding triamcinolone acetonide to a standard bladder instillation solution for treatment of interstitial cystitis-bladder pain syndrome.

METHODS

This was a single-center, randomized, double-blind trial that compared symptom response in women with interstitial cystitis-bladder pain syndrome who underwent six bladder instillations with triamcinolone acetonide or six instillations without. All instillation solutions contained heparin, viscous lidocaine, sodium bicarbonate, and bupivacaine. The primary outcome was the change in interstitial cystitis-bladder pain syndrome symptoms from the first to sixth bladder instillation between groups based on the total OLS (O'Leary-Sant Questionnaire) score. Assuming a 4.03-point or larger difference in the mean total OLS score from the first to sixth bladder instillation as compared between the groups, 64 participants were needed to show a significant difference with 80% power at the 0.05 significance level.

RESULTS

From January 2019 to October 2020, 90 women were enrolled-45 per group; 71 (79%) completed all six bladder instillations. Randomization resulted in groups with similar characteristics. There was no difference between groups in the primary outcome (bladder instillation with triamcinolone acetonide: mean OLS change -6.7 points, 95% CI 4.6-8.8 and bladder instillation without triamcinolone acetonide: mean OLS change -5.8 points, 95% CI 3.4-8.1; P=.31). Women in both groups had improvement in their interstitial cystitis-bladder pain syndrome symptoms as indicated by a decrease in the total OLS score from the first to sixth bladder instillation.

CONCLUSION

The addition of triamcinolone acetonide to a standard bladder instillation solution does not improve symptoms associated with interstitial cystitis-bladder pain syndrome.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03463915.

Anti-inflammatory iron chelator, DIBI, reduces leukocyte-endothelial adhesion and clinical symptoms of LPS-induced interstitial cystitis in mice

BACKGROUND

Interstitial cystitis (IC) is a prevalent and debilitating chronic inflammatory disease of the urinary bladder. Currently there are no fully effective therapeutic agents available, in part due to the still obscure pathogenesis of IC. Lipopolysaccharide (LPS) also known as endotoxin from Gram negative bacteria elicits IC in mice and has formed the basis of model systems for investigation. Excess free iron plays an important role in inflammation through generation of reactive oxygen species (ROS). The novel iron chelator DIBI has been shown to sequester excess free iron and dampen excess inflammatory responses to systemic LPS administration and also to Gram negative bacterial infections.

OBJECTIVE

The overall objective of this study was to evaluate the effects of DIBI on LPS induced IC in mice. Leukocyte activation, endothelial adhesion and functional capillary density were assessed by intravital microscopy of the bladder microcirculation following a single intravesical LPS administration with or without intravesical DIBI treatment. Clinical IC symptoms were also assessed through behavioral and pain threshold force measurements.

METHODS

Four groups of female BALB/c mice (n = 5-6/group) were randomized in this study: control group, IC group without therapy, IC group with DIBI therapy and control group with DIBI therapy. The groups were examined using intravital microscopy (IVM) of the bladder for leukocyte-endothelial interactions (adherent leukocytes, temporarily interacting leukocytes) and functional capillary density (FCD). A modified behavioral score by Boucher et al. and Von-Frey-Aesthesiometry were used to evaluate key behavioral indices related to pain and visceral pain perception.

RESULTS

LPS introduced intravesically induced an early (≤2h) inflammation of the bladder evidenced by leukocyte activation and adhesion to bladder capillary walls. Intravesical DIBI therapy of mice 30min following LPS administration and assessed after 1.5h treatment showed a significant decrease in the number of adherent leukocytes compared to IC animals without DIBI treatment. DIBI treated mice showed a significantly lowered increase in behavioral distress scores compared to IC mice without therapy. Untreated IC mice exhibited a significantly decreased threshold force value for evoked pain response and DIBI treatment improved the threshold pain response. A significant inverse correlation was found for the two pain and suffering evaluation methods results.

CONCLUSION

DIBI reduced inflammatory endothelial leukocyte adhesion and key indices related to pain and suffering over those observed in untreated IC mice. Our findings suggest a potential therapeutic role for DIBI for IC treatment.

Clinical Management of Bladder Pain Syndrome/Interstitial Cystitis: A Review on Current Recommendations and Emerging Treatment Options

Bladder pain syndrome (BPS) is a chronic condition characterized by pelvic pain or pressure which is perceived to be originating from the bladder, accompanied by one or more urinary symptoms, including frequency, urgency and nocturia. The precise etiology of BPS is not fully understood. Chronic bacterial infection, defective glycosaminoglycan (GAG) layer of the bladder urothelium, inappropriate activation of mast cells in the suburothelial layer of the bladder, autoimmune-mediated mechanisms and autonomic nervous system dysfunction have all been implicated. Treatments targeted at each of these mechanisms have been developed with mixed outcomes. High-quality research into the treatment options is lacking and it is difficult to draw definite conclusions. The treatment approach is multimodal and should be patient specific, targeting the symptoms which they find most bothersome. Conservative treatment, including patient education, behavioural modification, dietary advice, stress relief and physical therapy is an essential initial management strategy for all patients. If no response is observed, oral treatments such as amitriptyline are likely to offer the greatest response. Cystoscopy is essential to phenotype patients, and Hunner lesion directed therapy with fulguration or resection can be performed at the same time. Intravesical instillation of DMSO or lidocaine, detrusor injections of botulinum toxin A and neuromodulation can be used if initial management fails to improve symptoms. Oral cyclosporin can be trialled in those experienced with its use; however, it is associated with significant adverse events and requires intense monitoring. Lastly, radical surgery should be reserved for those with severe, unremitting BPS, in which quality of life is severely affected and not improved by previously mentioned interventions. Future work investigating exact aetiological factors will help target the development of efficacious treatment options, and several promising oral and intravesical treatments are emerging.

The role of bladder instillation in the treatment of bladder pain syndrome: Is intravesical treatment an effective option for patients with bladder pain as well as LUTS?

The aetiology of bladder pain syndrome/interstitial cystitis is still unknown. Numerous mechanisms have been proposed and treatments targeting various aspects of these are used. This review looks at the existing evidence on bladder instillations and whether they could be used in the treatment of lower urinary tract symptoms as well.

Hyaluronic acid improves pain symptoms more than bladder storage symptoms in women with interstitial cystitis

OBJECTIVE

Intravesical hyaluronic acid (HA) therapy is one of acceptable methods to treat bladder pain and storage symptoms (i.e., urgency, frequency and nocturia) of interstitial cystitis/bladder pain syndrome (IC/BPS). We aim to assess the impacts of intravesical HA on bladder pain and storage symptoms, respectively, and to investigate their associated factors in patients with IC/BPS.

MATERIALS AND METHODS

In this prospective, multicenter study, 103 women with refractory IC/BPS undergoing a standard protocol of intravesical HA therapy were enrolled. A pain Visual Analog Scale (VAS) and the Interstitial Cystitis Symptom and Problem Index (ICSI & ICPI) were used to assess symptoms and bother associated with IC/BPS. The Scaled Global Response Assessment (GRA) was used to evaluate patients' perception of overall changes in bladder pain and storage symptoms, respectively, after treatment.

RESULTS

Mean age of participants was 43.6 ± 11.8 years. The average duration of symptoms was 5.1 ± 5.0 years. Significant improvements in pain VAS, ICSI and ICPI scores were observed after treatment. However, patients reported significantly different rates of moderate/marked improvement in bladder pain and storage symptoms (73.8% vs. 47.6%; P < 0.001) on the GRA, respectively. "Lower pain VAS score" and "reduced functional bladder capacity" were found to be the factors that adversely affected the treatment responses of bladder pain and storage symptoms, respectively, after repeated statistical analyses.

CONCLUSION

Bladder instillation of HA seemed more efficient in improving bladder pain than storage symptoms associated with IC/BPS. The persistence of bladder storage symptoms after treatment might result from a reduced functional bladder capacity.

Inhibition of urease activity in the urinary tract pathogens Staphylococcus saprophyticus and Proteus mirabilis by dimethylsulfoxide (DMSO)

AIMS

Urease is a virulence factor for the urinary tract pathogens Staphylococcus saprophyticus and Proteus mirabilis. Dimethylsulfoxide (DMSO) is structurally similar to urea, used as a solvent for urease inhibitors, and an effective treatment for interstitial cystitis/bladder pain syndrome (IC/BPS). The aims of this study were to test DMSO as a urease inhibitor and determine its physiological effects on S. saprophyticus and P. mirabilis.

METHODS AND RESULTS

Urease activity in extracts and whole cells was measured by the formation of ammonium ions. Urease was highly sensitive to noncompetitive inhibition by DMSO (K_i about 6 mmol l^-1 ). DMSO inhibited urease activity in whole cells, limited bacterial growth in media containing urea, and slowed the increase in pH which occurred in artificial urine medium.

CONCLUSIONS

DMSO should be used with caution as a solvent when testing plant extracts or other potential urease inhibitors. Because it can inhibit bacterial growth and delay an increase in pH, it may be an effective treatment for urinary tract infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first detailed study of the inhibition of urease by DMSO. Dimethylsulfoxide may be used to treat urinary tract infections that are resistant to antibiotics or herbal remedies.

Experimental Cannabinoid 2 Receptor Activation by Phyto-Derived and Synthetic Cannabinoid Ligands in LPS-Induced Interstitial Cystitis in Mice

Interstitial cystitis (IC) is a chronic bladder disorder with unclear etiology. The endocannabinoid system has been identified as a key regulator of immune function, with experimental evidence for the involvement of cannabinoid receptors in bladder inflammation. This study used intravital microscopy (IVM) and behavioral testing in lipopolysaccharide-induced IC, to investigate the anti-inflammatory analgesic effects of a natural dietary sesquiterpenoid, beta-caryophyllene (BCP), which is present in cannabis among other plants, and has reported agonist actions at the cannabinoid 2 receptor (CB₂R). BCP’s anti-inflammatory actions were compared to the synthetic CB₂R-selective cannabinoid, HU308, and to an FDA-approved clinical treatment (dimethyl sulfoxide: DMSO). IVM data revealed that intravesical instillation of BCP and/or HU308 significantly reduces the number of adhering leukocytes in submucosal bladder venules and improves bladder capillary perfusion. The effects of BCP were found to be comparable to that of the selective CB₂R synthetic cannabinoid, HU308, and superior to intravesical DMSO treatment. Oral treatment with BCP was also able to reduce bladder inflammation and significantly reduced mechanical allodynia in experimental IC. Based on our findings, we believe that CB₂R activation may represent a viable therapeutic target for IC, and that drugs that activate CB₂R, such as the generally regarded as safe (GRAS) dietary sesquiterpenoid, BCP, may serve as an adjunct and/or alternative treatment option for alleviating symptoms of inflammation and pain in the management of IC.

Transrenal Ureteral Occlusion for Palliation of Refractory Urine Leaks Using Vascular Plugs and Liquid Ethylene Vinyl Alcohol

PURPOSE

To describe outcomes of transrenal embolization with vascular plugs and ethylene vinyl alcohol (EVOH) in a case series of patients with refractory urinary leak or fistula.

MATERIALS AND METHODS

Fifteen ureteral occlusions performed over 53 months in 9 consecutive patients (56% female; mean age 61 y; range, 45-80 y) were reviewed retrospectively. The main indication was palliation for refractory fistula or leak in the setting of malignancy not responding to urine diversion by percutaneous nephrostomy tube or nephroureteral stent. Transrenal ureteral occlusion was performed using EVOH injected between vascular plugs placed distal and proximal to the leak or fistula.

RESULTS

Technical success was 100%. Considerable reduction of urine leak or symptoms (clinical success) was achieved in 64% of ureters after mean follow-up of 105 days (range, 0-632 d). Complete ureteral occlusion on follow-up anterograde nephrostogram (imaging success) was achieved in 60% of ureters after mean follow-up of 139 days (range, 0-643 d). One patient with distal ureterovesical junction-perineal fistula had continued leak despite complete proximal occlusion of ureter owing to retrograde urine reflux from the bladder and was treated with endoscopic injection of intramural calcium hydroxyapatite to the ureteral segment distal to the fistula. Three ureters (33%) in 2 patients with vesicovaginal fistula had recanalization, requiring additional proximal embolization, yielding secondary success rates of 91% (clinical) and 90% (imaging) per ureter. One minor urinary tract infection and no major complications occurred.

CONCLUSIONS

Transrenal anterograde ureteral occlusion using EVOH between vascular plugs could be considered a relatively safe and potentially valuable treatment option for refractory ureteral fistulae.

Pharmacological management of interstitial cystitis /bladder pain syndrome and the role cyclosporine and other immunomodulating drugs play

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a symptomatic disorder characterized by pelvic pain and urinary frequency. Immunological responses are considered as one of the possible etiologies of IC/BPS. In this review, we focused on emerging targets, especially on those modulating immunological mechanisms for the treatments of IC/BPS. Area covered: This review was based on the literature search of PubMed/MEDLINE, for which key words following bladder pain syndrome, interstitial cystitis, and/or cyclosporine A (CyA) were used. We discussed current treatments and the drugs targeting the immune responses including CyA and other drugs with different mechanisms including NGF antibodies and P2X3 antagonists. Expert commentary: IC/BPS is often difficult to treat by current treatments. Immunosuppression agents, especially CyA are considered as effective treatments for IC/BPS with Hunner's lesion because these drugs suppress the inflammatory responses in the bladder underlying urinary symptoms of the disease. Base on the previous literatures, we should use CyA for the refractory IC/BPS, especially that with Hunner's lesion due to its side effects. New drugs targeting other mechanisms such as urothelial or afferent nerve dysfunction or new delivery systems such as sustained drug releasing devices or gene therapy techniques may be promising for the future treatments of IC/BPS.

[The dimethyl sulfoxide under general anesthesia: An alternative after failure without anesthesia in the painful bladder syndrome/interstitial cystitis?]

INTRODUCTION

The intravesical instillation of dimethyl sulfoxide (iDMSO), performed without anesthestic, is a therapeutic option for the painful bladder syndrome/interstial cystitis (PBS/IC). Some patients are against those iDMSO because of bad tolerance. Our study evaluates the tolerance and the outcome of the iDMSO under general anesthetic (GA) after the failure of the iDMSO without anesthetic.

PATIENTS AND METHODS

From May 2013 to April 2016, 11 patients with a PBS, 9 women (81.8 %), have been treated by iDMSO without anesthetic, without improvement because of bad tolerance and no possibility to have a one hour contact between the bladder and the DMSO. The 11 patients were evaluated by mictional calendar and Sant O'Leary score. All the patients had a hydrodistension and a per os treatment without improvement.

OUTCOMES

Six new iDMSO were performed under general anesthetic in ambulatory surgery with good tolerance for the 11 patients. The frequency and the nocturia before iDMSO without anesthetic and after iDMSO under general anesthetic were 32.2minutes [15; 60] and 6.3 per night [3; 10] and 126.9minutes [25; 240] and 3 per night [2; 6], so a variation respectively of 96.4minutes [0; 180] and of 3.75 per night [2; 6]. The symptom score and the problem index were 17.5 [13; 20] and 15.5 [13; 16] before and 13.5 [4; 20] and 12 [1; 16] after iDMSO under general anesthetic; a variation of 3.2 [0; 9] and 4 [0; 12].

CONCLUSION

The iDMSO under general anesthetic seems to improve objectively and subjectively the patients who are not improved by the instillations without anesthetic because of bad tolerance.

LEVEL OF EVIDENCE

4.