Increased prevalence of interstitial cystitis in women with detrusor overactivity refractory to anticholinergic therapy

Pathophysiology, assessment, and treatment of overactive bladder symptoms in patients with interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is prevalent, difficult to treat, and has close symptom overlap with overactive bladder (OAB). A review of the pathophysiology, assessment, and treatment of IC/BPS patients with overlapping OAB symptoms has not been summarized recently in the published literature.

METHODS

A review of the published literature on the overlap of IC/BPS and OAB was conducted using MeSH terminology (1992-2022).

RESULTS

The pathophysiology of IC/BPS is not fully understood. Animal research has found the bladder trigone and base are richly populated by afferent fibers, including many small unmyelinated C-fibers that may be upregulated in IC/BPS. Successful therapies with multimodal effects on OAB symptoms in patients with IC/BPS are likely to exert beneficial effects on both pain and lower urinary tract symptoms. Potentially efficacious therapies for the treatment of OAB in IC/BPS include pelvic floor physical therapy, oral pharmacotherapy (antimuscarinics and beta-3 agonists), sacral neuromodulation, percutaneous tibial nerve stimulation, and botulinum toxin A (BTA). Antimuscarinics and beta-3 agonists have yielded partial efficacy in IC/BPS, although may help differentiate symptoms of OAB from those associated with IC/BPS. The transvaginal trigone treatment (T3) intradetrusor injection approach allows for delivery of therapeutics to the bladder without the need for a cystoscope and appears to be feasible.

CONCLUSIONS

Further research is needed to understand the pathophysiology of IC/BPS and symptom overlap with OAB, which in turn should enable the development of more personalized therapeutics.

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.

Mechanisms Underlying Overactive Bladder and Interstitial Cystitis/Painful Bladder Syndrome

The bladder is innervated by extrinsic afferents that project into the dorsal horn of the spinal cord, providing sensory input to the micturition centers within the central nervous system. Under normal conditions, the continuous activation of these neurons during bladder distension goes mostly unnoticed. However, for patients with chronic urological disorders such as overactive bladder syndrome (OAB) and interstitial cystitis/painful bladder syndrome (IC/PBS), exaggerated bladder sensation and altered bladder function are common debilitating symptoms. Whilst considered to be separate pathological entities, there is now significant clinical and pre-clinical evidence that both OAB and IC/PBS are related to structural, synaptic, or intrinsic changes in the complex signaling pathways that mediate bladder sensation. This review discusses how urothelial dysfunction, bladder permeability, inflammation, and cross-organ sensitisation between visceral organs can regulate this neuroplasticity. Furthermore, we discuss how the emotional affective component of pain processing, involving dysregulation of the HPA axis and maladaptation to stress, anxiety and depression, can exacerbate aberrant bladder sensation and urological dysfunction. This review reveals the complex nature of urological disorders, highlighting numerous interconnected mechanisms in their pathogenesis. To find appropriate therapeutic treatments for these disorders, it is first essential to understand the mechanisms responsible, incorporating research from every level of the sensory pathway, from bladder to brain.

Symptomatic overlap in overactive bladder and interstitial cystitis/bladder pain syndrome: development of a new algorithm

OBJECTIVES

To address challenges in the diagnosis and classification of storage lower urinary tract symptoms (LUTS), we sought to define the fundamental features of overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), two conditions with considerable symptomatic overlap. Through retrospective comparison of self-reported symptoms in women with a range of clinical presentations and symptom severities, we have attempted to refine the diagnostic features of OAB and IC/BPS and to develop a novel clinical nomogram to improve patient screening and classification.

MATERIALS AND METHODS

We performed a univariate analysis comparing responses to the female Genitourinary Pain Index (fGUPI), the OAB Questionnaire and O'Leary-Sant Indices (the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index) in an initial cohort of 50 patients with OAB, patients with IC/BPS and control subjects. Only eight questions differed significantly between the IC/BPS and OAB groups; we used five unique questions and three measuring bother to generate a novel composite scoring system and nomogram that included urgency incontinence, bladder pain and symptomatic bother domains to differentiate these populations, which was validated in a second cohort of 150 patients. The addition of a self-reported bother index resulted in the creation of a diagnostic algorithm to identify and classify LUTS clusters across the total population.

RESULTS

While all validated questionnaires could distinguish between controls and patients with storage LUTS, no combined symptom scores differed significantly between the IC/BPS and OAB groups. These results are reflective of the prevalence of significant bladder pain (35%) in patients with OAB and the presence of urge incontinence (25%) in patients with IC/BPS. Only the fGUPI pain domain scores differed between patients in the OAB and IC/BPS groups, but it was not accurate enough for diagnostic evaluation (68% accuracy). Our composite scores and nomogram gave a much-improved diagnostic accuracy (94%) and demonstrated utility as a screening tool to identify storage LUTS in patients presenting for unrelated complaints, e.g. microhaematuria.

CONCLUSIONS

There is significant overlap of urinary tract symptoms between OAB and IC/BPS. We present a novel algorithm that provides a binary output capable of guiding clinical diagnosis. Future studies aimed at assessing the diagnostic value of novel classification schemes that address symptoms rather than specific diagnoses may improve patient prognosis.

Mirabegron as adjuvant treatment for patients with interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) patients represent a heterogeneous group with pain and urinary storage symptoms and varying responses to current treatment options. The novel beta-3 agonist, mirabegron, has been shown to improve storage symptoms of patients with bladder overactivity; however, its effect on symptoms in the IC/BPS population has yet to be studied.

METHODS

Patients diagnosed at a single IC centre with IC/BPS undergoing standard therapy were treated with additional daily mirabegron 25 mg and seen in followup post-treatment. Patients completed the Interstitial Cystitis Symptom Index and Problem Index (ICSI/ICPI), and the Pelvic Pain and Urgency/Frequency Patient Symptom Scale (PUF) prior to and following mirabegron treatment. Global (NRS) and symptom-specific outcomes were assessed by comparing the pre- and post-treatment mean scores using tailed-t test (p<0.05 considered statistically significant).

RESULTS

A total of 23 patients were available for review pre- and post-mirabegron treatment. There was no significant difference in ICSI (p=0.448), ICPI (p=0.352), or PUF (p=0.869) pre- and post-treatment. Analysis of symptom-specific outcomes show statistically significant improvements in urgency (p=0.048); however, no statistically significant improvements in frequency (p=0.951) or pain (p=0.952) were observed with mirabegron therapy.

CONCLUSIONS

IC/BPS patients treated with mirabegron had improvement of urinary urgency, but no significant benefit in terms of pain or urinary frequency. This data suggests that mirabegron's role in the IC/BPS patient should be that of adjuvant treatment to ameliorate urgency.

Near-Normalized Gene Expression Profiles in Bladder With Detrusor Overactivity in Rats With Bladder Outlet Obstruction After Deobstruction

PURPOSE

The pathophysiological role of detrusor overactivity (DO) in the bladder, which is commonly observed in various bladder diseases, is not well understood. DO appears in bladder outlet obstruction (BOO), and may continue even after subsequent deobstruction. DO therefore provides an excellent opportunity to observe molecular biological changes.

METHODS

In this study, to understand the molecular effects of persistent DO after BOO induction and deobstruction, we performed awake cystometry on female Sprague-Dawley rats divided into 4 groups: a sham group, a BOO group, a deobstructed group with DO after BOO (DDO), and a deobstructed group without DO after BOO (non-DDO). Total RNA was extracted from the bladder samples, and gene expression profiles were compared between the sham and model groups.

RESULTS

DO was observed in 5 of the 6 rats (83%) in the BOO group, and in 6 of the 13 rats (46%) in the deobstructed group. The non-DDO group showed a significantly greater residual volume than the DDO group. Through a clustering analysis of gene expression profiles, we identified 7,532 common upregulated and downregulated genes, the expression of which changed by more than 2 fold. In the BOO group, 898 upregulated and 2,911 downregulated genes were identified. The non-DDO group showed 3,472 upregulated and 4,025 downregulated genes, whereas in the DDO group, only 145 and 72 genes were upregulated and downregulated, respectively.

CONCLUSIONS

Abnormal function and gene expression profiles in bladders after BOO were normalized in the BOO rats with DO after deobstruction, whereas in those without DO, abnormal function persisted and the gene expression profile became more abnormal. DO may play a protective role against the stress to the bladder induced by BOO and deobstruction as a form of adaptive neuroplasticity.

Quantitative Changes in Cerebral Perfusion during Urinary Urgency in Women with Overactive Bladder

Purpose

To quantitatively measure changes in cerebral perfusion in select regions of interest in the brain during urinary urgency in women with overactive bladder (OAB) using arterial spin labeling (ASL).

Methods

Twelve women with OAB and 10 controls underwent bladder filling and rated urinary urgency (scale 0–10). ASL fMRI scans were performed (1) in the low urgency state after voiding and (2) high urgency state after drinking oral fluids. Absolute regional cerebral blood flow (rCBF) in select regions of interest was compared between the low and high urgency states.

Results

There were no significant differences in rCBF between the low and high urgency states in the control group. In the OAB group, rCBF (mean ± SE, ml/100 g/min) increased by 10–14% from the low to the high urgency state in the right anterior cingulate cortex (ACC) (44.56 ± 0.59 versus 49.52 ± 1.49, p < 0.05), left ACC (49.29 ± 0.85 versus 54.02 ± 1.46, p < 0.05), and left insula (50.46 ± 1.72 versus 54.99 ± 1.09, p < 0.05). Whole-brain analysis identified additional areas of activation in the right insula, right dorsolateral prefrontal cortex, and pons/midbrain area.

Conclusions

Urinary urgency is associated with quantitative increase in cerebral perfusion in regions of the brain associated with processing emotional response to discomfort.

Fourteen-day administration of corticosterone may induce detrusor overactivity symptoms

Introduction and hypothesis

Epidemiological studies demonstrated that patients suffering from overactive bladder often present with different mental problems, amongst which depression is the most frequently observed. The main goal of our study was to check if the repeated administration of corticosterone (CORT) is able to evoke the depressive-like behaviour and detrusor overactivity (DO) symptoms in rats. Moreover, we investigated whether the acute administration of common antidepressants (imipramine, 30 mg/kg, and fluoxetine, 15 mg/kg), antimuscarinic (oxybutynin chloride, 0.5 mg/kg) or CRF₁ (SN 003, 1 mg/kg) antagonists has an impact on the cystometric parameters, behaviour in the Porsolt test, and overall locomotor activity of animals exposed to CORT.

Methods

The experiments were carried out on female Wistar rats. All applied surgical and histopathology procedures, cystometric investigations, locomotor activity and forced swim measurements have been fully described in the published literature.

Results

Fourteen-day administration of CORT may induce both depressive and DO symptoms in rats, which are reversed by the inhibition of CRF₁ receptors.

Conclusions

It seems that the CRF₁ receptor could be an interesting target for overactive bladder pharmacotherapy, particularly in patients with co-existing depression.

How does interstitial cystitis begin?

BACKGROUND

Interstitial cystitis (IC) does not start as an endstage disease, it has a beginning when symptoms are milder, intermittent and the disease is misdiagnosed. To determine how IC develops patients were interviewed on when their symptoms began, what they were and are now as well as the various diagnoses that they received before they were determined to have IC.

METHODS

One hundred female IC patients were screened. They filled out a questionnaire asking about the age their disease presented, their initial and current symptoms, what their original diagnoses were, effect of the menstrual cycle and sexual activity on their symptoms and about any relatives with bladder symptoms or a current diagnosis of IC.

RESULTS

By age 30, 81% of patients had bladder symptoms, 21% before age 10. The first symptom was frequency in 81%, pain present in 59% and the symptoms were intermittent in 64%. Most common early misdiagnosis was UTI in 74% with 93% reporting negative urine cultures. Sex was painful and causes symptom flares in 82%, symptoms flared the week before the menses in 75%. Most common gynecologic diagnosis was yeast vaginitis, 42%. Urge incontinence was present in 33%. There were 51% that reported bladder symptoms in a first degree female relative.

CONCLUSIONS

IC begins primarily with frequency and is intermittent in most patients with symptom flares associated with sexual activity. Pain and urgency incontinence tend to be a later symptoms. When IC flares the most common misdiagnosis is UTI. Symptoms begin before age 30 in most but an IC diagnosis is often not made until age 40. Genetics appear to play a significant role. It is important to consider these facts when evaluating women with "early IC" because correct diagnosis will result in proper therapy and reduced health care costs.

A new model of detrusor overactivity in conscious rats induced by retinyl acetate instillation

INTRODUCTION

A credible animal overactive bladder model used in basic research is an indispensable harbinger of safe and ethical clinical trials on human subjects. Our objective was to develop a new animal model of a hyperactive bladder that will be void of inflammatory urothelium lesions and display significant sensitivity to muscarinic receptor antagonists.

METHODS

To examine the influence of 0.75% retinyl acetate solution on cystometric parameters, it was infused into the bladder for 5min. Cystometric studies with physiological saline were performed in conscious unrestrained rats 3days later. To examine the influence of retinyl acetate, acetic acid or cyclophosphamide on morphology of urinary bladders, the bladders were subjected to histopathological examination.

RESULTS

We demonstrated that in rats subject to previous 5-minute bladder instillations with retinyl acetate, an increase of basal pressure, threshold pressure, micturition voiding pressure, bladder contraction duration, relaxation time, detrusor overactivity index, nonvoiding contraction frequency and amplitude occurs. On the other hand, a decrease in voided volume, post-void residual, volume threshold, voiding efficiency, intercontraction interval, bladder compliance and volume threshold to elicit nonvoiding contractions was observed. Administration of oxybutynin chloride (0.5mg/kg, i.v.) reversed changes of cystometric parameters evoked by retinyl acetate. Contrary to acetic acid and cyclophosphamide, bladders subjected to retinyl acetate infusion had no signs of bladder inflammation.

DISCUSSION

The results obtained indicate that transient infusion of 0.75% retinyl acetate can induce detrusor overactivity, which is often observed in patients with overactive bladder syndrome (OAB). In addition, it was demonstrated that stimulating afferent C-fibres using retinyl acetate did not induce evident histopathological inflammatory lesions in the urinary bladder wall. It appears that in the future this model can prove useful in gaining more knowledge on the pathophysiology of OAB, and contribute to the preparation of new, more effective options of OAB pharmacotherapy.

Potential urine and serum biomarkers for patients with bladder pain syndrome/interstitial cystitis

There is a lack of consensus on the pathophysiology of bladder pain syndrome/interstitial cystitis. The chronic pain symptoms of bladder pain syndrome/interstitial cystitis refractory to local treatment could be a result of central nervous system sensitization and persisting abnormalities in the bladder wall, which activate the afferent sensory system. Evidence also shows that bladder pain syndrome/interstitial cystitis is a heterogeneous syndrome and that the two subtypes, the ulcerative (classic) and non-ulcerative types, represent different disease entities. There is a need for non-invasive markers for the differential diagnoses of the subtypes of bladder pain syndrome/interstitial cystitis, and between bladder pain syndrome/interstitial cystitis and bladder sensory disorders, such as hypersensitive bladder syndrome or overactive bladder. Bladder pain syndrome/interstitial cystitis, but not overactive bladder, involves an aberrant differentiation program in the bladder urothelium that leads to altered synthesis of several proteoglycans, cell adhesion and tight junction proteins, and bacterial defense molecules. These findings have led to the rationale for identifying urinary biomarkers to detect bladder pain syndrome/interstitial cystitis in patients with frequency urgency syndrome. Recently, the markers that have been the focus of the most research are antiproliferative factor, epidermal growth factor, heparin-binding epidermal growth factor, glycosaminoglycans and bladder nitric oxide. In addition, inflammatory proteins in the urine and serum play important roles in the pathogenesis of bladder pain syndrome/interstitial cystitis. The urinary proteome is an easily accessible source of biomarkers for differentiation between inflammatory bladder disorders. Analysis of multiple urinary proteins and serum cytokines could provide a diagnostic basis for bladder pain syndrome/interstitial cystitis, and could be a tool for the differential diagnosis of bladder pain syndrome/interstitial cystitis and other sensory bladder disorders.

Diagnosing the bladder as the source of pelvic pain: successful treatment for adults and children

The key to successful therapy of interstitial cystitis (IC) is to correctly diagnose it. The significant majority of patients with IC have a dysfunctional bladder epithelium that allows urinary solutes (primarily potassium) to leak into the bladder wall, causing symptoms and tissue damage. Drugs that correct this dysfunction and suppress symptoms are important to achieve successful outcomes in patients. Today over 95% of females with IC are misdiagnosed as having gynecologic chronic pelvic pain, vulvodynia, vaginitis, endometriosis, overactive bladder or urinary tract infection. Men are misdiagnosed as having prostatitis. Often children are not diagnosed at all. Multimodal drug therapy may be required and can achieve successful resolution of IC in over 90% of patients. IC in children can be treated successfully with pentosan polysulfate.

Mast cell activation and response to tolterodine in the rat urinary bladder in a chronic model of intravesical protamine sulfate and bacterial endotoxin-induced cystitis

The aim of the present study was to use an animal model of interstitial cystitis (IC) in order to investigate the histology and function of the bladder, with a particular focus on mast cell degranulation and response to detrusor overactivity (DO) to tolterodine. A total of 18 female Sprague‑Dawley rats were used. In 12 rats, lipopolysaccharide (LPS) was intravesically instilled following the induction of IC by protamine sulfate (PS) and six rats were subjected to sham instillations. Following 1 month, cystometry was performed. The effects of tolterodine were tested in half of the animals with IC. All rats in the IC group demonstrated DO during the filling phase and no significant changes in the frequency or pressure compared with that following tolterodine injection were identified. Histological examination revealed a significant increase in the total number of infiltrated mast cells in IC rats compared with that in the sham rats (P<0.05). Degranulated mast cells were evident in 80% of rats with IC; however, they were not apparent in the sham rats. Urinary bladder inflammation, similar to that in human IC in terms of degranulated mast cells and bladder function, was induced in rats. The animal model used in the present study provided insight into the pathophysiological mechanisms underlying the ineffectiveness of anticholinergics in patients with overlapping IC and overactive bladder (OAB).

Urgency and pain in patients with overactive bladder and bladder pain syndrome. What are the differences?

BACKGROUND

The Overactive Bladder Syndrome (OAB) and the Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) are different urological conditions sharing 'urgency' as a common symptom. The aim of this review is to address our existing knowledge and establish how these symptoms are interrelated and to determine whether or not there is a common link between both symptoms complexes that help to distinguish one from the other.

METHODS

Pubmed was used to obtain references for this non-systematic review aiming to discuss differences between OAB and BPS/IC. Guidelines of several professional associations and discussions based on expert opinion from the authors were implemented.

RESULTS

Whilst in BPS the hallmark symptom is pain on bladder filling, urgency is the defining symptom of OAB. Whilst it is likely that the pain in BPS/IC arises from local inflammation in the bladder wall, the nature of urgency as a symptom, its origin, and the relationship between urgency and pain, as well as the different afferent mechanisms associated with the genesis of these sensory symptoms, remains unknown. Although the aetiology of both OAB and PBS/IC is unclear, the influence of environmental factors has been suggested. Both are chronic conditions with very variable symptom resolution and response to therapy. The relationship with voiding dysfunction, gynaecological causes of chronic pelvic pain or the possible alteration of the hypothalamic-pituitary-adrenal axis and psychological disorders has not been established. Inflammation has been suggested as the common link between OAB and BPS/IC.

CONCLUSIONS

OAB and BPS/IC are different symptoms complexes that share urgency as a common symptom. None of them have a specific symptom although pain on bladder filling is the hallmark symptom in BPS/IC. Bladder pain with urgency should be a trigger for referral to the provider with appropriate knowledge and expertise in this disease state, whereas the management of OAB should be part of normal routine care in the community.

Sex differences in the physiology and pharmacology of the lower urinary tract

Sexual dimorphism is not only noticed in the prevalence of many diseases, but also in multiple physiological functions in the body. This review has summarized findings from published literature on the sex differences of the pathophysiology and pharmacology of the lower urinary tract (LUT) of humans and animals. Sex differences have been found in several key areas of the LUT, such as overactive bladder, expression and function of neurotransmitter receptors in the bladder and urethra, and micturition patterns in humans and animals. It is anticipated that this review will not only evoke renewed interest for further research on the mechanism of sex differences in the pathophysiology of the LUT (especially for overactive bladder), but might also open up the possibilities for gender-based drug development by pharmaceutical industries in order to find separate cures for men and women with diseases of the LUT.

Dissimilar effects of tolterodine on detrusor overactivity in awake rats with chemical cystitis and partial bladder outlet obstruction

Purpose

We investigated bladder function, with a special focus on nonvoiding contractions (NVCs), in awake rats with chronic chemical cystitis and bladder outlet obstruction (BOO) by use of simultaneous registrations of intravesical and intraabdominal pressures. In addition, we tested the effects of tolterodine on the NVCs in these models.

Methods

A total of 20 female Sprague-Dawley rats were used in this study. In eight rats, chemical cystitis was induced by intravesical instillation of HCl. Twelve rats were subjected to sham instillations or partial BOO. Four weeks after intravesical instillation or 2 weeks after partial BOO, cystometrograms were obtained by use of simultaneous recording of intravesical and intraabdominal pressure in all unanesthetized, unrestrained rats in metabolic cages.

Results

A total of 17 rats survived. In the rats with acute injury by HCl, 50% showed detrusor overactivity (DO), which was not seen in the sham group. The cystitis group had lower DO pressure without a difference in DO frequency compared with the BOO group. After the administration of tolterodine, the cystitis group showed no difference in DO frequency or pressure, whereas the BOO group showed decreased values for both parameters.

Conclusions

Our study showed that toleterodine produced no effect on DO during the filling phase in rats with chronic chemical cystitisbut decreased the frequency and pressure of DO in rats with BOO. Clinically, studies are needed to improve the treatment effect of anticholinergic drugs ininterstitial cystitis patients with overactive bladder.

Urodynamic evaluation of female cats with idiopathic cystitis

OBJECTIVE

To compare values of urodynamic measurements of cats with idiopathic cystitis (IC) with previously published data for healthy female cats.

ANIMALS

11 female cats with IC.

PROCEDURES

2 sequential cystometrograms and 2 urethral pressure profiles were obtained for each cat. All tracings were evaluated for evidence of overactive urinary bladder (OAB). Maximum urethral pressure (MUP), maximum urethral closure pressure (MUCP), and functional profile length were recorded.

RESULTS

Only 3 cats had obvious micturition events. None of the 11 cats had evidence of OAB. Although not significant, threshold pressure was lower in cats with IC than in healthy cats (mean ± SD, 89.0 ± 12.0 cm H(2)O vs 75.7 ± 16.3 cm H(2)O, respectively); however, the total volume infused was significantly lower in cats with IC (4.8 ± 2.1 mL/kg vs 8.3 ± 3.2 mL/kg). The MUCP was significantly higher in cats with IC than in healthy cats (158.0 ± 47.7 cm H(2)O vs 88.9 ± 23.9 cm H(2)O, respectively). The MUP was also significantly higher in all portions of the urethra in cats with IC.

CONCLUSIONS AND CLINICAL RELEVANCE

No evidence of OAB was identified in any cat evaluated; therefore, medications used to target this abnormality did not appear justified. The high MUCP in cats with IC suggested that α(1)-adrenoceptor antagonists or skeletal muscle relaxants may be useful in this disease, and if these data were applicable to male cats, then α(1)-adrenoceptor antagonism may help prevent recurrent obstructive IC. Further studies are indicated to determine the effects, if any, these drugs might have in cats with IC.

Pelvic pain in urogynaecology. Part I: evaluation, definitions and diagnoses

Aim of this review is to summarise the available literature on the definitions and assessment of pelvic pain in the urogynaecological patient. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association were performed. Sixty-nine articles were reviewed. The site of pain was specified in 45% of the articles, 20% used the digital examination of pelvic myofascial trigger points for the diagnosis; 20%, the Pelvic Pain and Urgency/Frequency Symptom Scale; 26%, the Interstitial Cystitis Symptom and Problem Index and 39%, a simple visual analogue scale. The diagnosis was interstitial cystitis in 67% and chronic pelvic pain in 19% of the articles. Consensus on the diagnostic procedures and definition of pelvic pain in the urogynaecological patient should be achieved in order to provide exact diagnostic information which will lead to more satisfying treatment options.

Paediatric painful bladder syndrome/interstitial cystitis: diagnosis and treatment

To describe the pathophysiology, diagnosis and controversies surrounding the diagnosis and pharmacological treatments of painful bladder syndrome/interstitial cystitis (PBS/IC) in children, we reviewed adult and paediatric literature pertaining to PBS/IC. Paediatric PBS/IC presents similarly to adult PBS/IC. The diagnosis is made by exclusion. Paediatric PBS/IC patients complain most commonly of urinary frequency, and abdominal pain occurs in up to 88% of affected children. Enuresis may also be a presenting complaint. Urinalysis and urine cultures are unremarkable. Management of paediatric PBS/IC is similar to that of adult PBS/IC, and non-surgical management includes dietary, lifestyle and pharmacological therapy. Pharmacological options include pentosan polysulfate, amitriptyline, hydroxyzine, cimetidine or intravesical therapies (dimethyl sulfoxide or 'therapeutic solution').

Interstitial cystitis: bladder pain and beyond

BACKGROUND

Interstitial cystitis is characterized by over 6 months of chronic pain, pressure and discomfort felt in the lower pelvis or bladder. It is often relieved with voiding, along with daytime frequency and nocturia in the absence of a urinary tract infection. Interstitial cystitis occurs primarily in females including adolescents and its diagnosis is still one of exclusion. It is now recognized as a serious medical condition associated with significant disability.

OBJECTIVE

The aim of this paper was to review the pathogenesis and treatment of interstitial cystitis with emphasis on new pathogenetic trends and therapeutic modalities.

METHODS

About 713 mostly original papers were reviewed in Medline from 1990 to August. 2008. All authors independently reviewed the literature. Large, double-blind, placebo-controlled, clinical trials were few and the medical histories of the patients used varied considerably making conclusions difficult. Promising pilot trials turned out mostly negative on follow-up.

RESULTS

Increasing evidence of co-morbid diseases, neurogenic inflammation and the effect of stress are promising as new targets for pathophysiology. No new effective treatments have emerged. Oral pentosanpolysulfate, amitriptyline, hydroxyzine and quercetin, as well as intravesical heparin/bicarbonate/lidocaine solutions, are still used with variable success. Some pilot open-label trials presented encouraging findings.

CONCLUSION

Interstitial cystitis contributes substantially to chronic pelvic pain and to poor quality of life. Oral or intravesical administration of solutions containing sodium hyaluronate, chondroitin sulfate and quercetin to both reduce bladder inflammation and 'replenish' the glycosaminoglycan layer should be tried. There is a clear need for therapeutic modalities. New potential translational research areas are suggested.

Cholinergic nitric oxide release from the urinary bladder mucosa in cyclophosphamide-induced cystitis of the anaesthetized rat

BACKGROUND AND PURPOSE

Previous reports have suggested that nitric oxide (NO) may be released by cholinergic stimuli in the rat bladder in cyclophosphamide-induced cystitis, affecting bladder function. In the current study, we evaluated the effects of cyclophosphamide-induced cystitis on muscarinic whole bladder contractile responses in vivo, and further, if NO might be released from the mucosa by cholinergic stimuli.

EXPERIMENTAL APPROACH

Male rats were pre-treated either with cyclophosphamide (100 mg kg(-1); to induce cystitis) or saline (serving as controls). 60 h later, rats were anaesthetized and bladder pressure monitored.

KEY RESULTS

The muscarinic receptor agonist methacholine (MeCh; 0.5-5 microg kg(-1) i.v.) induced similar contractions (i.e. bladder pressure increases) in inflamed bladders as in controls, which were attenuated dose-dependently by the muscarinic M1/M3/M5 antagonist 4-diphenylacetoxy-N-methylpiperidine (4-DAMP; 0.1-1000 microg kg(-1) i.v.). In inflamed bladders, the cholinergic bladder contractions were enhanced after removing the mucosa, while cholinergic contractions were similar in intact and urothelium-denuded inflamed bladders in the presence of the NO synthase inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME; 30 mg kg(-1) i.v.). L-NAME attenuated the antagonistic effect of 4-DAMP on MeCh-induced contractions in intact inflamed bladders. However L-NAME did not affect the antagonism by 4-DAMP of MeCh-induced contractions of urothelium-denuded bladders, under control conditions or with cyclophosphamide-induced cystitis.

CONCLUSIONS AND IMPLICATIONS

In cyclophosphamide-induced cystitis, the cholinergic function of the bladder is altered. In the inflamed bladder, NO seems to be released via cholinergic stimuli through mucosal muscarinic M3/M5 receptors, presumably on urothelial cells, affecting bladder function.

Influence of intravesical potassium on pelvic floor activity in women with overactive bladder syndrome: comparative urodynamics might provide better detection of dysfunctional voiding

OBJECTIVES

To assess the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with symptoms of overactive bladder (OAB), by using comparative urodynamics (CUD).

PATIENTS AND METHODS

The study included 175 women who met the criteria of OAB (mean age 52.7 years, range 18-87). CUD included two sessions of pressure-flow studies (0.9% saline vs 0.2 m KCl) with simultaneous measurement of PFA using perineal electromyography (EMG) with surface electrodes. Dysfunctional voiding (DV) was diagnosed if significant PFA was measured by EMG during voiding.

RESULTS

In 44 patients (25%) there was increased EMG activity only in the presence of KCL; in 58 (33%) there was DV with increased PFA during filling with saline. In all these patients PFA was significantly greater in the presence of KCl (P < 0.001). In patients with DV, filling with KCl prompted a statistically significant difference in maximum bladder capacity, maximum flow rate, mean flow rate and postvoid residual urine volume (P < 0.05). In summary, 102 patients (58%) had DV.

CONCLUSION

These findings suggest that DV is associated with epithelial dysfunction of the bladder mucosa, which clinically leads to OAB syndrome and can be revealed by CUD. The detection of DV might elude conventional urodynamics, but can be significantly enhanced by CUD (0.9% saline vs 0.2 m KCl).

Epidemiologic issues in interstitial cystitis

As a result of variations in disease definition and diagnostic criteria for interstitial cystitis (IC), the performance of epidemiologic studies has been challenging. Initial prevalence studies used physician-confirmed diagnoses of IC; more recent studies, which have incorporated the use of patient responses to validated symptom questionnaires, indicate that the true prevalence of IC is much greater than the early studies suggested. Over the last decade, the recognized prevalence of IC has increased, and it is consistently greater among women compared with men. The most recent estimates indicate that at > or = 197 of every 100,000 women and > or = 41 of every 100,000 men in the United States are affected by IC. Because IC is substantially underdiagnosed, its actual prevalence may be much higher. Indeed, the disease may affect as many as 1 in 4 to 5 women and 1 in 20 men.

Advances in the treatment of interstitial cystitis

Recent years have brought dramatic advances in the clinician's ability to offer effective pharmacotherapy to patients who have interstitial cystitis. Medical treatments have been developed and applied to reduce the interstitial cystitis symptoms of pelvic pain and urinary urgency/frequency, and to address underlying causes of the disorder. In addition, advances in the understanding of the natural history of interstitial cystitis have revealed that it is insidiously progressive and the classical definition--rare, severe and difficult to treat--is in fact the relatively uncommon, advanced stage of a disorder that affects most individuals in a mild-to-moderate and readily treatable form. This recognition has led to the identification of large numbers of previously unsuspected cases of interstitial cystitis, and the successful treatment of many individuals in the early stages of interstitial cystitis when it is far more responsive to therapy. A heparinoid-based multimodal medical regimen can effectively control symptoms and address disease pathophysiology in the majority of cases. Intravesical therapeutic solutions are new and promising adjunctive therapies that can offer immediate symptom relief during symptom flares, and for patients who are just beginning medical therapy.