Responsiveness of symptom scales for interstitial cystitis

Intravesical Interferon Therapy vs Hyaluronic Acid for Pain Among Female Individuals With Interstitial Cystitis: A Randomized Clinical Trial

Importance

Interstitial cystitis (IC) is a debilitating condition. Although viral infection is a potential etiological cause, few studies have detected the effect of antiviral treatment.

Objective

To determine the efficacy and safety of intravesical interferon instillation compared with hyaluronic acid in female patients with IC.

Design, Setting, and Participants

This double-masked, randomized phase 2/3 clinical trial with parallel group design was implemented from October 2022 to April 2023 and had a 6-month follow-up period. The study was conducted at a single center. Eligible participants were female patients aged 18 to 70 years with a diagnosis of IC for more than 6 months. The last visit took place in October 2023. Data were analyzed between October and November 2023.

Intervention

Patients were randomized 1:1 to receive either intravesical instillation of interferon or hyaluronic acid.

Main Outcomes and Measures

The primary end point was change in visual analog scale pain score. Secondary end points included changes in voiding frequency, functional bladder capacity, symptom index, and global response assessment. Adverse events were closely monitored.

Results

Among the 52 patients, the mean (SD) age was 50.0 (14.1) years and they were randomized to either the interferon group (26 [50%]) or hyaluronic acid (26 [50%]). The visual analog pain score showed the interferon group decreased more significantly than hyaluronic acid (-1.3; 95% CI, -2.3 to -0.3; P = .02) at month 6, with 20 patients (77%) exhibiting a 30% or higher reduction in pain compared with baseline. Secondary end points of voiding frequency, functional bladder capacity, and nocturia episodes showed no significant difference between 2 therapies. However, interferon showed a significantly higher reduction in the Interstitial Cystitis Symptom Index (-3.0; 95% CI, -5.3 to -0.7; P = .01) and the Problem Index (-2.5; 95% CI, -4.5 to -0.4; P = .02) at month 6, with 22 patients (85%) presenting as moderately or markedly improved. The frequencies of adverse events were similar between 2 groups. Only 1 patient discontinued hyaluronic acid because of poor effectiveness.

Conclusions and Relevance

In this randomized clinical trial, female patients with IC could benefit from intravesical interferon therapy, without serious adverse events. These results offered hope for antiviral approaches in IC, but larger-scale, multicenter trials and long-term follow-up should be considered.

Trial Registration

ClinicalTrials.gov Identifier: NCT05912946.

Current status of patient-reported outcome measures and other subjective assessment grading tools in bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS) is characterised by chronic pain in the bladder area accompanied by urgency and/or frequency without the presence of other confusable diseases. Owing to a lack of gold standard diagnostic tests and definitive cure it is paramount to define treatment goals and validated measurements of outcomes. Patient-reported outcome measures (PROMs) are validated questionnaires completed by patients that can help to reduce ambiguity in the BPS patient treatment pathway, but they are currently underutilised. We present to our knowledge the first summary and analysis of all available PROMs in BPS patients.

METHODS

Review and critical evaluation of all relevant BPS guidelines presented in English language and a systematic search for PubMed database articles relating to PROMs and subjective assessment grading tools in BPS, interstitial cystitis and chronic pelvic pain syndrome.

RESULTS

The ideal PROMs for BPS should assess urinary symptoms, pain, quality of life and sexual health. There are five PROMs designed specifically for BPS patients. The most universally used and quoted is the O'Leary-Sant questionnaire followed by the Pelvic Pain and Urgency Score and the Wisconsin Interstitial Cystitis scale. However, there is no single PROM for BPS that is ideal, and for comprehensive assessment several questionnaires are often used simultaneously.

CONCLUSIONS

Patient-reported outcome measures are a valuable tool for use in the long-term management of patients burdened with BPS. There are now several disease-specific PROMs in use that have their respective advantages and disadvantages. Their use should be encouraged in future research as well as continued efforts to develop new PROMs that can address current shortcomings.

Multimodal Treatment with Cognitive Behavioral Therapeutic Intervention Plus Bladder Treatment Is More Effective than Monotherapy for Patients with Interstitial Cystitis/Bladder Pain Syndrome-A Randomized Clinical Trial

(1) Background: Introduction: Interstitial cystitis/bladder pain syndrome (IC/BPS) not only induces physiological damage but also greatly affects psychological stress. Multidisciplinary therapy has been recommended for IC/BPS treatment, but clinical trial data of combined bladder therapy and cognitive behavioral therapy (CBT) are lacking. This study evaluated CBT efficacy in patients with IC/BPS. (2) Methods: Patients with IC/BPS were randomized to the bladder monotherapy (BT) or combined CBT (CBT) group. The primary endpoint was the self-reported outcome by global response assessment (GRA). Secondary endpoints included IC symptoms and problem index, bladder pain score, Beck’s anxiety inventory (BAI), and depression inventory, and objective parameters were also compared. (3) Result: A total of 30 patients receiving BT and 30 receiving CBT therapy were enrolled. Significant improvement of the BAI at 8 (p = 0.045) and 12 weeks (p = 0.02) post-treatment was observed in the CBT group, with significantly greater GRA scores at 12 weeks (p < 0.001). Repeated measures analysis of variance showed a significant effect within the CBT group on IC/BPS patients’ self-reported treatment outcomes (p = 0.001) and anxiety severity BAI scores (p = 0.033). (4) Conclusion: A multimodal treatment of CBT combined with suitable bladder treatment more effectively improves anxiety severity and treatment outcomes in patients with IC/BPS.

Clinical presentation, videourodynamic characteristics, and treatment outcome in men with interstitial cystitis-like lower urinary tract symptoms

PURPOSE

In men, lower urinary tract symptoms (LUTS) similar to interstitial cystitis/bladder pain syndrome (IC/BPS) are difficult to diagnose, and treatment outcomes are poor. This study investigated clinical characteristics and videourodynamic study (VUDS) parameters, pathophysiology, and treatment outcomes in men with IC-like LUTS.

METHODS

Men with frequency, urgency, dysuria, and bladder pain initially diagnosed as IC/BPS by ESSIC criteria were assessed to rule out other lower urinary tract diseases (LUTD) by voiding diary, digitorectal examination, urinalysis, VUDS, and cystoscopic hydrodistention. Subsequent treatments for LUTD and specific treatment for IC/BPS were based on VUDS and cystoscopic findings. Clinical VUDS characteristics and treatment outcomes were compared with those of women with IC/BPS.

RESULTS

Seventy consecutive men (median age 54.5 years) were enrolled. The median maximum bladder capacity under cystoscopic hydrodistention was 650 mL (IQR 495-763) and glomerulation grade was 2 (1.0-2.0). The patients had moderate anxiety and depression severity; 49% had improved treatment outcomes. On VUDS, 42 (60%) patients had variable LUTD, including detrusor overactivity (n = 14), bladder neck dysfunction (n = 15), dysfunctional voiding (n = 3), and poor relaxation of the external sphincter (n = 24); also, 22 (31.4%) had a previous bladder outlet procedure. The self-reported treatment outcome was significantly better for patients with vs. without LUTD (p = 0.014).

CONCLUSIONS

Men with IC-like LUTS diagnosed as IC/BPS may have bladder outlet dysfunction as well as bladder dysfunction, causing a hypersensitive and painful bladder. The IC-like symptoms in the patients with LUTD might, in part, originated from bladder outlet dysfunction rather than the bladder alone.

Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery

BACKGROUND

Patients with intractable pain in the pudendal nerve distribution may benefit from pudendal neuromodulation; however, some may have previously undergone pudendal nerve entrapment surgery (PNES), potentially altering nerve anatomy and function.

AIM

We examined pudendal neuromodulation outcomes in patients with prior PNES.

METHODS

Patients with a history of PNES and quadripolar, tined pudendal lead placement for urogenital pain were reviewed. Symptoms and outcomes were collected from existing medical records.

OUTCOMES

Patients with pudendal neuromodulation and prior PNES were compared to patients with no prior PNES who had pudendal lead placement.

RESULTS

Fifteen patients with a history of 1, 2, or 3 prior PNES (n = 13, 1, and 1, respectively) were evaluated. Most (10; 67%) were female, with bilateral pain (9; 60%), and symptoms of 5-26 years. After trialing the lead, bladder symptoms and pain were improved in 8 of 12 and 9 of 14 patients, respectively, and 80% of patients (12/15) underwent permanent generator implantation. When prior PNES patients were compared to those with no prior PNES (n = 43), gender (67% vs 77% female; P = .50) and age (median 63 vs 58 years; P = .80), were similar; however, BMI differed (mean 24 vs 29; P = .008) and a lower proportion (12/15; 80% vs 42/43; 98%; P = .049) had generator implantation. Importantly, median lead implant time (48 vs 50 minutes; P = .65) did not differ between the 2 groups.

CLINICAL IMPLICATIONS

Pudendal neuromodulation has the potential to provide pain relief for a very difficult-to-treat population; furthermore, it does not appear that prior PNES surgery made lead placement significantly more challenging.

STRENGTHS & LIMITATIONS

Study strengths include being a tertiary referral center for urogenital pain and having a single surgeon perform all procedures in a regimented way. Limitations include the retrospective study design, small sample size and various approaches to PN CONCLUSION: Chronic pudendal neuromodulation can be a viable option even after prior PNES. Kristen M. Meier, Patrick M. Vecellio, Kim A. Killinger, Judith A. Boura, Kenneth M. Peters. Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery. J Sex Med 2022;19:995-1001.

Changes in the Ultrastructure of the Bladder Urothelium in Patients with Interstitial Cystitis after Intravesical Injections of Platelet-Rich Plasma

Urothelial dysfunction is considered a key pathological mechanism of interstitial cystitis/bladder pain syndrome (IC/BPS). Intravesical platelet-rich plasma (PRP) injections might be effective for treating IC/BPS. This prospective study investigated the changes in electron microscopic findings among IC/BPS patients after intravesical PRP injections. Twenty-six patients with refractory non-ulcer IC/BPS underwent monthly intravesical PRP injections for 4 months. Changes in clinical symptom scores and video urodynamic study parameters were assessed from baseline to after the PRP injections. A post-treatment Global Response Assessment (GRA) score ≥ 2 was considered a successful outcome. The mean GRA score was significantly higher after 4 PRP injections than at baseline. Approximately 42% of patients experienced successful outcomes after PRP treatment. Urothelial ultrastructural defects showed no significant differences between baseline and after the PRP injections. However, patients showed variable improvements in different urothelial defects (grade improvements: urothelium cell layers, 31%; umbrella cell integrity, 42%; umbrella cell surface uroplakin plaque, 54%; tight junctions between adjacent umbrella cells, 46%; lysed organelles, 58%; inflammatory cell infiltration, 31%). Patients with successful treatment outcomes showed significant improvements in urothelial tight junction defects. Repeated intravesical PRP injections are effective for improving IC/BPS symptoms as they promote urothelial ultrastructural defect recovery.

Use of Urinary Cytokine and Chemokine Levels for Identifying Bladder Conditions and Predicting Treatment Outcomes in Patients with Interstitial Cystitis/Bladder Pain Syndrome

BACKGROUND

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a condition causing bladder inflammation. Urinary biomarkers have been assessed as suitable for the diagnosis and treatment. This study aimed at investigating the role of urinary biomarkers in identifying bladder conditions and predicting the treatment outcome of IC/BPS.

METHODS

A total of 309 patients with IC/BPS and 30 controls were enrolled in this study. All patients underwent a comprehensive urological workup of symptoms, pain severity, and cystoscopic hydrodistention findings including maximal bladder capacity (MBC) and glomerulation grade. Urine samples were collected to investigate the levels of urinary cytokines and chemokines. According to MBC and glomerulation grade, patients with IC/BPS were further classified into the Hunner's IC (HIC) and non-HIC groups. The urinary biomarkers between IC/BPS and control groups and HIC and non-HIC groups were compared. Moreover, the treatment response was graded according to global response assessment (GRA) scores, and urinary biomarker levels were analyzed based on different GRAs.

RESULTS

Patients with IC/BPS had significantly high urinary monocyte chemoattractant protein-1, eotaxin, tumor necrosis factor -alpha (TNF-α), and prostaglandin E2 levels. Significantly higher levels of urinary interleukin-8, C-X-C motif chemokine ligand 10 (CXCL 10), brain-derived neurotrophic factor, eotaxin, and regulated-on-activation, normal T-cell expressed and secreted (RANTES) were noted in HIC than those with non-HIC and controls. Among all biomarkers, TNF-α had the best sensitivity, specificity, positive predictive value, and negative predictive value. There was a significant correlation between biomarker levels and GRA.

CONCLUSIONS

Significantly higher urine cytokines and chemokine levels were found in patients with IC/BPS. Most urinary biomarkers were significantly associated with MBC, glomerulation grade, and treatment outcome.

Effect of videourodynamic subtypes on treatment outcomes of female dysfunctional voiding

INTRODUCTION AND HYPOTHESIS

Dysfunctional voiding (DV) is not uncommon in women and is typically challenging to treat. This study retrospectively investigated the long-term treatment outcomes of DV women with different videourodynamics (VUDS) characteristics.

METHODS

Data of women with VUDS-proven DV (n = 302) were retrospectively analyzed. All patients at first received biofeedback pelvic floor muscle training and medications; urethral sphincter botulinum toxin A injection was administered after treatment failure. Long-term follow-up outcomes were graded by global response assessment (GRA) and objective responses of decrease of detrusor pressure (Pdet), increase in maximum flow rate (Qmax) and voiding efficiency (VE). The treatment outcomes were investigated among different VUDS subgroups.

RESULTS

Of 302 women, 165 (54.6%) had mid-urethral DV, 117 (38.7%) had distal urethral DV, and 20 (6.6%) had both bladder neck dysfunction (BND) and mid-urethral DV. A total of 170 (56.3%) patients were available for follow-up VUDS after treatment. Pdet was decreased in all three subgroups, but increase in Qmax and VE was only noted in the BND plus DV subgroup. Overall, 120 (70.6%) patients showed improvement (GRA ≥ 1), including 14 with BND plus DV (93.3%), 50 with mid-urethral DV (60.8%) and 56 with distal urethral DV (77.8%) (p = 0.044). All three subgroups showed significant reduction in bladder outlet obstruction index after treatment, with BND plus DV subgroup showing the greatest reduction.

CONCLUSIONS

Women with DV have different VUDS characteristics resulting from different pathophysiological mechanisms and treatment results. The VUDS characteristics may help predict treatment outcomes of female DV.

Improved Urothelial Cell Proliferation, Cytoskeleton and Barrier Function Protein Expression in the Patients With Interstitial Cystitis/Bladder Pain Syndrome After Intravesical Platelet-Rich Plasma Injection

Purpose

To investigate urothelial cell proliferation, cytoskeleton, inflammation, and barrier function protein expressions in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) after intravesical platelet-rich plasma (PRP) injections

Methods

A total of 19 patients with IC/BPS underwent 4 monthly intravesical PRP injections. Bladder biopsies were taken at the first and fourth PRP treatment. The bladder specimens were analyzed using the Western blot and immunochemical staining for progenitor cell markers for sonic hedgehog (Shh), CD34, and cytoskeleton proteins cytokeratin 5 (CK5), CK14, CK20; barrier function markers for zonula occludens-1 (ZO-1), E-cadherin, and intercellular adhesive molecule-1, tryptase and transforming growth factor-β (TGF-β). Global response assessment (GRA) was used to evaluate treatment outcomes.

Results

The mean age of patients was 55.6 years. After PRP injections, the functional bladder capacity and maximum flow rate increased, and the visual analogue scale (VAS) of pain, interstitial cystitis (IC) symptom index, IC problem index, O’Leary-Sant symptom score, and GRA improved in all patients. Urothelium Shh, CK5, ZO-1, E-cadherin, and TGF-β expressions increased significantly after repeated PRP injections. By subgrouping, according to PRP treatment outcomes, significant increases in Shh, E-cadherin, and ZO-1 expressions were noted only in patients with GRA ≥1 or improved VAS, but not in patients with GRA=0 and no improvement in VAS.

Conclusions

The level of urothelial barrier function protein and cell proliferation protein expression in the patients with IC/BPS was increased after repeat intravesical PRP injections. Intravesical repeat PRP injections may have potential to improve urothelial health and result in symptoms improvement in the patients with IC/BPS.

Evidence for Early Cyclosporine Treatment for Hunner Lesion Interstitial Cystitis

OBJECTIVES

The objective of this study was to evaluate our experience using cyclosporine A (CyA) in the treatment of Hunner lesion interstitial cystitis (HLIC).

METHODS

Retrospective chart review was performed on patients with HLIC treated with CyA from August 2012 to September 2019. Demographic and clinical variables, number of interstitial cystitis therapies, frequency, nocturia, and bladder pain visual analog scores before and after CyA treatment were collected, as well as the Global Response Assessment (GRA) and the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index. CyA responders were defined as those with moderately or markedly improved GRA scores.

RESULTS

A total of 51 patients with HLIC treated with CyA were identified. Mean follow-up was 3 years (0.36-6.8 years). Seventy-six percent (28 of 37) were female; mean age was 68 years (51-84 years). Before CyA treatment, an average of 8 previous therapies were tried and patients reported an average of 8 of 10 bladder pain. Daytime frequency was 11-20 times per day, and nocturia was 7 times per night. Per the GRA, 84% (31 of 37) were considered CyA responders. Posttherapy Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index scores were lower in responders compared with nonresponders (8.9 ± 5.7 vs 21.3 ± 7.0, P = 0.001). Bladder pain, number of hydrodistentions/fulgurations, nocturia, and daytime frequency improved significantly after CyA treatment.

CONCLUSIONS

The cyclosporine A response rate was 84%, with most of these patients reporting marked improvement. Bladder pain, daytime frequency, and nocturia were significantly improved after CyA treatment, and the number of interventions after CyA treatment decreased. Cyclosporine A should be considered earlier than fifth-line therapy in HLIC.

Cystoscopic hydrodistention characteristics provide clinical and long-term prognostic features of interstitial cystitis after treatment

To evaluate the correlations of clinical symptoms, urodynamic parameters, and long-term treatment outcomes with different findings of cystoscopic hydrodistention (HD) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). This retrospective analysis of 486 patients with IC/BPS investigated baseline clinical symptoms, disease duration, medical comorbidities, urodynamic findings, cystoscopic characteristics [including maximal bladder capacity (MBC) and the presence of glomerulations and Hunner’s lesions], and outcomes according to the five IC/BPS HD subtypes based on the glomerulation grade, MBC, and the presence of Hunner’s lesions. Receiver operation characteristic analysis identified an optimal cutoff value of MBC ≥ 760 ml as a predictor of satisfactory outcomes. Glomerulation grade and MBC were significantly correlated (r =  − 0.403, P < 0.001), and both were significantly associated with IC Symptom Index scores. The rate of satisfactory outcomes was better for the patients with low glomerulation grade and MBC ≥ 760 ml (64.2%), and significantly worse for those with Hunner’s lesions (36.8%); no significant differences were noted among the other groups. The results suggested that IC/BPS patients can be classified into the following three distinct subgroups: (1) those with low glomerulation grade and MBC ≥ 760 ml; (2) those with low glomerulation grade and MBC < 760 ml, or with high glomerulation grade regardless of MBC; and (3) those with Hunner’s lesions. The results showed that three IC/BPS subgroups had distinct bladder characteristics and treatment outcomes. The patients with high MBC and low glomerulation grade after HD had more medical comorbidities but a significantly higher rate of satisfactory treatment outcome.

IRB: 105-25-B.

A comparison of two intravesical bladder instillations for interstitial cystitis/bladder pain syndrome

OBJECTIVE

Bladder pain syndrome (BPS) is a chronic pain condition associated with injury to the glycosoaminoglycan (GAG) layer. We aimed to prospectively evaluate iAluRil® with multi-centre tertiary urogynaecology collaboration. We hypothesised that iAluRil® (a GAG therapy) would demonstrate equivalent symptom, pain and QOL scores compared to DMSO controls.

STUDY DESIGN

iAluRil® was administered for 7 instillations over 3 months in 34 women over 6 sites. 18 historical DMSO controls were matched 2:1. At baseline and 3 months post treatment validated questionnaires were collected.

RESULTS

Both iAluRil® and DMSO were associated with statistically significant improvements in IC/BPS specific questionnaire scores. iAluRil® showed statistically significant improvements in pain, symptoms, and QOL. 45 % of iAluRil® recipients had a greater than 50 % reduction in pain score as represented by the VAS. DMSO was also effective in improving measures of IC/BPS with statistically significant decreases in ICSI and ICPI. There was no statistically significant difference in the size of the effect between DMSO and IAluRil®.

CONCLUSIONS

iAluRil® is well tolerated and associated with significant improvements in pain and symptom scores. Almost half of refractory BPS will have a 50 % decrease in pain score at three months post treatment. This effect size is similar to DMSO.

Repeated intravesical injections of platelet-rich plasma improve symptoms and alter urinary functional proteins in patients with refractory interstitial cystitis

Repeated intravesical injections of autologous platelet-rich plasma (PRP) have been shown to improve symptoms in patients with interstitial cystitis/bladder pain syndrome (IC/BPS); however, there is a paucity of objective evidence of the effectiveness of this therapy. In this study, we investigated the changes in urinary markers after PRP treatment. Forty patients with IC/BPS who were refractory to conventional therapy received four injections of PRP at monthly intervals; 10 mL PRP solution with 2.5 times the peripheral blood platelet concentration was used. Urine levels of thirteen functional proteins, growth factors, and cytokines were assessed at baseline and at the 4th PRP injection. The clinical parameters included visual analog scale (VAS) pain score, daily urinary frequency, nocturia episodes, functional bladder capacity, and global response assessment (GRA). The GRA and symptom score significantly decreased post-treatment. In patients with GRA ≥ 2, the success rates at 1 month and at 3 months after the 4th PRP injection were 70.6% and 76.7%, respectively. The VAS pain score, frequency, and nocturia showed a significant decrease (all p < 0.05). Urinary levels of nerve growth factor, matrix metalloproteinase-13, and vascular endothelial growth factor significantly decreased post-treatment (p = 0.043, p = 0.02, and p = 0.000, respectively); platelet-derived growth factor-AB showed a significant increase (p = 0.004) at the 4th PRP treatment compared with baseline. In this study, repeated intravesical PRP injections provided significant symptom improvement in IC/BPS patients with concomitant changes in the related biomarker levels.Trial registration: ClinicalTrial.gov: NCT03104361; IRB: TCGH 105-48-A.

Percutaneous tibial nerve stimulation for the treatment of interstitial cystitis/bladder pain syndrome: a pilot study

OBJECTIVES

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain condition that requires multimodal management. The American Urologic Association includes sacral neuromodulation in the treatment algorithm for refractory IC/BPS. We sought to determine the rate of overall symptom improvement of IC/BPS symptoms, using validated measures, after treatment with percutaneous tibial nerve stimulation (PTNS), a form of peripheral neuromodulation.

METHODS

This was a single-arm, dual-center, pilot study examining a standard PTNS protocol in subjects with IC/BPS. Our primary outcome was subject response of "moderately" or "markedly improved" on the Global Response Assessment (GRA) scale after 12-weekly PTNS sessions. Assuming a 60% response rate, 24 subjects were needed to detect a response rate between 40 and 80% with 95% confidence. Secondary objectives included change in urinary frequency on a 24-h bladder diary, bladder pain as measured by VAS and responses to validated questionnaires for pelvic pain and IC/BPS.

RESULTS

Of 21 subjects enrolled, 16 initiated and 10 completed the PTNS treatment course. The GRA response rate was 40% at week 6 and 30% at week 12. Seventy percent of the cohort had some degree of improvement. There were no adverse events.

CONCLUSIONS

While only a minority of subjects with IC/BPS were responders to PTNS per GRA criteria, 70% of the cohort had some degree of improvement. Due to low recruitment and loss to follow-up, we did not achieve our predetermined significance. However, our promising findings add to the limited literature on this subject.

Questionnaire-guided evaluation of the effectiveness of long-term intravesical 0.2% chondroitin sulfate therapy in interstitial cystitis

INTRODUCTION AND HYPOTHESIS

To investigate the long-term feasibility, safety and effectiveness of intravesical chondroitin sulfate therapy in patients with one or more forms of chronic cystitis.

METHODS

The study included 62 female patients with interstitial cystitis/painful bladder syndrome (IC/PBS) who received intravesical chondroitin sulfate (40 ml/80 mg) therapy between 2014 and 2018. A total of 15 doses of intravesical treatment were applied, once weekly in the first month and once monthly from the second month onward. A 3-day voiding diary, a visual analog scale (VAS), the O'Leary Sant Indexes (ICSI/ICPI), the Pelvic Pain and Urgency/Frequency Symptom (PPUFS) Scale and PPUF Bother scores were recorded and evaluated through prospective comparison before treatment and at the first month and first year. Patients were also assessed using the Global Response Assessment (GRA) at the end of the first month and first year to assess the effectiveness of responses to treatment.

RESULTS

In the first month of treatment, 0.2% chondroitin sulfate was ineffective in 22.5% of patients, with mild improvement observed in 40.0% and moderate-good improvement in 37.0%. Evaluation at the end of the first year revealed mild improvement in 21.0% of patients and moderate-good improvement in 79.0%. Statistically significant improvements were observed in all scoring systems at 1 and 12 months compared with pre-treatment values (p < 0.001).

CONCLUSION

Long-term intravesical chondroitin sulfate therapy is a safe and highly successful therapeutic modality that produces significant improvement in patients' quality of life and symptoms in the treatment of IC/PBS.

Therapeutic potential of intravesical injections of platelet-rich plasma in the treatment of lower urinary tract disorders due to regenerative deficiency

The bladder urothelium plays an important role of barrier function to prevent influx of urinary toxic substance and bacteria. When there is insult to the urinary bladder, the urothelium will start to regenerate on injury. However, several factors might affect the regenerative function of bladder urothelium, including aging, chronic inflammation, and system diseases such as diabetes and chronic kidney diseases (CKDs). Impairment of bladder mucosal regenerative function might result in defective urothelial cell differentiation as well as barrier function, which might be the underlying pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) and recurrent bacterial cystitis. Our previous immunohistochemistry (IHC) study and electron microscopic study revealed that the loss of normal umbrella cells and defective junction proteins in IC/BPS and recurrent cystitis. Platelet-rich plasma (PRP) has been previously used in many medical aspects as regenerative medicine therapy. PRP is rich in many growth factors and cytokines which modulate the process of inflammation and regeneration in the wound healing process. Recent pilot studies have shown that intravesical PRP injections improve IC symptoms and yield a success rate of 70% at 3 months after treatment. The results highly suggest that PRP injection could improve urothelial regenerative function and reduce chronic inflammation in IC patients. This article reviews recently published researches on the urothelial dysfunction biomarkers, urothelial cell differentiation, and urinary regenerative and inflammatory proteins in patients with IC/BPS or recurrent bacterial cystitis. The pathophysiology of the insufficient urothelial regeneration and differentiation; and chronic inflammation may induce urothelial dysfunction and further affect the regenerative ability of the diseased bladder urothelium in IC/BPS and recurrent bacterial cystitis are discussed.

Intravesical injections of platelet-rich plasma is effective and safe in treatment of interstitial cystitis refractory to conventional treatment-A prospective clinical trial

AIMS

Current treatments for interstitial cystitis/bladder pain syndrome (IC/BPS) are usually unsuccessful in achieving long-term bladder pain relief and irritable symptom improvement. This study investigated the clinical efficacy of platelet-rich plasma (PRP) intravesical injections on IC/BPS patients refractory to conventional therapies.

METHODS

Forty patients received four monthly intravesical injections of 10 mL PRP extracted from 50 mL of whole blood. The primary end-point was Global Response Assessment (GRA) at 3 months after the 4th PRP injection. Secondary endpoints included changes in O'Leary-Sant symptom score (OSS), visual analog scale (VAS) of pain, daily frequency, nocturia, functional bladder capacity (FBC), maximum flow rate, voided volume, post-void residual volume (PVR) from baseline to 3 months after the 4th PRP injection.

RESULTS

All 40 patients (37 women and 3 men, aged 55.5 ± 11.1 years) completed the four injections and follow-up visits. GRA improved after the 1st PRP injection and the satisfaction persists till the primary end-point. The success rate was 45%, 52%, 70%, 70%, and 67.5% after the 1st, 2nd, 3rd, 4th, and 3 months after the 4th PRP injection, respectively. OSS and VAS also significantly decreased. The PVR did not change after repeated PRP injections, FBC increased, frequency, and nocturia were decreased after PRP injections. All patients were free of urinary tract infection or difficulty urinating.

CONCLUSION

The study demonstrated that repeated intravesical injections of autologous PRP can increase bladder capacity and provide IC symptom improvement in patients with IC/BPS refractory to conventional therapy. Autologous PRP injection is safe and effective in selected patients.

A Randomized, Double-blind, Placebo-controlled Trial of Certolizumab Pegol in Women with Refractory Interstitial Cystitis/Bladder Pain Syndrome

BACKGROUND

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic, disabling bladder disease, with an uncertain pathophysiology and no universally effective treatment.

OBJECTIVE

To evaluate the efficacy and safety of certolizumab pegol compared with placebo in women with refractory IC/BPS.

DESIGN, SETTING, AND PARTICIPANTS

Eligible women, aged 18-65 yr with moderate to severe IC/BPS, were enrolled in this randomized, double-blind, placebo-controlled pilot study.

INTERVENTION

Study patients were randomized at a 2:1 ratio to receive either certolizumab pegol or placebo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome measure was a patient-reported global response assessment (GRA). Secondary endpoints included Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), and a numeric rating scale for pain and urgency.

RESULTS AND LIMITATIONS

The primary endpoint of GRA improvement at week 2 was not met. However, by week 18, there was significant improvement in GRA for certolizumab pegol compared with placebo in pain (odds ratio [OR]=17.3, p=0.002), urgency (OR=9.92, p=0.02), and overall symptoms (OR=15.0, p=0.006). At week 18, there was a statistically significant improvement for certolizumab pegol compared with placebo in change from baseline for ICSI of -3.6 (95% confidence interval [CI]: -6.9 to -0.29, p=0.03), ICPI of -3.0 (95% CI: -6.1 to 0.12, p=0.042), pain scale of -2.0 (95% CI: -3.9 to -0.15, p=0.02), and urgency scale of -1.7 (95% CI: -3.5 to 0.06, p=0.03). There was a significant difference in greater than 30% reduction in pain from baseline comparing certolizumab pegol with placebo at week 18 (OR=13.0, p=0.02). Limitations include a larger, longer, multicenter trial is warranted with phenotypic categorization of patients.

CONCLUSIONS

Women with moderate to severe refractory IC/BPS were more likely to experience significant improvement in symptoms with certolizumab pegol compared with placebo therapy. Further investigation of certolizumab pegol for the treatment of IC/BPS is warranted with a larger, longer, multicenter, randomized, placebo-controlled trial.

PATIENT SUMMARY

Women with moderate to severe interstitial cystitis/bladder pain syndrome were helped with a medication used to treat autoimmune diseases.

Repeated intravesical injections of platelet-rich plasma are effective in the treatment of interstitial cystitis: a case control pilot study

OBJECTIVE

Interstitial cystitis (IC), also known as bladder pain syndrome (BPS), is a debilitating chronic disease. There are few treatment options for IC/BPS refractory to current medical therapy. This study investigated the clinical efficacy of intravesical injections of platelet-rich plasma (PRP) in IC/BPS.

METHODS

Fifteen patients with IC/BPS received 4 intravesical injections, at 1-monthly intervals, of 12 mL PRP extracted from 50 mL of the patient's whole blood, followed by cystoscopic hydrodistention. The primary endpoint was the change in O'Leary-Sant symptom (OSS) index from baseline to 1 month after the 4th PRP injection. Secondary endpoints were changes in pain (measured using a visual analog scale [VAS]), daily frequency, nocturia, functional bladder capacity (FBC), maximum flow rate, voided volume, post-void residual (PVR) volume, and global response assessment (GRA). Urinary cytokine levels were measured at baseline and 1 month after the 1st PRP treatment.

RESULTS

Of the 15 women in the study, 13 completed the 4 injections and follow-up visits (mean [± SD] age 52.9 ± 12.1 years). The OSS index and VAS pain score decreased significantly and FBC and GRA increased after the 1st PRP injection and lasted until the final endpoint. There was no change in PVR after repeated PRP injections, and all patients were free of urinary tract infections and difficulty urinating. Urinary interleukin (IL)-2 and IL-8 concentrations increased significantly after the 1st PRP injection. In patients with reductions in the VAS pain score ≥1, urinary IL-8 and vascular endothelial growth factor increased. In patients without reductions in the VAS pain score, IL-6 concentrations increased after PRP injection.

CONCLUSIONS

Repeated intravesical PRP injections are well tolerated and appear to be safe and effective in medically refractive IC/BPS, providing significant symptom improvement.

Chronic Pelvic Pain: Assessment, Evaluation, and Objectivation

Chronic Pelvic Pain (CPP) and Chronic Pelvic Pain Syndrome (CPPS) have a significant impact on men and women of reproductive and nonreproductive age, with a considerable burden on overall quality of life (QoL) and on psychological, functional, and behavioural status. Moreover, diagnostic and therapeutic difficulties are remarkable features in many patients. Therefore evaluation, assessment and objectivation tools are often necessary to properly address each patient and consequently his/her clinical needs. Here we review the different tools for pain assessment, evaluation, and objectivation; specific features regarding CPP/CPPS will be highlighted. Also, recent findings disclosed with neuroimaging investigations will be reviewed as they provide new insights into CPP/CPPS pathophysiology and may serve as a tool for CPP assessment and objectivation.

Long-term Outcomes of Augmentation Enterocystoplasty in Patients With End-Stage Bladder Diseases: A Single-Institute Experience Involving 102 Patients

Purpose

Augmentation enterocystoplasty (AE) has been shown to improve clinical symptoms in patients with end-stage bladder disease (ESBD). Herein, we report the long-term outcomes of a series of patients with different etiologies of ESBD who received AE.

Methods

We retrospectively reviewed 102 patients with ESBD who received AE at the Hualien Tzu Chi General Hospital from 1992 to 2014. ESBD in this study was defined as including neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) or myelomeningocele, inflammatory bladder disease (IBD), ESBD occurring after pelvic cancer surgery, and other etiologies. Complications including active lower urinary tract problems and urinary tract infection (UTI), as well as patients’ self-reported satisfaction with the procedure, were evaluated.

Results

A total of 102 patients were included in the study. A majority of patients received AE for NLUTD (n=43), followed by IBD (n=38), ESBD after pelvic cancer surgery (n=15), and the other etiologies (n=6). Patients had a mean age of 39.4±18.7 years and were followed for a mean of 78 months. All patients had significantly increased cystometric bladder capacity and compliance at the time of follow-up. Fifty-four patients (52.9%) reported moderate to excellent satisfaction with the outcome, and there were no significant differences among the groups (P=0.430). The most common reason for dissatisfaction was the need for clean intermittent catheterization (CIC; 41.7%), followed by urinary incontinence (25.0%) and recurrent UTI (16.7%).

Conclusions

AE is a safe and effective procedure for patients with ESBD. Postoperative urinary incontinence and UTI as well as the need for CIC may affect quality of life and decrease patient satisfaction.

Adverse Events of Intravesical OnabotulinumtoxinA Injection between Patients with Overactive Bladder and Interstitial Cystitis--Different Mechanisms of Action of Botox on Bladder Dysfunction?

Intravesical onabotulinumtoxinA (BoNT-A) injections have been proposed to treat both overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS) in patients with refractory conditions. We compared adverse events (AEs) after BoNT-A treatment between IC/BPS and OAB in women. IC/BPS patients who failed conventional treatments were enrolled to receive suburothelial injections of BoNT-A (100 U) followed by hydrodistention. Age matched OAB female patients refractory to antimuscarinic agents underwent BoNT-A (100 U) injections. The bladder capacity, maximum flow rate (Qmax), post-void residual (PVR), and voiding efficiency (VE) at baseline, 3 and 6 months, and the post-treatment AEs were analyzed between groups. Finally, 89 IC/BPS and 72 OAB women were included. In the OAB group, the bladder capacity and PVR increased, and VE decreased significantly at three and six months after BoNT-A treatment. In the IC/BPS group, the Qmax increased significantly at six months. There were significant differences in changes of capacity, Qmax, PVR and VE between the two groups. Moreover, OAB patients suffered more frequently from events of hematuria, UTI, and large PVR (>200 mL), but less frequently from events of straining to void. In conclusion, OAB women had higher PVR volume and lower VE than those in IC/BPS after BoNT-A injections. These results imply that the bladder contractility of OAB patients are more susceptible to BoNT-A, which might reflect the different mechanisms of action of Botox on bladder dysfunction. Further investigations to confirm this hypothesis are warranted.

O'Leary-Sant Symptom Index Predicts the Treatment Outcome for OnabotulinumtoxinA Injections for Refractory Interstitial Cystitis/Bladder Pain Syndrome

Although intravesical injection of onabotulinumtoxinA (BoNT-A) has been proved promising in treating patients with interstitial cystitis/bladder pain syndrome (IC/BPS), what kind of patients that may benefit from this treatment remains unclear. This study investigated the predictors for a successful treatment outcome. Patients with IC/BPS who failed conventional treatments were enrolled to receive intravesical injection of 100 U of BoNT-A immediately followed by hydrodistention. Variables such as O’Leary-Sant symptom and problem indexes (ICSI and ICPI), pain visual analogue scale (VAS), functional bladder capacity (FBC), voiding diary, and urodynamic parameters were measured at baseline and six months after treatment. A global response assessment (GRA) ≥ 2 at six months was defined as successful. There were101 patients enrolled. Significant improvements were observed in mean ICSI, ICPI, OSS (ICSI + ICPI), pain VAS, FBC, frequency, nocturia and GRA at six months after BoNT-A injections (all p < 0.05). The successful rate at six months was 46/101 (45.54%). Multivariate logistic regression revealed the baseline ICSI (odds ratio = 0.770, 95% confidence interval = 0.601–0.989) was the only predictor for a treatment outcome. ICSI ≥ 12 was the most predictive cutoff value for a treatment failure, with a ROC area of 0.70 (sensitivity = 69.1%, specificity = 60.9%).

The MAPP research network: a novel study of urologic chronic pelvic pain syndromes

Urologic chronic pelvic pain syndrome (UCPPS) may be defined to include interstitial cystitis/bladder pain syndrome (IC/BPS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The hallmark symptom of UCPPS is chronic pain in the pelvis, urogenital floor, or external genitalia often accompanied by lower urinary tract symptoms. Despite numerous past basic and clinical research studies there is no broadly identifiable organ-specific pathology or understanding of etiology or risk factors for UCPPS, and diagnosis relies primarily on patient reported symptoms. In addition, there are no generally effective therapies. Recent findings have, however, revealed associations between UCPPS and “centralized” chronic pain disorders, suggesting UCPPS may represent a local manifestation of more widespread pathology in some patients. Here, we describe a new and novel effort initiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the U.S. National Institutes of Health (NIH) to address the many long standing questions regarding UCPPS, the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. The MAPP Network approaches UCPPS in a systemic manner, in which the interplay between the genitourinary system and other physiological systems is emphasized. The network’s study design expands beyond previous research, which has primarily focused on urologic organs and tissues, to utilize integrated approaches to define patient phenotypes, identify clinically-relevant subgroups, and better understand treated natural history and pathophysiology. Thus, the MAPP Network provides an unprecedented, multi-layered characterization of UCPPS. Knowledge gained is expected to provide important insights into underlying pathophysiology, a foundation for better segmenting patients for future clinical trials, and ultimately translation into improved clinical management. In addition, the MAPP Network’s integrated multi-disciplinary research approach may serve as a model for studies of urologic and non-urologic disorders that have proven refractory to past basic and clinical study.

Instillation of Hyaluronic Acid via Electromotive Drug Administration Can Improve the Efficacy of Treatment in Patients With Interstitial Cystitis/Painful Bladder Syndrome: A Randomized Prospective Study

PURPOSE

In the treatment of interstitial cystitis, intravesical hyaluronic acid application may be suggested as a treatment option. In this randomized prospective study, the authors aimed to identify whether instilling the hyaluronic acid with electromotive drug administration (EMDA) would increase the tissue uptake and improve the efficacy.

MATERIALS AND METHODS

The data of 31 patients who had been diagnosed with bladder pain syndrome/interstitial cystitis (BPS/IC) between 2004 and 2005 were examined. The patients were randomized to two groups: patients in group A received hyaluronic acid directly with a catheter and patients in group B received hyaluronic acid with EMDA. The patients were followed for 24 months and the two groups were compared at certain time intervals. The primary end points of the study were visual analogue scale (VAS) score, global response assessment, and micturition frequency in 24 hours.

RESULTS

There were 6 males and 25 females. The two groups were similar in baseline parameters. The decrease in VAS score and the micturition frequency in 24 hours were significantly lower with EMDA at months 6 and 12. The difference between the two groups was not significant at months 1 and 24. Also, treatment with EMDA, positive KCl test, and pretreatment voiding frequency >17 were associated with higher response rates.

CONCLUSIONS

Hyaluronic acid installation is an effective glycosaminoglycan substitution therapy in patients with BPS/IC. Instillation of hyaluronic acid via EMDA can improve the efficacy of the treatment; however, lack of long-term efficacy is the major problem with this glycosaminoglycan substitution therapy.

The efficacy and safety of duloxetine in a multidrug regimen for chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVE

To evaluate the efficacy and safety of duloxetine hydrochloride in the treatment of patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

Thirty-eight CP/CPPS patients completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and International Index of Erectile Function-Erectile Function-5 (IIEF-5) questionnaires, uroflowmetry, and evaluation of psychologic status using Hamilton Anxiety Scale (HAM-A) and Hamilton Depression Scale (HAM-D). Patients were randomly assigned to 2 treatments groups. Treatment in group 1 consisted of a simultaneous oral administration of tamsulosin (0.4 mg/d, 60 mg/d), saw palmetto (320 mg/d), and duloxetine (60 mg/d). Treatment in group 2 consisted of tamsulosin (0.4 mg/d) and saw palmetto (320 mg/d). NIH-CPSI and IIEF-5 questionnaires, uroflowmetry, and evaluation of the psychological status were repeated at 16 weeks of follow-up.

RESULTS

At 16 weeks, a significant improvement in NIH-CPSI pain subscore, NIH-CPSI quality of life subscore, and NIH-CPSI total score were observed in group 1 patients compared with those in group 2 (P <.01, respectively), together with a significant improvement in HAM-A and HAM-D scores (P <.01, respectively). Patients in group 2 showed a significant improvement in NIH-CPSI total score, in the urinary symptoms subscore, and in the HAM-A total score. No significant differences were observed in IIEF-5 scores in the 2 groups. Maximum flow rate significantly increased in both groups. In group 1, 20% of patients stopped the study due to adverse effects.

CONCLUSION

The use of duloxetine in a multimodal treatment with an α-blocker medication and a saw palmetto extract allowed better results in controlling clinical symptoms, psychologic status and quality of life patients affected by CP/CPPS.

The urodynamic characteristics and prognostic factors of patients with interstitial cystitis/bladder pain syndrome

AIMS

The role of urodynamic study (UDS) in diagnosis of interstitial cystitis/bladder pain syndrome (IC/BPS) remains inconclusive, nor has the predictor for a treatment success been elucidated. We evaluated the diagnostic and prognostic values of UDS in patients with IC/BPS.

MATERIALS AND METHODS

IC/BPS patients with complete data of a symptom assessment, video UDS, potassium chloride (KCl) test, cystoscopic hydrodistention and treatment records were reviewed retrospectively. O'Leary-Sant symptom index and problem index (ICSI, ICPI) were available in part of the patients. The associations between UDS parameters with symptom scores, KCl test result, cystoscopy findings and treatment outcome were analysed. The UDS parameters, including first sensation of filling (FSF), first desire to void (FD), strong desire to void (SD), cystometric bladder capacity (CBC), maximum flow rate (Q(max)), detrusor pressure at Q(max) (Pdet), voided volume (VV) and postvoid residual (PVR). Univariate and multivariate logistic regression analyses were used to identify the variable predicting treatment success.

RESULTS

A total of 214 IC/BPS patients were enrolled in this study. The mean volumes at FSF, FD, SD, CBC and VV were inversely correlated with ICSI and ICPI (all p < 0.05). The patients with a positive KCl test had significantly lower mean volumes at SD, CBC, VV and lower Q(max) (all p < 0.05). Significantly lower mean volumes for FSF, FD, SD, CBC and VV were found in patients with higher grade of glomerulation under cystoscopy (all p < 0.01). The anaesthetic maximal bladder capacity (MBC) was positively correlated with FSF, FD, SD, CBC, Q(max) and VV (all p < 0.01). Female gender and the volume at SD were found to be the independent predictors for treatment outcome.

CONCLUSIONS

Our study demonstrated that there might be a role of UDS to help in diagnosis and prognostication for IC/BPS. Future prospective investigations are warranted.

Predictors of successful first-line antimuscarinic monotherapy in men with enlarged prostate and predominant storage symptoms

OBJECTIVE

To identify predictors of successful first-line antimuscarinic monotherapy for patients with enlarged prostate and predominant storage symptoms.

METHODS

Men aged ≥ 50 years with total International Prostate Symptom Score (IPSS-T) ≥ 8, total prostate volume (TPV) ≥ 20 mL, IPSS quality of life (QOL) index ≥ 2, IPSS voiding to storage (IPSS-V/S) subscore ratio ≤ 1, and post-void residual (PVR) ≤ 250 mL were recruited into a prospective open-label study. All men received tolterodine ER (4 mg) daily. Global response assessment (GRA) ≥ 1 after treatment was considered successful treatment and an indication for continued antimuscarinic monotherapy.

RESULTS

One hundred ninety-seven men aged 50-89 years (average TPV 44.4 mL) received first-line tolterodine monotherapy. Mean IPSS-T, IPSS storage (IPSS-S) subscore, and QOL improved significantly at 2, 4, and 12 weeks. Average PVR increased significantly; no patient developed acute urinary retention. One hundred thirty-six patients (69.0%) showed improvement (GRA ≥ 1) at both 2 and 4 weeks. Regression analysis showed that IPSS-S (P = .039) and maximum urine flow (Qmax, P = .033) were significant predictors of therapeutic success. Patients with smaller baseline TPV, higher IPSS-S, and higher Qmax had significantly higher treatment success rates.

CONCLUSION

First-line antimuscarinic monotherapy is safe and effective within 12 weeks in selected patients with benign prostatic hyperplasia (BPH) Higher baseline IPSS-S, higher baseline Qmax, and lower TPV were predictors of successful antimuscarinic monotherapy.

Health-related quality of life in patients with interstitial cystitis/bladder pain syndrome and frequently associated comorbidities

PURPOSE

To estimate the association of chronic non-urologic conditions [i.e., fibromyalgia (FM), chronic fatigue syndrome (CFS), and irritable bowel syndrome (IBS)] with health-related quality of life (HRQOL) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

A total of 276 women with established diagnoses of IC/BPS completed a telephone interview which included demographics, self-reported medical conditions, the SF-36 health survey, and the interstitial cystitis symptom index (ICSI). Multivariate linear regression analysis was used to identify correlates of SF-36 physical and mental component summary scores.

RESULTS

Mean patient age was 45.1 (SD 15.9) years, and 83% of the subjects were white. Mean values for the SF-36 Physical Component Score (PCS) and Mental Component Score (MCS) means were 39 (SD 14) and 45 (SD 12), respectively, indicating significant HRQOL reductions. Mean ICSI score was 11.27 (SD = 4.86). FM and IBS were significantly associated with worse SF-36 scores: -8 points on the PCS (p < 0.001) and -6 points on the MCS (p < 0.001). CFS and the presence of other pelvic conditions (overactive bladder, vulvodynia, endometriosis) were not significantly associated with SF-36 PCS and MCS scores.

CONCLUSIONS

In patients with IC/BPS, the presence of FM, CFS, and IBS has a significant association with HRQOL, equivalent in impact to the bladder symptoms themselves. These results emphasize the importance of a multidisciplinary approach to treating patients with IC/BPS and other conditions.

Diagnosis and treatment of interstitial cystitis in adolescents

Interstitial cystitis (IC), or painful bladder syndrome, is characterized by irritative voiding symptoms and can be a challenging problem that affects children and adolescents. Diagnosis and management in children and adolescents is challenging because of strict diagnostic criteria and the paucity of investigations focusing on this age group, which often can lead to delayed or missed diagnosis. Clinical features suggestive of IC include bladder pain, urgency, frequency, nocturia, and pressure. Symptoms may wax and wane and often are exacerbated by menstruation, intercourse, dietary triggers, and stress. Diagnosis can be made by history, physical exam findings such as suprapubic tenderness, voiding diaries, and exclusion of other etiologies. Some diagnostic tests such as the potassium sensitivity test and cystoscopy are invasive and often impractical in younger patients. Treatment of IC consists of a multimodal approach that should be tailored to the individual needs of the patient. Therapies for younger patients include oral medication, intravesical therapy, cystoscopy with hydrodistention, and conservative measures such as dietary modification. This review of the literature focuses on diagnosing IC in younger patients and on what treatment modalities are appropriate and effective for this age group.

Apremilast in the Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Pilot Study

OBJECTIVE

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a disease with an uncertain cause and limited effective treatments. Apremilast (Celgene Corporation, Summit, NJ, USA) is a selective phosphodiesterase type 4 (PDE4) inhibitor that modulates the immune system. An open-label, one-arm, pilot study was conducted to explore its potential for improving CP/CPPS symptoms.

METHODS

Males ≥ 18 years of age were treated with 20 mg oral apremilast twice daily for up to 12 weeks. Outcomes were measured with Global Response Assessment (GRA), pain visual analog scale (VAS), Chronic Prostatitis Symptom Index (CPSI), Pittsburgh Sleep Quality Index (PSQI), SF-12 mental (MCS) and physical (PCS) health-related quality of life subscales, and voiding diaries. Repeated measures and paired t-tests evaluated changes from baseline to end of treatment, and at a final visit 4 weeks off the drug.

RESULTS

Seventeen men (94% Caucasian; mean age 48.2 ± 10 years) were treated (mean 115.8 ± 56.1 doses). Mean VAS (3.4 ± 2.0 vs 1.8 ± 1.7; P = 0.0011), PSQI (9.4 ± 4.4 vs 7.4 ± 4.2; P = 0.037) and CPSI (26.1 ± 5.0 vs 17.2 ± 8.3; P = 0.0016) scores improved from baseline to end of treatment. Incontinence episodes per day improved slightly (P = 0.042). When only those completing at least 8 weeks of treatment were examined (n = 9), significant changes in CPSI, VAS, and PSQI were still observed. At the final visit, 8/9 (88.9%) men also reported some improvement in pain related to sex. Side-effects were generally mild and well tolerated.

CONCLUSION

These results suggest that apremilast may improve CP/CPPS symptoms with only mild side-effects. However, placebo controlled studies are necessary to determine efficacy.

Therapeutic effect of α-blockers and antimuscarinics in male lower urinary tract symptoms based on the International Prostate Symptom Score subscore ratio

AIMS

To investigate if the International Prostate Symptom Score (IPSS) voiding-to-storage subscore ratio (IPSS-V/S) can help to guide the treatment for male lower urinary tract symptoms (LUTS).

METHODS

Men aged 40 years or older with a total IPSS (IPSS-T) 8 or more were constitutively enrolled from January 2010 to December 2010. The IPSS voiding (IPSS-V) and storage subscore (IPSS-S) were recorded separately, and the IPSS-V/S was calculated. Patients were divided into two groups according to the baseline IPSS-V/S value. First-line doxazosin (4 mg per day) and tolterodine (4 mg per day) monotherapy were given to patients with IPSS-V/S > 1 and IPSS-V/S ≤ 1, respectively. The IPSS-T, IPSS-V, IPSS-S, quality of life (QoL), maximum flow rate (Qmax), voided volume and postvoid residual (PVR) were measured at 1 month (visit 1) and 3 months (visit 2) after treatment.

RESULTS

After medical treatment for 1 month, 89/116 (76.7%) patients receiving tolterodine and 218/279 (78.1%) patients receiving doxazosin reported an improved outcome (global response assessment, GRA ≥ 1 point). The mean IPSS-T, IPSS-S decreased, and QoL improved significantly in both groups. Significant increased Qmax, voided volume, decreased IPSS-V and PVR were noted only in patients receiving doxazosin. There was no significant increase of PVR (from 50.1 to 60.4 ml, p = 0.106), and no patient developed urinary retention after tolterodinie monotherapy for 1 month. However, patients aged more than 70 years had significant association with increased PVR (≥ 50 ml).

CONCLUSION

Initial treatment with doxazosin for patients with IPSS-V/S > 1 and tolterodine for patients with IPSS-V/S ≤ 1 is safe and feasible. Elderly people (≥ 70 years) and patients with Qmax < 10 ml/s are more likely to have increased PVR (≥ 50 ml).

Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening

INTRODUCTION

All women who have given birth vaginally experience stretching of their vaginal tissue. Long-term physical and psychological consequences may occur, including loss of sensation and sexual dissatisfaction. One significant issue is the laxity of the vaginal introitus.

AIM

To evaluate safety and tolerability of nonsurgical radiofrequency (RF) thermal therapy for treatment of laxity of the vaginal introitus after vaginal delivery. We also explored the utility of self-report questionnaires in assessing subjective effectiveness of this device.

METHODS

Pilot study to treat 24 women (25-44 years) once using reverse gradient RF energy (75-90 joules/cm(2) ), delivered through the vaginal mucosa. Post-treatment assessments were at 10 days, 1, 3, and 6 months.

MAIN OUTCOME MEASURES

Pelvic examinations and adverse event reports to assess safety. The author modified Female Sexual Function Index (mv-FSFI) and Female Sexual Distress Scale-Revised (FSDS-R), Vaginal Laxity and Sexual Satisfaction Questionnaires (designed for this study) to evaluate both safety and effectiveness, and the Global Response Assessment to assess treatment responses.

RESULTS

No adverse events were reported; no topical anesthetics were required. Self-reported vaginal tightness improved in 67% of subjects at one month post-treatment; in 87% at 6 months (P<0.001). Mean sexual function scores improved: mv-FSFI total score before treatment was 27.6 ± 3.6, increasing to 32.0 ± 3.0 at 6 months (P < 0.001); FSDS-R score before treatment was 13.6 ± 8.7, declining to 4.3 ± 5.0 at month 6 post-treatment (P < 0.001). Twelve of 24 women who expressed diminished sexual satisfaction following their delivery; all reported sustained improvements on SSQ at 6 months after treatment (P = 0.002).

CONCLUSION

The RF treatment was well tolerated and showed an excellent 6-month safety profile in this pilot study. Responses to the questionnaires suggest subjective improvement in self-reported vaginal tightness, sexual function and decreased sexual distress. These findings warrant further study.

Early termination of a trial of mycophenolate mofetil for treatment of interstitial cystitis/painful bladder syndrome: lessons learned

PURPOSE

We evaluated the efficacy and tolerability of mycophenolate mofetil in patients with treatment refractory interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

A total of 210 patients with interstitial cystitis/painful bladder syndrome were to be randomized into a multicenter, placebo controlled trial using a 2:1 randomization. Participants in whom at least 3 interstitial cystitis/painful bladder syndrome specific treatments had failed and who had at least moderately severe symptoms were enrolled in a 12-week treatment study. The primary study end point was the global response assessment. Secondary end points were general and disease specific symptom questionnaires, and voiding diaries.

RESULTS

Only 58 subjects were randomized before a black box warning regarding mycophenolate mofetil safety was issued by the manufacturer in October 2007. The trial was halted, and interim analysis was performed and presented to an independent data and safety monitoring board. Six of the 39 subjects (15%) randomized at study cessation were considered responders for mycophenolate mofetil compared to 3 of 19 controls (16%, p=0.67). Secondary outcome measures reflected more improvement in controls.

CONCLUSIONS

In a randomized, placebo controlled trial that was prematurely halted mycophenolate mofetil showed efficacy similar to that of placebo to treat symptoms of refractory interstitial cystitis/painful bladder syndrome. The results of this limited study cannot be used to confirm or refute the hypothesis that immunosuppressive therapy may be beneficial to at least a subgroup of patients with interstitial cystitis/painful bladder syndrome. Despite study termination lessons can be gleaned to inform future investigations.

Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial

BACKGROUND

Evidence suggests that the urogenital pain of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) may be neuropathic.

METHODS

This randomized, double-blind, placebo-controlled trial was conducted across 10 tertiary care centers in North America to determine whether pregabalin, which has been proved effective in other chronic pain syndromes, is effective in reducing CP/CPPS symptoms. In 2006-2007, 324 men with pelvic pain for at least 3 of the previous 6 months were enrolled in this study. Men were randomly assigned to receive pregabalin or placebo in a 2:1 ratio and were treated for 6 weeks. Pregabalin dosage was increased from 150 to 600 mg/d during the first 4 weeks. The primary outcome was a 6-point decrease in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score. Multiple secondary outcomes were assessed.

RESULTS

Of 218 men assigned to receive pregabalin, 103 (47.2%) reported at least a 6-point decrease in the NIH-CPSI total score at 6 weeks compared with 35.8% (38 of 106 men) assigned to receive placebo (P = .07, exact Mantel-Haenszel test, adjusting for clinical sites). Compared with the placebo group, men assigned to receive pregabalin experienced reductions in the NIH-CPSI total score and subscores (P < .05), a higher Global Response Assessment response rate (31.2% and 18.9%; P = .02), and improvement in total McGill Pain Questionnaire score (P = .01). Results for the other outcomes did not differ between groups.

CONCLUSION

Pregabalin therapy for 6 weeks was not superior to placebo use in the rate of a 6-point decrease (improvement) in the NIH-CPSI total score in men with CP/CPPS.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00371033.

The relationship between subjective and objective assessments of sacral neuromodulation effectiveness in patients with urgency-frequency

AIMS

Global response assessment (GRA) has been used to evaluate patients' perceptions of treatment effectiveness. However, few studies have scrutinized the relationship between GRAs and objective voiding diary outcomes data. This study explores the relationship between self-reported symptom-specific GRA responses and objective changes in frequency, urgency and pelvic pain in patients with urgency-frequency with or without pelvic pain after implantation of a prosthetic sacral nerve stimulation device.

METHODS

Patients scheduled for a staged procedure were enrolled in a prospective, observational, longitudinal study. Post implantation, patietns were grouped into "responders" or "non-responders" based on their answers to symptom-specific GRAs at three and six months. Treatment responders were defined as those reporting "moderately" or "markedly improved" on a 7-point scale, and all others were considered non-responders. Pre- and post-implant changes in mean 24-hour voiding frequency, voided volume, urgency and pelvic pain scores as recorded on voiding diaries were compared between groups using paired t-test.

RESULTS

At three months, responders demonstrated corresponding statistically significant improvement in voiding frequency (P < 0.001), average voided volume (P = 0.003), urgency (P = 0.022) and pelvic pain (P = 0.039). At six months, responders demonstrated statistically significant improvements in frequency (P = 0.025) and urgency (P = 0.006). None of the symptom changes were statistically significant in treatment non-responders.

CONCLUSIONS

The GRA non-responders groups' perceptions of treatment response agreed with their objective changes in bothersome symptoms and responders' changes agreed with their perception of improvement in the majority of symptoms. Further study is needed to standardize the GRA, and explore its potential for use in clinical practice.

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.