Elevated urinary norepinephrine in interstitial cystitis

Interstitial cystitis-an imbalance of risk and protective factors?

Interstitial cystitis (IC) presents as a chronic pain condition with variable combinations of symptoms depending on the species and individual patient. It is diagnosed by the presence of lower urinary tract signs and symptoms in combination with a variety of comorbid health problems, a history of life adversities, and the absence of other conditions that could cause the lower urinary tract signs. IC occurs naturally in humans and cats as a dimensional condition, with patients presenting with mild, moderate, and severe symptoms. Most patients appear to recover without specific treatment. A number of rodent models of IC have been used to study its causes and treatments. Unfortunately, current therapies generally fail to ameliorate IC symptoms long-term. The recent classification of IC as a chronic primary pain disorder calls for a rethinking of current clinical and research approaches to it. Beginning when a patient encounters a clinician, precipitating, perpetuating, and palliating risk factors can be addressed until a cause or reliably effective therapy is identified, and identifying predisposing and preventive factors can inform epidemiological studies and health promotion interventions. Predisposing, precipitating, and perpetuating risk factors, including environmental, psychological, and biological, increase the activity of the central threat response system (CTRS), which plays a clinically important role in IC symptoms. Studies in cats and rodent models have revealed that environmental enrichment (EE), in the absence of bladder-directed therapies, leads to amelioration of IC symptoms, implying a central role for the CTRS in symptom precipitation and perpetuation. Conceptually moving the source of IC pain to the brain as a motivational state rather than one resulting from peripheral nociceptive input offers both clinicians and researchers novel opportunities to improve care for patients with IC and for researchers to use more ecologically valid rodent models. It may even be that IC results from an excess of risk to protective factors, making this imbalance a targetable cause rather than a consequence of IC.

Autonomic responses during bladder hydrodistention under general versus spinal anaesthesia in patients with interstitial cystitis/bladder pain syndrome: a randomized clinical trial

Blocking the abrupt increase in systolic blood pressure associated with autonomic response during bladder hydrodistention in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) is essential for patient safety. We conducted this study to compare autonomic responses during bladder hydrodistention in patients with IC/BPS under general and spinal anaesthesia. Thirty-six patients were randomly allocated to a general anaesthesia (GA, n = 18) or a spinal anaesthesia (SA, n = 18) group. Blood pressure and heart rate were measured continuously and ΔSBP, defined as maximum increases in SBP during bladder hydrodistention from baseline, was compared between groups. Heart rate variability was analysed using electrocardiograms. The post-anaesthesia care unit assessed postoperative pain using a numeric (0-10) rating scale. Our analyses yield a significantly greater ΔSBP (73.0 [26.0-86.1] vs. 2.0 [- 4.0 to 6.0] mmHg), a significantly lower root-mean-square of successive differences in heart rate variability after bladder hydrodistention (10.8 [7.7-19.8] vs. 20.6 [15.1-44.7] ms), and significantly higher postoperative pain scores (3.5 [0.0-5.5] vs. 0.0 [0.0-0.0]) in the GA compared to the SA group. These findings suggest that SA has advantages over GA for bladder hydrodistention in preventing an abrupt increase in SBP and postoperative pain in IC/BPS patients.

Feline Uroepithelial Cell Culture as a Novel Model of Idiopathic Cystitis: Investigations on the Effects of Norepinephrine on Inflammatory Response, Oxidative Stress, and Barrier Function

Feline idiopathic cystitis (FIC) is one of the most common urinary tract disorders in domestic cats. As stress is suggested to play a key role in the pathogenesis of FIC, the effects of norepinephrine (NE) as a stress mediator were investigated on a novel feline primary uroepithelial cell culture, serving as an in vitro model of the disease. The uroepithelial cells gained from the mucosa of the bladder of a euthanized cat were cultured for 6 days and were acutely exposed to NE (10, 100, and 1000 µM) for 1 h. NE increased the metabolic activity of the cultured cells and elevated the extracellular concentrations of the pro-inflammatory mediators interleukin-6 (IL-6) and stromal cell derived factor 1 (SDF-1), confirming that NE can trigger an inflammatory response in the uroepithelium. Cellular protein carbonyl levels were increased by NE exposure, while malondialdehyde and glucose regulated protein 78 concentrations remained unchanged, indicating that NE may provoke the oxidative damage of proteins without inducing lipid peroxidation or endoplasmic reticulum stress. Further, it can be strongly suggested that an acute NE challenge might diminish the barrier function of uroepithelial cells, as reflected by the decreased glycosaminoglycan concentration, claudin-4 protein expression, and reduced TER values of the NE-treated cell cultures. Based on these results, short-term NE exposure mimicking acute stress can provoke an inflammatory response and decrease the barrier integrity of cultured feline uroepithelial cells. Hence, it is highly expected that stress-associated NE release may play an important mediatory role in the pathogenesis of FIC.

Small Fiber Polyneuropathy May Be a Nexus Between Autonomic Nervous System Dysregulation and Pain in Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a highly heterogeneous chronic and debilitating condition which effects millions of women and men in the United States. While primarily defined by urinary symptoms and pain perceived to be emanating from the bladder, IC/BPS patients frequently have co-occurring conditions and symptoms, many of which affect diverse body systems related to autonomic nervous system function. The impact on the autonomic system appears to stem from increased sympathetic innervation of the urinary tract, along with increased systemic sympathetic tone and decreased parasympathetic tone. Concurrent with these findings is evidence for destruction of peripheral sympathetic innervation to the sweat glands which may relate to small fiber polyneuropathy. It is unknown to what degree the wider alterations in autonomic function are also related to destruction/alterations in the small fibers carrying autonomic innervation. This potential nexus is an important point of investigation to better understand the unclarified pathophysiology of interstitial cystitis/bladder pain syndrome, the numerous co-occurring symptoms and syndromes, and for the identification of novel targeted therapeutic strategies.

The Role of Biogenic Amines in Nutrition Toxicology: Review

Biogenic amines, which are responsible for the realization of many physiological conditions of our body, are compounds that can be produced by microorganisms especially in fermented foods with high protein content. They can have harmful effects on human health only when taken in high amounts with food. However, in individuals with impaired anti-toxic metabolism, which is responsible for detoxification, even lower amounts may cause toxic effects. The most common health effects are nausea, vomiting, severe headaches, hypotension, hypertension, tachycardia, various allergic reactions, abdominal pain and death in more severe cases. For these reasons, legislations on biogenic amines in foods have been established with some restrictions. Food producers have been asked to comply with these legislations. However, despite all precautions, biogenic amines in foods have not been completely removed. Further research is still needed to find effective solutions to prevent biogenic amine formation. In addition, consumers need to be made aware of this issue.

Stress-induced autonomic dysregulation of mitochondrial function in the rat urothelium

AIM

Chronic stress exacerbates the symptoms of most pain disorders including interstitial cystitis/bladder pain syndrome (IC/BPS). Abnormalities in urothelial cells (UTC) occur in this debilitating bladder condition. The sequence of events that might link stress (presumably through increased sympathetic nervous system-SNS activity) to urothelial dysfunction are unknown. Since autonomic dysregulation, mitochondrial dysfunction, and oxidative stress all occur in chronic pain, we investigated whether chronic psychological stress initiated a cascade linking these three dysfunctions.

METHODS

Adult female Wistar Kyoto rats were exposed to 10 days of water avoidance stress (WAS). Bladders were then harvested for Western blot and single cell imaging in UTC cultures.

RESULTS

UTC from WAS rats exhibited depolarized mitochondria membrane potential (Ψm ∼30% more depolarized compared to control), activated AMPK and altered UT mitochondria bioenergetics. Expression of the fusion protein mitofusion-2 (MFN-2) was upregulated in the mucosa, suggesting mitochondrial structural changes consistent with altered cellular metabolism. Intracellular calcium levels were elevated in cultured WAS UTC, consistent with impaired cellular function. Stimulation of cultured UTC with alpha-adrenergic (α-AR) receptor agonists increased reactive oxidative species (ROS) production, suggesting a direct action of SNS activity on UTC. Treatment of rats with guanethidine to block SNS activity prevented most of WAS-induced changes.

CONCLUSIONS

Chronic stress results in persistent sympathetically mediated effects that alter UTC mitochondrial function. This may impact the urothelial barrier and signaling, which contributes to bladder dysfunction and pain. This is the first demonstration, to our knowledge, of a potential autonomic mechanism directly linking stress to mitochondrial dysfunction.

Norepinephrine augmented in vitro growth of uropathogenic E. coli in Type 2 diabetes mellitus and its suppression by silodosin (alpha blocker)

Norepinephrine is secreted under conditions of stress in humans. The ability of bacteria to sense mammalian hormone may have a role in propagation of infection. The present study investigated the effect of norepinephrine on in vitro growth of uropathogenic E. coli (UPEC) and the effect of silodosin on norepinephrine-induced changes. The spot urine samples were collected from 56 individuals (14 diabetic patients with UTI, 14 diabetic without UTI, 14 non-diabetic UTI and 14 healthy volunteer controls) for the measurement of urinary norepinephrine concentrations. The concentration of norepinephrine, as found in urine of human subjects, was reproduced in artificial urine medium to study the growth of UPEC. The norepinephrine concentration showing maximum growth response was selected to study the effect of silodosin on the growth inhibition of UPEC. Result showed significantly elevated urinary norepinephrine in diabetic patients with and without UTI and also in nondiabetic UTI groups. The norepinephrine concentration equivalent to that in diabetic UTI patients enhanced the growth of UPEC. Furthermore, silodosin (0.32 μM) inhibited the growth of the UPEC.

Current Pharmacologic Approaches in Painful Bladder Research: An Update

The symptoms of interstitial cystitis (IC)/bladder pain syndrome (BPS) may have multiple causes and involve many contributing factors. Traditional treatments (intravesical instillations) have had a primary focus on the bladder as origin of symptoms without adequately considering the potential influence of other local (pelvic) or systemic factors. Systemic pharmacological treatments have had modest success. A contributing factor to the low efficacy is the lack of phenotyping the patients. Individualized treatment based on is desirable, but further phenotype categorization is needed. There seems to be general agreement that IC is a unique disease and that BPS is a syndrome with multiple pathophysiologies, but this has so far not been not been well reflected in preclinical research with the aim of finding new pharmacological treatments. Current research approaches, including anti-nerve growth factor treatment, anti-tumor necrosis factor-α treatment, activation of SHIP1 (AQX-1125), and P2X3 receptor antagonists, and α₁-adrenoceptor antagonists are potential systemic treatments, implying that not only the bladder is exposed to the administered drug, which may be beneficial if the IC/BPS is a bladder manifestation of a systemic disease, or negative (adverse effects) if it is a local bladder condition. Local treatment approaches such as the antagonism of Toll-like receptors (which still is only experimental) and intravesical liposomes (with positive proof-of-concept), may have the advantages of a low number of systemic adverse effects, but cannot be expected to have effects on symptoms generated outside the bladder. Assessment of which of the treatment approaches discussed in this review that can be developed into useful therapies requires further studies.

Autonomic response during bladder hydrodistention reflects the severity of symptoms in patients with bladder pain syndrome/interstitial cystitis

AIMS

To evaluate the correlation between symptom severity of bladder pain syndrome/interstitial cystitis (BPS/IC) and autonomic nervous system activity, we examined autonomic responses during bladder hydrodistention.

METHODS

Medical records were collected from a prospective database for patients who underwent bladder hydrodistention with a fixed protocol from March 2012 to December 2013. A total of 40 patients (16 males, 24 females) were included for the analysis. Hydrodistention was performed under general anesthesia (31 patients), spinal anesthesia (six patients), and both types of anesthesia (three patients) at different times. Twenty-five patients who underwent holmium laser enucleation of the prostate served as controls. Pulse rate (PR), systolic (SBP), and diastolic blood pressure (BP) were measured pre-hydrodistention, during hydrodistention, and after drainage.

RESULTS

The spinal anesthesia and control groups exhibited little change in BP and PR during hydrodistention, while a significant increase was demonstrated in the general anesthesia group (e.g., ΔSBP 4.89 ± 4.80, 10.40 ± 19.03, and 56.26 ± 30.38 mm Hg, respectively, P < 0.001). Under general anesthesia, autonomic response during hydrodistention was more prominent in patients with preoperative visual analogue scale (VAS) pain score ≥7, Hunner's lesion, and glomerulation grade 4. Preoperative maximal cystometric capacity negatively correlated with changes in SBP during hydrodistention (R²  = 0.294, P = 0.009), while VAS score and interstitial cystitis problem index demonstrated a positive correlation with the changes (R²  = 0.208, P = 0.012; R²  = 0.173, P = 0.015).

CONCLUSIONS

Under general anesthesia, exaggerated autonomic responses to bladder hydrodistention were demonstrated in BPS/IC patients, which reflected the severity of symptoms. These results support the hypothesis of altered activity of autonomic system in BPS/IC. Neurourol. Urodynam. 36:677-682, 2017. © 2016 Wiley Periodicals, Inc.

Sympathetic nervous system and chronic bladder pain: a new tune for an old song

Chronic bladder pain (CBP) patients present with pelvic pain or discomfort during bladder filling, for at least a period of 6 months, which may be accompanied by lower urinary tract symptoms such as frequency, nocturia, and urgency. However, both the etiology of CBP and pathophysiological mechanisms are not well described. A number of clinical and basic animal model findings support involvement of sympathetic nervous system in chronic pain syndromes such as CBP. Examples include sympathetic overactivity and high plasma or urinary catecholamine levels that have a high correlation with nociceptive symptoms. In this review, we explored the current evidence in support of the involvement of sympathetic overactivity in CBP. As bladder inflammation often occurs among subgroups of CBP patients, we discuss the possible role of sympathetic nervous system in mastocytosis as well examples examples of animal models that further support the involvement of sympathetic dysfunction in CBP. As there is substantive evidence for cross-organ sensitization in the pelvis can lead to co-morbidity of genitourinary and gastrointestinal dysfunctions, we also include how sympathetic dysfunction may play a role in a number of co-morbid chronic pain syndromes.

Characterizing aptamer small molecule interactions with backscattering interferometry

Aptamers are segments of single-strand DNA or RNA used in a wide array of applications, including sensors, therapeutics, and cellular process regulators. Aptamers can bind many target species, including proteins, peptides, and small molecules (SM) with high affinity and specificity. They are advantageous because they can be identified in vitro by SELEX, produced rapidly and relatively economically using oligonucleotide synthesis. The use of aptamers as SM probes has experienced a recent rebirth, and because of their unique properties they represent an attractive alternative to antibodies. Current assay methodology for characterizing small molecule-aptamer binding is limited by either mass sensitivity, as in biolayer interferometry (BLI) and surface plasmon resonance (SPR), or the need for using a fluorophore, as in thermophoresis. Here we report that backscattering interferometry (BSI), a label-free and free-solution sensing technique, can be used to effectively characterize SM-aptamer interactions, providing Kd values on microliter sample quantities and at low nanomolar sensitivity. To demonstrate this capability we measured the aptamer affinity for three previously reported small molecules; bisphenol A, tenofovir, and epirubicin showing BSI provided values consistent with those published previously. We then quantified the Kd values for aptamers to ampicillin, tetracycline and norepinephrine. All measurements produced R(2) values >0.95 and an excellent signal to noise ratio at target concentrations that enable true Kd values to be obtained. No immobilization or labeling chemistry was needed, expediting the assay which is also insensitive to the large relative mass difference between the interacting molecules.

Interstitial Cystitis - Elucidation of Psychophysiologic and Autonomic Characteristics (the ICEPAC Study): design and methods

BACKGROUND AND PURPOSE

Interstitial cystitis/bladder pain syndrome (IC/BPS) is relatively common and associated with severe pain, yet effective treatment remains elusive. Research typically emphasized the bladder's role, but given the high presence of systemic comorbidities, the authors hypothesized a pathophysiologic nervous system role. This paper reports the methodology and approach to study the nervous system in women with IC/BPS. The study compares neurologic, urologic, gynecologic, autonomic, gastrointestinal, and psychological features of women with IC/BPS, their female relatives, women with myofascial pelvic pain (MPP), and healthy controls to elucidate the role of central and peripheral processing.

METHODS AND RESULTS

In total, 228 women (76 IC/BPS, 76 MPP, 38 family members, and 38 healthy controls) will be recruited. Subjects undergo detailed screening, structured neurologic examination of limbs and pelvis, tender point examination, autonomic testing, electrogastrography, and assessment of comorbid functional dysautonomias. Interpreters are blinded to subject classification. Psychological and stress response characteristics are examined with assessments of stress, trauma history, general psychological function, and stress response quantification. As of December 2012, data collection is completed for 25 healthy controls, 33 IC/BPS ± MPP, eight MPP, and three family members. Recruitment rate is accelerating and strategies emphasize maintaining and encouraging investigator participation in study science, internet advertising, and presentations to pelvic pain support groups.

CONCLUSION

The study represents a comprehensive, interdisciplinary approach to sampling autonomic and psychophysiologic characteristics of women with IC/BPS. Despite divergent opinions on study methodologies based on specialty experiences, the study has proven feasible to date and different perspectives have proved to be one of the greatest study strengths.

Can the adrenergic system be implicated in the pathophysiology of bladder pain syndrome/interstitial cystitis? A clinical and experimental study

AIMS

To evaluate sympathetic system activity in bladder pain syndrome/interstitial cystitis (BPS/IC) patients and to investigate if chronic adrenergic stimulation in intact rats induces BPS/IC-like bladder modifications.

METHODS

Clinical study--In BPS/IC patients and aged and body mass index matched volunteers TILT test was undertaken and catecholamines were measured in plasma and 24 hr urine samples. Experimental study--Phenylephrine was injected subcutaneously (14 days) to female Wistar rats. Pain behavior, spinal Fos expression, urinary spotting, number of fecal pellets expelled, frequency of reflex bladder contractions, and urothelial height were analyzed. Urothelium permeability was investigated by trypan blue staining. Immunoreactivity against caspase 3 and bax were studied in the urothelium and against alpha-1-adrenoreceptor and TRPV1 in suburothelial nerves. Mast cell number was determined in the sub-urothelium. In rats with lipopolysaccharide-induced cystitis, urinary catecholamines, and Vesicular Monoamine Transporter 2 (VMAT2) expression in bladder nerves were analyzed.

RESULTS

The TILT test showed an increase of sympathetic activity. Noradrenaline levels in blood at resting conditions and in 24-hr urine samples were higher in BPS/IC patients. Phenylephrine administration increased visceral pain, spinal Fos expression, bladder reflex activity, urinary spotting and the number of expelled fecal pellets. The mucosa showed urothelial thinning and increased immunoreactivity for caspase 3 and bax. Trypan blue staining was only observed in phenylephrine treated animals. Suburothelial nerves co-expressed alpha1 and TRPV1. Mastocytosis was present in the suburothelium. Cystitis increased sympathetic nerve density and urinary noradrenaline levels.

CONCLUSIONS

Excessive adrenergic stimulation of the bladder may contribute to the pathophysiological mechanisms of BPS/IC.

miR-199a-5p regulates urothelial permeability and may play a role in bladder pain syndrome

Defects in urothelial integrity resulting in leakage and activation of underlying sensory nerves are potential causative factors of bladder pain syndrome, a clinical syndrome of pelvic pain and urinary urgency/frequency in the absence of a specific cause. Herein, we identified the microRNA miR-199a-5p as an important regulator of intercellular junctions. On overexpression in urothelial cells, it impairs correct tight junction formation and leads to increased permeability. miR-199a-5p directly targets mRNAs encoding LIN7C, ARHGAP12, PALS1, RND1, and PVRL1 and attenuates their expression levels to a similar extent. Using laser microdissection, we showed that miR-199a-5p is predominantly expressed in bladder smooth muscle but that it is also detected in mature bladder urothelium and primary urothelial cultures. In the urothelium, its expression can be up-regulated after activation of cAMP signaling pathways. While validating miR-199a-5p targets, we delineated novel functions of LIN7C and ARHGAP12 in urothelial integrity and confirmed the essential role of PALS1 in establishing and maintaining urothelial polarity and junction assembly. The present results point to a possible link between miR-199a-5p expression and the control of urothelial permeability in bladder pain syndrome. Up-regulation of miR-199a-5p and concomitant down-regulation of its multiple targets might be detrimental to the establishment of a tight urothelial barrier, leading to chronic pain.

Autonomic response during bladder hydrodistention in patients with bladder pain syndrome

PURPOSE

We determined whether patients with bladder pain syndrome who have typical interstitial cystitis endoscopic findings, including glomerulations and/or Hunner ulcer, have a distinct autonomic response during bladder hydrodistention.

MATERIALS AND METHODS

Included in the study were 50 consecutive patients (40 females and 10 males) who met International Society for the Study of BPS recommendations. All patients underwent the same clinical evaluation, consisting of medical history, physical examination, urine and blood tests, urine cytology and culture, urinary tract ultrasound and urodynamics. Bladder hydrodistention and biopsies were performed using general anesthesia. Systolic and diastolic blood pressure, and heart rate were recorded after the induction of general anesthesia and at the end of the filling phase. Patients were divided into 2 groups, including patients with and without typical endoscopic findings, respectively. Clinical, histological and urodynamic variables, and autonomic parameters were compared between the 2 groups.

RESULTS

No significant differences in demographics, symptoms, pain severity, comorbidities, previous surgery, urodynamic variables, anesthetic bladder capacity or histological findings were found between the 2 groups. In patients with endoscopic findings average ± SD systolic and diastolic blood pressure increased by 25 ± 19 and 21 ± 12 mm Hg, respectively, and average heart rate increased by 12 ± 11 beats per minute. All hemodynamic changes were statistically significant (p <0.001). In patients without endoscopic findings a minor decrease in hemodynamic parameters was observed.

CONCLUSIONS

Patients with bladder pain syndrome who have typical interstitial cystitis findings on endoscopy show a marked autonomic response during bladder hydrodistention, consisting of an increase in heart rate, and systolic and diastolic blood pressure.

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

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

Panic disorder, social anxiety disorder, and a possible medical syndrome previously linked to chromosome 13

BACKGROUND

Several studies have identified increased medical problems among individuals with panic disorder (PD). We previously found that specific conditions--interstitial cystitis (IC), mitral valve prolapse (MVP), migraines, and thyroid disorders--aggregated non-randomly among panic families (we called this the "PD syndrome") and that families with and without the syndrome were genetically distinguishable on chromosome 13. We present data from a new case-control study that replicates and extends the syndrome phenotype clinically.

METHODS

Probands with a definite diagnosis and family history of PD (n=219), social anxiety disorder (SAD; n=199), or both (n=173) and 102 control subjects with no personal/family history of anxiety were interviewed with the SADS-LA diagnostic instrument. Medical history was obtained via medical checklist and the family history screen; IC symptoms were assessed with criteria developed by the National Institute for Diabetes and Digestive and Kidney Diseases. Subjects and interviewers were unaware of the syndrome hypothesis; final best-estimate diagnoses were blind to syndrome data.

RESULTS

Probands with PD or SAD, as compared with control subjects, were five or more times as likely to report IC symptoms and twice as likely to report MVP and migraines (other genitourinary and cardiovascular problems were not elevated). First-degree relatives of probands with PD or SAD were also at increased risk for IC, MVP, thyroid problems, and headaches, regardless of whether the proband reported the same condition.

CONCLUSIONS

These findings are consistent with previous data supporting a PD syndrome and further suggest that this syndrome might include other anxiety disorders well.

The effects of intravesical pentosanpolysulfate treatment on the symptoms of patients with bladder pain syndrome/interstitial cystitis: preliminary results

The objective of the study was to determine whether intravesical pentosanpolysulfate (PPS) reduces symptoms associated with bladder pain syndrome/interstitial cystitis (BPS/IC). In a prospective, uncontrolled, open-label study, 29 female patients with BPS/IC received 300 mg PPS intravesically twice a week for 10 weeks and thereafter a voluntary maintenance therapy once a month. Treatment response was assessed by Visual Analog Scale (VAS) for quality of life and O'Leary-Sant Symptom and Problem Index (OSPI). Patients were tested before treatment, after 5 weeks of treatment, and 1 week, 3, 6, and 12 months after termination of the initial treatment. Twenty-five patients underwent the 10-week treatment and the 3-month follow-up. Mean reduction of VAS/OSPI was from 8.8/26.4 before to 4/15.3 after treatment, 3.8/15.2 after 3 months, 3.8/14 after 6 months, and 3.4/12.1 after 12 months. In 21 patients, renewed instillation or maintenance therapy was necessary. Intravesical treatment with PPS reduces both the VAS and the OSPI in patients with BPS/IC.

Chronic psychological stress enhances nociceptive processing in the urinary bladder in high-anxiety rats

This study sought to determine whether acute and/or chronic psychological stress produce changes in urinary bladder nociception. Female Sprague-Dawley (SD; low/moderate anxiety) or Wistar-Kyoto (WK; high-anxiety) rats were exposed to either an acute (1 day) or a chronic (10 days) water avoidance stress paradigm or a sham stress paradigm. Paw withdrawal thresholds to mechanical and thermal stimuli and fecal pellet output, were quantified at baseline and after the final stress or sham stress exposure. Rats were then sedated, and visceromotor responses (VMRs) to urinary bladder distension (UBD) were recorded. While acute stress exposure did not significantly alter bladder nociceptive responses in either strain of rats, WK rats exposed to a chronic stress paradigm exhibited enhanced responses to UBD. These high-anxiety rats also exhibited somatic analgesia following acute, but not chronic, stress. Furthermore, WK rats had greater fecal pellet output than SD rats when stressed. Significant stress-induced changes in nociceptive responses to mechanical stimuli were observed in SD rats. That chronic psychological stress significantly enhanced bladder nociceptive responses only in high-anxiety rats provides further support for a critical role of genetics, stress and anxiety as exacerbating factors in painful urogenital disorders such as interstitial cystitis (IC).

Neural Upregulation in Interstitial Cystitis

Interstitial cystitis (IC) is a syndrome of bladder hypersensitivity with symptoms of urgency, frequency, and chronic pelvic pain. Although no consensus has been reached on the underlying cause of IC, several pathophysiologic mechanisms, including epithelial dysfunction, mast cell activation, and neurogenic inflammation, have been proposed. Despite multiple different causes of urinary cystitis, the bladder's response to cystitis is limited and typical. Animal experiments have shown upregulation of proteinase-activated receptors, tryptase, beta-nerve growth factor, inducible nitric oxide synthase, nuclear transcription factor-kappaB, c-Fos, phosphodiesterase 1C, cyclic adenosine monophosphate (cAMP)-dependent protein kinase, and proenkephalin B. After the noxious stimulus has abated, downregulation of genes appears to follow. Distention of the bladder results in the release of adenosine triphosphate (ATP) from urothelial cells, which activates purinergic P2X3 receptors. Activation by ATP of P2X3-expressing afferents is a fundamental signaling factor in bladder sensation and appears to play a role in bladder reflexes. Fos proteins present in spinal cord neurons have been shown to be upregulated in animals that have undergone cyclophosphamide-induced chemical cystitis. These and other findings suggest that neural upregulation occurs both peripherally and centrally in subjects with chronic cystitis. It is unclear whether neural mechanisms and inflammation are the cause of IC or the result of other initiating events. Neural upregulation is known to play a role in the chronicity of pain, urgency, and frequency and represents an exciting area of research that may lead to additional treatments and a better understanding of IC.

Corticotropin releasing factor: a mediator of emotional influences on bladder function

PURPOSE

We review evidence linking overactive bladder (OAB) and interstitial cystitis with anxiety and depression, and highlight the importance of corticotropin releasing factor (CRF) as a potential mediator of these conditions.

MATERIALS AND METHODS

We review the literature and describe ongoing experiments.

RESULTS

CRF is expressed in areas of the central nervous system that control voiding and response to stress. CRF is increased during anxiety, depression and pain as well as functional disorders of the pelvic viscera. Epidemiological studies reveal an association between anxiety and voiding disorders. Experiments in our laboratory show that CRF stimulates bladder activity while CRF antagonists inhibit OAB.

CONCLUSIONS

Epidemiological, genetic and neuropharmacological evidence links disorders of voiding and anxiety. CRF may participate in these events and warrants further investigation as a therapeutic target in the treatment of OAB and interstitial cystitis.

Evaluation of the effects of stress in cats with idiopathic cystitis

OBJECTIVE

To determine the effects of stress in cats with feline idiopathic cystitis (FIC) by evaluating bladder permeability, sympathetic nervous system function, and urine cortisol:creatinine (C:Cr) ratios during periods of stress and after environmental enrichment.

DESIGN

Prospective study.

ANIMALS

13 cats with FIC and 12 healthy cats.

PROCEDURE

Cats subjected to an acute-onset moderate stressor for 8 days received IV injections of fluorescein. Serum fluorescein concentrations were determined and compared with those of controls to evaluate bladder permeability, and urine C:Cr ratios were compared to evaluate function of the hypothalamic-pituitary-adrenal (HPA) axis. Plasma catecholamine concentrations were analyzed in a subset of cats. After 8 days of moderate stress, cats were moved to an enriched environment, and tests were repeated after 21 days.

RESULTS

Serum fluorescein concentrations were significantly higher in cats with FIC at all time points. In the cats in which plasma catecholamine concentrations were determined, concentrations of dihydroxyphenylalanine, norepinephrine, and dihyroxyphenylglycol were significantly higher in cats with FIC at all time points, whereas no differences in urine C:Cr ratio between groups were observed.

CONCLUSION AND CLINICAL RELEVANCE

Cats with FIC appeared to have altered bladder permeability, most notably during the period of initial stress. The increase in plasma dihydroxyphenylalanine concentration suggests that there may be stress-induced increase in the activity of tyrosine hydroxylase, which catalyzes the rate-limiting step in catecholamine synthesis. In contrast, no effects of stress on C:Cr ratios were observed, which suggests there was dissociation between the sympathetic nervous system and HPA-axis responses to stress.

Beta-adrenergic receptor activation in immortalized human urothelial cells stimulates inflammatory responses by PKA-independent mechanisms

Background

Interstitial cystitis (IC) is a debilitating disease characterized by chronic inflammation of the urinary bladder, yet specific cellular mechanisms of inflammation in IC are largely unknown. Multiple lines of evidence suggest that β-adrenergic receptor (AR) signaling is increased in the inflamed urothelium, however the precise effects of these urothelial cell signals have not been studied. In order to better elucidate the AR signaling mechanisms of inflammation associated with IC, we have examined the effects of β-AR stimulation in an immortalized human urothelial cell line (UROtsa). For these studies, UROtsa cells were treated with effective concentrations of the selective β-AR agonist isoproterenol, in the absence or presence of selective inhibitors of protein kinase A (PKA). Cell lysates were analyzed by radioimmunoassay for generation of cAMP or by Western blotting for induction of protein products associated with inflammatory responses.

Results

Radioligand binding demonstrated the presence of β-ARs on human urothelial UROtsa cell membranes. Stimulating UROtsa cells with isoproterenol led to concentration-dependent increases of cAMP production that could be inhibited by pretreatment with a blocking concentration of the selective β-AR antagonist propranolol. In addition, isoproterenol activation of these same cells led to significant increases in the amount of phosphorylated extracellular signal-regulated kinase (pERK), inducible nitric oxide synthase (iNOS) and the induced form of cyclooxygenase (COX-2) when compared to control. Moreover, preincubation of UROtsa cells with the selective PKA inhibitors H-89 or Rp-cAMPs did not diminish this isoproterenol mediated phosphorylation of ERK or production of iNOS and COX-2.

Conclusion

Functional β-ARs expressed on human urothelial UROtsa cell membranes increase the generation of cAMP and production of protein products associated with inflammation when activated by the selective β-AR agonist isoproterenol. However, the increased production of iNOS and COX-2 by isoproterenol is not blocked when UROtsa cells are preincubated with inhibitors of PKA. Therefore, UROtsa cell β-AR activation significantly increases the amount of iNOS and COX-2 produced by a PKA-independent mechanism. Consequently, this immortalized human urothelial cell line can be useful in characterizing potential AR signaling mechanisms associated with chronic inflammatory diseases of the bladder.

Botulinum toxin a has antinociceptive effects in treating interstitial cystitis

OBJECTIVES

To present clinical evidence with botulinum toxin A (BTX-A) suggesting an antinociceptive role in patients with interstitial cystitis (IC). Intriguing evidence in a somatic pain model has suggested that BTX-A injection may have an antinociceptive effect on both acute and chronic (inflammatory) pain.

METHODS

Thirteen female patients (6 in the United States and 7 in Poland) with IC according to the criteria of the National Institute of Diabetes, Digestive and Kidney Disease were included. Under short general anesthesia or sedation, 100 to 200 U of Dysport (Polish patients) or Botox (U.S. patients) was injected through a cystoscope into 20 to 30 sites submucosally in the trigone and floor of the bladder. Patients were evaluated with the O'Leary-Sant validated IC questionnaire or with voiding charts and a visual analog pain scale 1 month postoperatively and at subsequent 3-month intervals. The Polish patients also underwent pretreatment and post-treatment urodynamic evaluations.

RESULTS

Overall, 9 (69%) of 13 patients noted subjective improvement after BTX-A treatment. The Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index mean scores improved by 71% and 69%, respectively (P <0.05). Daytime frequency, nocturia, and pain by visual analog scale decreased by 44%, 45%, and 79%, respectively (P <0.01). The first desire to void and maximal cystometric capacity increased by 58% and 57%, respectively (P <0.01).

CONCLUSIONS

Our results suggest that BTX-A has an antinociceptive effect on bladder afferent pathways in patients with IC, producing both symptomatic and functional (ie, urodynamic) improvements.

COMORBIDITY OF INTERSTITIAL CYSTITIS WITH OTHER UNEXPLAINED CLINICAL CONDITIONS

PURPOSE

The aims of this review are 1) to consider the hypothesis that interstitial cystitis (IC) is not a single disease entity in all patients by reviewing the evidence for the presence of IC subtypes and for the comorbidity of various unexplained clinical conditions in some patients with IC, and 2) to describe recent results obtained in humans and in cats with severe feline IC (FIC) that suggest the presence of an underlying neuroendocrine abnormality.

MATERIALS AND METHODS

The IC literature concerning comorbidity with other disorders was reviewed and these findings were compared with those of investigators studying the comorbid disorders and comparable data on cats with FIC.

RESULTS

A significant overlap of symptoms exists among a number of unexplained clinical conditions and a common stress response pattern of increased sympathetic nervous system function in the absence of comparable activation of the hypothalamic-pituitary-adrenal axis occurs in a subset of patients with many of these conditions. A comparable pattern exists in cats with FIC, which also includes increased corticotropin releasing factor activity and decreased adrenocortical reserve.

CONCLUSIONS

Further investigation of the stress response system of patients with IC seems merited, which may provide novel approaches to therapy in some patients.

Autonomic response to stress in interstitial cystitis

PURPOSE

Previous studies have documented elevations in indices of sympathetic activity in cats and humans with interstitial cystitis (IC). To examine potential autonomic dysregulation in IC we examined the effects of a laboratory mental stress challenge on blood pressure and heart rate (HR) in patients with IC and healthy controls.

MATERIALS AND METHODS

A total of 14 female patients with IC and 14 age matched controls participated in a laboratory session, including a 25-minute mental stress challenge. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and HR were measured at intervals before, during and following the stressor. The level of chronic stress, symptom severity and pain at voiding were assessed.

RESULTS

Mean age was 49 years (range 32 to 66). The resting HR of patients with IC (82.02 bpm) was significantly higher than that of controls (63.31 bpm, p = 0.0001). There was also suggested evidence of elevated resting DBP in patients with IC (p = 0.07) but no significant difference in mean resting SBP. Autonomic arousal elicited by the laboratory stressor did not differ between the groups and subjects in each group perceived the task as equally stressful. Patients with IC had significantly elevated HR at each time point compared with controls (p <0.0001) with an average mean difference +/- SD between the groups of 19.5 +/- 4.0 (main effect for group p <0.0001). Although consistent increases in SBP and DBP were observed in patients after baseline, these differences were not significant.

CONCLUSIONS

Patients with IC had an increased HR at baseline and throughout a laboratory mental stress challenge compared to healthy age matched women. No differences in HR or blood pressure reactivity were observed between the 2 groups.

Current and future directions in diagnostic markers in interstitial cystitis

Interstitial cystitis (IC) is a chronic bladder disorder of unknown etiology that is often diagnosed by symptom criteria with or without cystoscopic findings. Several potential diagnostic markers have recently been described that may facilitate diagnosis of this disorder. A summary of the literature and a discussion regarding these biomarkers is provided, along with a brief discussion of new biomarkers presented at the meeting.

Urine markers of interstitial cystitis

This article describes the current state of the art with regard to urine markers of interstitial cystitis (IC), and describes the areas that need continuing research. Articles referenced in MEDLINE that describe urine alterations in IC were reviewed. Additional articles were identified by cross-referencing. The different marker alterations were tabulated. The relevant articles were discussed, considering different purposes for urine markers including: (1) diagnosing IC; (2) confirming a specific pathophysiology for IC; and (3) predicting or following response to a specific treatment. Currently, 2 markers (glycoprotein-51 and antiproliferative factor [APF]) clearly separate IC and control subjects, with minimal overlap. Markers that correlate with specific bladder biopsy features include 1,4-methylimidazole acetic acid and eosinophil cationic protein (ECP), which correlate with mast cell density, and interleukin (IL)-6, which correlates with mononuclear inflammation. Markers that changed after treatment were as follows: (1) nitric oxide synthase and cyclic guanosine monophosphate increased with oral L-arginine; (2) ECP decreased with subcutaneous heparin; (3) prostaglandin E(2) and kallikrein decreased after bladder distention; (4) neutrophil chemotactic activity decreased after dimethyl sulfoxide; (5) IL-2 inhibitor decreased after oral nifedipine; (6) IL-2, IL-6, and IL-8 decreased after bacille Calmette-Guérin (BCG) vaccine; and (7) APF and heparin-binding epidermal growth factor changed to or toward normal levels after bladder distention or sacral nerve stimulation. A larger number of urine alterations have been reported, and a few are being pursued further by correlating with bladder biopsy findings or treatment responses. Further research is needed.

Sensitivity and specificity of antiproliferative factor, heparin-binding epidermal growth factor-like growth factor, and epidermal growth factor as urine markers for interstitial cystitis

We previously determined that the urine of interstitial cystitis (IC) patients specifically contains a factor (antiproliferative factor [APF]) that inhibits primary bladder epithelial cell proliferation, and that it has significantly decreased levels of heparin-binding epidermal growth factor-like growth factor (HB-EGF) and increased levels of epidermal growth factor (EGF) compared with urine from asymptomatic controls and patients with bacterial cystitis. We sought to confirm the specificity of these findings for IC using a larger patient population, including control patients with a variety of urogenital disorders. Clean catch urine specimens were collected from 219 symptomatic IC patients, 113 asymptomatic controls without bladder disease, and 211 patients with various urogenital diseases including acute bacterial cystitis, vulvovaginitis, chronic nonbacterial prostatitis, overactive bladder, hematuria, stress incontinence, neurogenic bladder, benign prostatic hyperplasia, bladder or pelvic pain without voiding symptoms, bladder cancer, prostate cancer, or miscellaneous diagnoses including anatomic disorders. APF activity was determined by (3)H-thymidine incorporation into primary normal adult human bladder epithelial cells. HB-EGF and EGF levels were determined by enzyme-linked immunosorbent assay. APF activity was present significantly more often in IC than control urine specimens (P <0.005 for IC vs any control group; sensitivity = 94%, specificity = 95%, P <10(-82) for IC vs all controls). HB-EGF levels were also significantly lower and EGF levels significantly higher in IC urine than in specimens from controls (P <10(-84) and P <10(-36), respectively). These findings confirm the utility of APF, HB-EGF, and EGF as markers for IC. Understanding the reasons for altered levels of these markers may lead to understanding the pathogenesis of this disorder.

In vivo models of interstitial cystitis

PURPOSE

We systematically identified and evaluated various animal models that have been studied to help identify the underlying mechanisms of and possible treatment options for interstitial cystitis.

MATERIALS AND METHODS

Models of interstitial cystitis published between 1983 and 2001 were obtained by searching MEDLINE and other Internet databases using cystitis and model as the primary key words. Models with characteristics of interstitial cystitis similar to those defined by National Institutes of Arthritis, Diabetes, Digestive and Kidney Diseases criteria were reviewed. Some articles describing animal models with similar pathological conditions in other organs were also included to enlarge the base of potentially relevant material.

RESULTS

We identified and evaluated some 16 animal models of interstitial cystitis, which we categorized as bladder inflammation induced by intravesical administration of an irritant or immune stimulant, systemic and environmentally induced inflammation, and a naturally occurring model of interstitial cystitis that occurs in cats. Some abnormalities identified in humans and cats with interstitial cystitis can be reproduced in healthy animals using luminal, systemic or environmental stimuli. At the level of the bladder the source of stimulation cannot be discriminated. Variability in the extent of bladder distention complicated the interpretation of some studies. In addition, the noxious stimuli used can affect many epithelial surfaces as well as the urothelium, suggesting they are nonspecific responses to injury rather than specific to interstitial cystitis.

CONCLUSIONS

No model in bladder injury in healthy animals currently reproduces as many features of interstitial cystitis as the naturally occurring disease in cats. While induced models of relative injury may help to provide insight into the bladder response to injury, feline interstitial cystitis follows a similar chronic waxing and waning time course as does interstitial cystitis in humans, which may be more suitable for studying the effects of stressors on the severity of clinical signs as well as newly proposed therapies.

Increased plasma norepinephrine concentration in cats with interstitial cystitis

PURPOSE

Interstitial cystitis is a chronic urological syndrome affecting humans and domestic animals, including cats (feline interstitial cystitis). The symptoms of interstitial cystitis seem to be exacerbated by stress, suggesting involvement of the sympathetic nervous system and/or hypothalamic-pituitary-adrenal axis. Others have described sympathetic nervous system abnormalities in patients with interstitial cystitis but to our knowledge no data on plasma catecholamine concentrations or hypothalamic-pituitary-adrenal axis function in such patients have been reported. To evaluate the role of these systems in cats with feline interstitial cystitis we simultaneously measured baseline plasma concentrations of catecholamines and their metabolites to assess sympathetic activity, and the response of plasma adenocorticotropic hormone and cortisol concentrations to the infusion of corticotropin-releasing factor.

MATERIALS AND METHODS

Eight healthy cats and 8 with feline interstitial cystitis were anesthetized and a catheter was placed in the external jugular vein. Four hours after recovery samples were obtained for high performance liquid chromatography analysis of plasma norepinephrine, dihydroxyphenylglycol, epinephrine, dihydroxyphenylalanine, dopamine and dihydroxyphenylacetic acid. In 4 cats per group 1 microg. ovine corticotropin-releasing factor per kg. body weight was infused and blood samples were collected at intervals for 120 minutes for determining adenocorticotropic hormone and cortisol.

RESULTS

Significant increases in plasma norepinephrine and dihydroxyphenylglycol as well as a trend toward increased epinephrine were found, whereas no effect on dihydroxyphenylalanine, dopamine, dihydroxyphenylacetic acid, adenocorticotropic hormone or cortisol was identified in cats with feline interstitial cystitis.

CONCLUSIONS

These results support and extend previous studies identifying an increase in sympathetic activity in cats with feline interstitial cystitis.

Chronic urologic pain syndromes

Chronic pains typically evaluated by a urologist are discussed from the perspective of a non-urologist pain clinician. The pathophysiology of some pains is understood and so we believe the patient's symptoms: examples are cancer-related pain and recurrent urolithiasis. We treat these pains with traditional analgesics. Other pains, such as those of interstitial cystitis, chronic prostatodynia, and chronic orchialgia are less understood and so are treated in a more conservative and often empiric fashion. Proposed therapies for these disorders are discussed.

Visceral pain in humans: lessons from animals

Acute and persistent neuropathic and inflammatory injuries of healthy animals have contributed importantly to our current understanding of nociception and pain. Studies have differentiated somatic from visceral nociceptive input, and elucidated the pathways of transduction, transmission, perception, and modulation of the input. Other animal studies have identified important genetic and environmental influences on responses to nociception. Studies of naturally occurring visceral pain syndromes in animals also have added to our understanding of comparable syndromes in humans. Because of the aversive nature of pain, use of healthy animals to study pain in the service of other animals and humans is a decision to be taken carefully, and carries with it the responsibility of treating the animals as humanely as possible.

Pathophysiology of interstitial cystitis

Despite being described over 80 years ago, interstitial cystitis remains a disease of undetermined aetiology and poor treatment outcomes. Generally agreed diagnostic criteria of this condition, which occurs primarily in females, are frequency, urgency and pain, a low-capacity hypersensitive bladder, and mucosal haemorrhages and tearing on bladder distention. Although current theories of pathophysiology are predominantly conjecture, important elements of the disease process are increased afferent and efferent neuronal activity, an excess of inflammatory mediators, increased epithelial permeability and possibly reduced bladder vascularity. Improved treatment outcome will follow a better understanding of pathophysiology.

Non-bacterial cystitis

The concept of non-bacterial cystitis (NBC) combines sterile urine and cystitic symptoms as well as inflammatory changes, in particular in the mucosa and submucosa of the bladder. It includes a multiplicity of vicious circles along the entire continence reflex. An understanding of NBC presupposes knowledge of the origin of the normal urinary urge and its successful control. Against the background of the steadily increasing incidence of interstitial cystitis (often irreversible end-stage NBC), it is suggested here that in the face of a failure of first-line therapeutics (anticholinergics, cyclic antidepressants or oestrogens), one must consider without delay the possible presence of NBC.