Current management of interstitial cystitis

A Pilot Open Label Study of Cystoprotek® in Interstitial Cystitis

Interstitial cystitis (IC) is a disorder of the urinary bladder characterized by urgency, frequency, nocturia and suprapubic pain. IC occurs primarily in women and symptoms are exacerbated by stress, ovulatory hormones and certain foods. IC pathogenesis is unknown, but the most consistent findings involve some dysfunction of the bladder glycosaminoglycan (GAG) protective layer and a high number of activated bladder mast cells. There is no effective therapy even through intravesical administration of dimethylsulfoxide (DMSO) or oral pentosanpolysulfate (PPS) have had variable success. A dietary supplement, CystoProtek®, was formulated with the natural GAG components chondroitin sulfate and sodium hyaluronate to provide urothelial cytoprotection, together with the flavonoid quercetin that has anti-inflammatory properties and inhibits activation of mast cells. Thirty-seven female patients diagnosed by the NIDDK criteria who had failed all forms of therapy took six softgel CystoProtek® capsules per day for 6 months. Global assessment scale was reduced from 9.0 ± 2.9 to 4.3 ± 2.1 (p <0.05); moreover, the O'Leary/Sant Symptom Index decreased from 16.3 ± 3.1 to 6.9 ± 4.2 (p <0.05) and the Problem Index from 13.1 ± 3.7 to 5.4 ± 4.0 (p <0.05). These results are very promising and warrant a larger study that may permit further analyses with respect to other, especially atopic, comorbid diseases.

Effect of sacral neuromodulation on female sexual function and quality of life: Are they correlated?

INTRODUCTON

Sacral neuromodulation (SNM) has become an established therapy for voiding dysfunction. Additional benefits, such as improved bowel functions and bladder pain, have been reported. Improvement in female sexual function after SNM treatment has been suggested; however, reports examining the effects of SNM on female sexual functions are scarce. We evaluate the effects of SNM on female sexual function and its impact on quality of life and analyze any correlation.

METHODS

Data were collected from January 2010 to May 2012 for all female patients who underwent SNM InterStim (Medtronic, Minneapolis, MN) therapy at a single centre in Canada. They were treated for voiding dysfunction, including refractory over-active bladder, frequency-urgency syndrome and non-obstructive urinary retention. Patients were screened by percutaneous nerve evaluation (PNE) to assess their response to therapy using a 4-day voiding diary. Patients who experienced 50% or more improvement in their voiding parameters were permanently implanted. All patients completed the Female Sexual Function Index (FSFI), Short-Form Health Survey (SF-36), and incontinence questionnaires (Urinary Distress Inventory [UDI]-6) preoperatively and 4 months postoperatively.

RESULTS

A total of 33 female patients had SNM therapy; 10 were excluded from the study because they were not sexually active. The indications were: refractory overactive bladder in 19, frequency-urgency syndrome in 2, and non-obstructive urinary retention in another 2 patients. SNM therapy significantly improved the total FSFI score (p = 0.011); the components of desire and orgasm showed significant improvement (p = 0.014 and p = 0.035, respectively). Age, body mass index, diagnosis, and urinary symptoms did not show significant correlation with FSFI score improvement. Quality of life showed significant improvement after SNM treatment in 5 categories. There was no correlation between improvement in quality of life and FSFI.

CONCLUSION

SNM may improve female sexual function and quality of life, yet there is no correlation between the improvement in FSFI and quality of life.

Role of inflammation in bladder function and interstitial cystitis

Cystitis, or inflammation of the bladder, has a direct effect on bladder function. Interstitial cystitis is a syndrome characterized by urinary bladder pain and irritative symptoms of more than 6 months duration. It commonly occurs in young to middle-aged women with no known cause and in fact represents a diagnosis of exclusion. Many factors have been suggested, including chronic or subclinical infection, autoimmunity and genetic susceptibility, which could be responsible for initiating the inflammatory response. However, a central role of inflammation has been confirmed in the pathogenesis of interstitial cystitis. Patients with interstitial cystitis are usually managed with multimodal therapy to break the vicious cycle of chronic inflammation at every step. Patients who develop irreversible pathologies such as fibrosis are managed surgically, which is usually reserved for refractory cases.

A murine model of inflammatory bladder disease: cathelicidin peptide induced bladder inflammation and treatment with sulfated polysaccharides

PURPOSE

Studies show that LL-37 is a naturally occurring urinary defensin peptide that is up-regulated during urinary tract infections. Although normal urinary LL-37 levels are antimicrobial, we propose that increased LL-37 may trigger bladder inflammation. We further suggest that anti-inflammatory sulfated polysaccharides known as semi-synthetic glycosaminoglycan ether compounds can treat/prevent LL-37 mediated bladder inflammation.

MATERIALS AND METHODS

C57BL/6 mice were catheterized/instilled with LL-37 (320 μM, 150 μl) for 45 minutes. Animals were sacrificed at 12 and 24 hours, and tissues were examined using hematoxylin and eosin. Separate experiments were performed for myeloperoxidase to quantify inflammation. GM-1111 semi-synthetic glycosaminoglycan ether treatments involved instillation of 10 mg/ml for 45 minutes directly before or after LL-37. Tissues were harvested at 24 hours. To compare semi-synthetic glycosaminoglycan ether efficacy, experiments were performed using 10 mg/ml heparin. Finally, tissue localization of semi-synthetic glycosaminoglycan ether was examined using a fluorescent GM-1111-Alexa Fluor® 633 conjugate.

RESULTS

Profound bladder inflammation developed after LL-37. Greater tissue inflammation occurred after 24 hours compared to that at 12 hours. Myeloperoxidase assays revealed a 21 and 61-fold increase at 12 and 24 hours, respectively. Semi-synthetic glycosaminoglycan ether treatment after LL-37 showed mild attenuation of inflammation with myeloperoxidase 2.5-fold below that of untreated bladders. Semi-synthetic glycosaminoglycan ether treatment before LL-37 demonstrated almost complete attenuation of inflammation. Myeloperoxidase results mirrored those in controls. In heparin treated bladders minimal attenuation of inflammation occurred. Finally, instillation of GM-1111-Alexa Fluor 633 revealed urothelial coating, significant tissue penetration and binding to endovasculature.

CONCLUSIONS

We developed what is to our knowledge a new model of inflammatory bladder disease by challenge with the naturally occurring urinary peptide LL-37. We also noted that a new class of anti-inflammatory sulfated polysaccharides prevents and mitigates bladder inflammation.

Risk factors for poor sleep quality among patients with interstitial cystitis in Taiwan

AIMS

Previous research has suggested that patients with interstitial cystitis have more sleep disturbances and higher levels of depression. However, reports that employ validated sleep questionnaires are rare for this population. The present study investigates the relationship between sleep quality, anxiety, depression, and the severity of urologic interstitial cystitis symptoms in outpatients, and risk factors for poor sleep quality.

METHODS

A total of 69 patients (52 female) with interstitial cystitis met National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) criteria, completed all instruments. The O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) was performed to assess interstitial cystitis severity. The Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS) were used to evaluate quality of sleep and depression level, respectively. Multiple linear regressions were used to identify independent factors of sleep quality.

RESULTS

Mean PSQI global score was 9.5 +/- 4.2 (range: 1-19); 81.2% of subjects had poor sleep quality (PSQI > 5). Regression analysis suggested that the severity of interstitial cystitis (Beta coefficient = 0.42, P < 0.001) and level of anxiety and depression (Beta coefficient = 0.26, P < 0.05) were significant independent risk factors for poor sleep quality, after controlling for age, gender, marital status, years of education, and years of symptomatic duration. Further analysis of ICSI subdomain scores shows that association between nighttime urination and poor sleep quality remains significantly (Beta coefficient = 0.32, P < 0.05), after adjustment for demographic data and anxiety and depression.

CONCLUSIONS

Poor sleep quality is common in interstitial cystitis patients and severity of urological symptoms and depression levels are important independent risk factors.

Evaluation of health-related quality of life in patients with painful bladder syndrome/interstitial cystitis and the impact of four treatments on it

OBJECTIVE

Painful bladder syndrome/interstitial cystitis (PBS/IC) is an inflammatory bladder disease of unknown origin. Symptoms of PBS/IC compromise patients' quality of life (QoL). This study evaluated a health-related quality of life (HRQoL) questionnaire in PBS/IC.

MATERIAL AND METHODS

151 patients with PBS/IC filled in the HRQoL questionnaire before and after the treatment. Of these, 87 patients participated in a 3-month randomized study testing intravesical dimethyl sulfoxide (DMSO) and bacille Calmette-Guerin (BCG) and 64 patients took part in a 6-month randomized study evaluating oral cyclosporine A (CyA) and pentosan polysulfate sodium (PPS). The changes in HRQoL questionnaire were evaluated with respect to the changes in global response assessment (GRA).

RESULTS

The results of the HRQoL questionnaire reflected well the post-treatment GRA. Patients responding to their treatment had improved QoL. CyA treatment had more impact on emotional well-being, social functioning, activity limitation days, pain and physical capacity than PPS treatment (p<0.05). More patients responded to DMSO than BCG treatment according to GRA (p<0.01), but the results in HRQoL questionnaire were equal after DMSO and BCG treatments.

CONCLUSIONS

The HRQoL questionnaire can be used in evaluating QoL in PBS/IC patients. Treatment of PBS/IC had obvious effects on QoL.

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.

EEC syndrome, Arg227Gln TP63 mutation and micturition difficulties: Is there a genotype-phenotype correlation?

We report on two unrelated families with EEC syndrome (ectrodactyly, ectodermal dysplasia, cleft lip/palate), each with an Arg227Gln TP63 gene mutation, where the phenotype overlapped extensively with the allelic disorder, limb-mammary syndrome (LMS). Features common to both families were an ectodermal dysplasia principally affecting tooth, breast and nipple development, dacryostenosis and severe micturition difficulties. Additional findings included post-axial digital hypoplasia, cleft uvula, anal stenosis, hypoplasia of the perineal body and biopsy-proven interstitial cystitis. No individual had cleft lip. Split hand-split foot malformation (SHFM) occurred in one child-born after the molecular diagnosis was established. Unlike previous reports, the urinary symptoms were refractory to treatment with oral Fibrase and persisted into adulthood. Of the six cases/families now reported with EEC syndrome and Arg227Gln TP63 mutation, four have manifested this distinct urological abnormality, indicative of a genotype-phenotype correlation.

Treatment approaches for painful bladder syndrome/interstitial cystitis

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a disease of unknown aetiology, characterised by severe pressure and pain in the bladder area or lower pelvis that is frequently or typically relieved by voiding, along with urgency or frequency of urination in the absence of urinary tract infections. PBS/IC occurs primarily in women, is increasingly recognised in young adults, and may affect as many as 0.1-1% of adult women. PBS/IC is often comorbid with allergies, endometriosis, fibromyalgia, irritable bowel syndrome and panic syndrome, all of which are worsened by stress. As a result, patients may visit as many as five physicians, including family practitioners, internists, gynaecologists, urologists and pain specialists, leading to confusion and frustration. There is no curative treatment; intravesical dimethyl sulfoxide, as well as oral amitriptyline, pentosan polysulfate and hydroxyzine have variable results, with success more likely when these drugs are given together. Pilot clinical trials suggest that the flavonoid quercetin may be helpful. Lack of early diagnosis and treatment can affect outcomes and leads to the development of hyperalgesia/allodynia.

Evidence-Based Management of Feline Lower Urinary Tract Disease

Many treatments have been recommended for managing cats with feline urinary tract disease (FLUTD). Veterinarians making therapeutic decisions should consider the quality of evidence supporting a recommendation to use (or not use) a particular treatment for cats with FLUTD. Whenever possible, recommendations should be based on results of randomized and well-controlled scientific studies performed in clinical patients with the spontaneously occurring disease of interest. In the absence of such studies, one is left to make the best recommendation possible with consideration of all information, including the quality of the evidence. At this time, additional studies are needed to evaluate evidence for many currently recommended treatments for cats with FLUTD.

Intravesical Suplatast Tosilate (IPD-1151T) Inhibits Experimental Bladder Inflammation

PURPOSE

Interstitial cystitis is a painful bladder disease characterized by urgency, frequency and variable inflammation but there is no curative therapy. Suplatast tosilate (IPD-1151T) is an immunoregulatory compound that decreases interstitial cystitis symptoms but to our knowledge its mechanism of action is unknown. We investigated the effect of intravesical IPD-1151T on mediator release from bladder explants in experimental cystitis.

MATERIALS AND METHODS

A catheter was inserted into the bladder of female mice. After urine was emptied normal saline, carbachol (100 nM) or lipopolysaccharide (10 mg/ml) was introduced with or without 10-minute pretreatment with IPD-1151T. Urine was removed after 45 minutes for histamine and tumor necrosis factor-alpha assays. The bladder was removed after 4 hours, minced into 1 mm2 pieces and cultured with or without triggers overnight for mediator release. The effect of IPD-1151T was also tested on rat skin vascular permeability as well as on purified rat peritoneal mast cells and human cord blood derived mast cells.

RESULTS

Carbachol significantly increased histamine release in urine (61.3% in 8 preparations, p<0.05) but not in explant medium. IPD-1151T inhibited this effect by 77%. Lipopolysaccharide induced a 350% urine histamine increase in 9 preparations (p<0.05) and a 300% tumor necrosis factor-alpha increase in explant medium. IPD-1151T inhibited the lipopolysaccharide induced medium tumor necrosis factor-alpha increase by 95% in 5 preparations (p<0.05). IPD-1151T did not inhibit rat skin vascular permeability or purified rat peritoneal mast cell activation by compound 48/80 or human cord blood derived mast cells by anti-IgE.

CONCLUSIONS

IPD-1151T inhibits bladder release of histamine and tumor necrosis factor-alpha through a mechanism that does not appear to involve direct mast cell inhibition. These findings may justify a beneficial effect of IPD-1151T in interstitial cystitis.

Local drug delivery to bladder using technology innovations

Local delivery of drugs directly into the bladder by way of a urethral catheter is a clever approach to optimize drug delivery to the disease site while reducing systemic bioavailability. Pharmacotherapy by this route is referred to as intravesical delivery. In recent years, intravesical delivery has been used in combination with and oral regimen of drugs or as second-line treatment for neurogenic bladder and detrusor overactivity. Negligible absorption of instilled drugs into the systemic circulation explains the near-minimal adverse toxicity reported with this form of therapy. The authors discuss shortcomings of the current options available for intravesical delivery and provide a broad overview of the latest advances through technology innovation to overcome these drawbacks.

Recent advances in intravesical drug/gene delivery

Targeting of drugs administered systemically relies on the higher affinity of ligands for specific receptors to obtain selectivity in drug response. However, achieving the same goal inside the bladder is much easier with an intelligent pharmaceutical approach that restricts drug effects by exploiting the pelvic anatomical architecture of the human body. This regional therapy involves placement of drugs directly into the bladder through a urethral catheter. It is obvious that drug administration by this route holds advantage in chemotherapy of superficial bladder cancer, and it has now become the most widely used treatment modality for this ailment. In recent years, the intravesical route has also been exploited either as an adjunct to an oral regimen or as a second-line treatment for neurogenic bladder. (Lamm, D. L.; Griffith, J. G. Semin. Urol. 1992, 10, 39-44. Igawa, Y.; Satoh, T.; Mizusawa, H.; Seki, S.; Kato, H.; Ishizuka, O.; Nishizawa, O. BJU Int. 2003, 91, 637-641.) Instillation of DNA via this route using different vectors has been able to restrict the transgene expression in organs other than bladder. The present review article will discuss the shortcomings of the current options available for intravesical drug delivery (IDD) and lay a perspective for future developments in this field.

Management of patients with interstitial cystitis or chronic pelvic pain of bladder origin: a consensus report

BACKGROUND

Interstitial cystitis (IC) remains a challenging disease to treat, but increased awareness, better diagnostic tools, and effective pharmacologic agents can help non-urologists successfully manage this condition. Interstitial cystitis is much more prevalent than previously thought and is often misdiagnosed. Left untreated, IC can have a deleterious effect on the quality of life of the affected individual. In-office symptom-based techniques have been developed to screen for the presence of IC in both women and men presenting with symptoms of chronic pelvic pain (CPP) or chronic prostatitis (CP), and effective pharmacologic treatments exist that can provide acute and long-term symptom relief. Individual patient response to therapy varies, with some patients taking up to several months to achieve an optimal therapeutic response. To optimize patient response, a comprehensive algorithm for the diagnosis and management of IC should be utilized. Symptoms and progress should be assessed at each follow-up visit and changes in therapy made accordingly. Patients should be encouraged to learn as much as possible about IC and to take charge of the management of symptoms using their physician for guidance in decision making. The importance of this aspect of therapy should be reinforced at each subsequent visit. The entire office staff also has an important role in understanding and acknowledging each patient's pain and frustration as well as in providing support and education about IC.

SCOPE

This paper presents recommendations from a multidisciplinary panel for the evaluation, diagnosis, treatment, and follow-up care of patients with IC or CPP of bladder origin.

Selecting patients for sacral nerve stimulation

Patient selection for SNS remains empiric. A key is to think of voiding dysfunctions in terms of voiding behaviors and pelvic floor muscle function, not organ-based labels. Patients who have intractable urinary frequency, urgency, urge incontinence, or idiopathic urinary retention should be considered as prime candidates. Evidence of high-tone pelvic floor muscle dysfunction also may be demonstrated on routine physical examination, as well as diagnostic studies such as pelvic-floor EMG. A successful trial stimulation remains the best indicator for patient selection, and should be used as a routine diagnostic test among patients who have chronic, life-altering voiding complaints that cannot be resolved adequately by medications or behavioral interventions.

Mast cells and mast cell mediators as targets of dietary supplements

OBJECTIVE

To review the increasing amount of data that support or dispel the use of dietary supplements in the treatment of inflammatory conditions that involve mast cells, such as allergies, arthritis, and chronic pelvic pain syndrome.

DATA SOURCES

A search was conducted in MEDLINE for natural substances, dietary supplements, flavonoids, and proteoglycans for their in vitro or in vivo effects on allergic and inflammatory conditions.

STUDY SELECTION

Studies were selected for inclusion because of the impact factor of the journal, the definitive nature of the findings, the soundness of the study design, and the expert opinion of the authors.

RESULTS

Dietary supplements include a large group of products, such as vitamins, minerals, plant, or animal extracts, as well as herbal preparations that are often called medicinal herbs. Many of the available dietary supplements contain a multitude of ingredients, the source and/or purity of which is seldom disclosed; some of these may have biologic effects of their own or may interact with other supplements or drugs, often leading to adverse effects. The most well-documented evidence published to date is on the inhibitory action of natural compounds, especially flavonoids, on mast cells and allergic symptoms. Some flavonoids have weak inhibitory activity, whereas others may have no benefit or may be detrimental. Sulfated proteoglycans could provide synergistic action but require formulations with increased absorption.

CONCLUSIONS

Combining the most active flavonoids with proteoglycans could be helpful in atopic and inflammatory conditions. However, a complete list of active ingredients and their source, purity, and exact concentration should be a requirement for nutraceuticals to standardize, compare, and promote their safe use.