Scanning electron microscopic findings in interstitial cystitis

Low-Energy Shock Wave Plus Intravesical Instillation of Botulinum Toxin A for Interstitial Cystitis/Bladder Pain Syndrome: Pathophysiology and Preliminary Result of a Novel Minimally Invasive Treatment

Low-energy shock wave (LESW) therapy is known to facilitate tissue regeneration with analgesic and anti-inflammatory effects. LESW treatment has been demonstrated to be effective in treating chronic prostatitis and pelvic pain syndrome as well as overactive bladder, and it has a potential effect on interstitial cystitis/bladder pain syndrome (IC/BPS) in humans. LESW reduces pain behavior, downregulates nerve growth factor expression, and suppresses bladder overactivity by decreasing the expression of inflammatory proteins. Previous rat IC models have shown that LESW can increase urothelial permeability, facilitate intravesical delivery of botulinum toxin A (BoNT-A), and block acetic acid-induced hyperactive bladder, suggesting that LESW might be a potential therapeutic module for relieving bladder inflammatory conditions, such as bladder oversensitivity, IC/BPS, and overactive bladder. A recent clinical trial showed that LESW monotherapy was associated with a significant reduction in pain scores and IC symptoms. BoNT-A detrusor injection or liposome-encapsulated BoNT-A instillation could also inhibit inflammation and improve IC symptoms. However, BoNT-A injection requires anesthesia and certain complications might occur. Our preliminary study using LESW plus intravesical BoNT-A instillation every week demonstrated an improvement in global response assessment without any adverse events. Moreover, an immunohistochemistry study revealed the presence of cleaved SNAP25 protein in the suburothelium of IC bladder tissue, indicating that BoNT-A could penetrate across the urothelial barrier after application of LESW. These results provide evidence for the efficacy and safety of this novel IC/BPS treatment by LESW plus BoNT-A instillation, without anesthesia, and no bladder injection. This article reviews the current evidence on LESW and LESW plus intravesical therapeutic agents on bladder disorders and the pathophysiology and pharmacological mechanism of this novel, minimally invasive treatment model for IC/BPS.

The extracellular matrix proteoglycan versican is strongly expressed in the urothelium of healthy rats

Objective: We have previously demonstrated protein expression of the extracellular matrix degrading protein ADAMTS5 in the nuclei of urothelial cells in healthy rats. The proteoglycan versican constitutes one of the main substrates for this protease. In this follow up study we investigated a potential co-localization of versican and ADAMTS5 in the urinary bladder wall.Material and Methods: The study was conducted with archive material (paraffin embedded bladder tissue from our previous study, i.e., 8 male Sprague-Dawley rats). Protein expression of versican was investigated by immunohistochemistry. Furthermore, the occurrence of versican mRNA was examined by in-situ hybridization.Results: Positive immunoreactivity for versican was evident in the urothelium but also, weakly, in the detrusor. This expression was localized only in the cytoplasm, leaving the nuclei devoid of reactivity. Interestingly, versican mRNA was only sparsely observed in the urothelial cells.Conclusions: We found by immunohistochemistry that the substrate for ADAMTS5, versican, was localized in the cytosol of urothelial cells. This demonstrates a difference regarding the expression of ADAMTS5, which was emphasized in the nuclei. This could imply an additional, non-enzymatic, function of ADAMTS5 in the urothelium.

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.

Electron microscopic characteristics of interstitial cystitis/bladder pain syndrome and their association with clinical condition

Background

Electron microscopy (EM) characteristics of the urothelium in interstitial cystitis/bladder pain syndrome (IC/BPS) and their association with clinical condition are unclear.

Methods

Ten IC/BPS patients who were admitted for hydrodistention and 5 patients with stress urinary incontinence (control patients) were enrolled. All patients provided detailed clinical histories and underwent urodynamic studies. Cystoscopic bladder biopsies were obtained and processed for transmission EM (TEM) and scanning EM (SEM). The severity of the urothelium findings was graded on a 4-point scale (0: none, 1: mild, 2: moderate, and 3: severe). The EM findings between IC/BPS and control patients were compared; the results were analyzed using the chi-square test.

Results

Compared with the urothelium of control patients, the urothelium of IC/BPS patients had more severe defects of the urothelial cell layers and integrity of umbrella cells in TEM (p = 0.045 and 0.01, respectively). In SEM, umbrella cell pleomorphism increased and microplicae of the cell membrane decreased in the IC/BPS group, and both were more severe than in the control group (p = 0.022 and 0.007, respectively). The patients with moderate to severe defects of umbrella cell integrity had more severe bladder pain and smaller maximal bladder capacity (MBC) (both p = 0.010). Patients with moderate to severe defects in microplicae of the cell membrane had smaller cystometric bladder capacity and MBC (p = 0.037 and 0.047, respectively).

Conclusions

The results revealed significant urothelium defects in IC/BPS, especially in the umbrella cells. Defects of umbrella cells may play an important role in the pathogenesis of IC/BPS.

[CLINICAL EFFICACY OF DIETARY MANIPULATION AS COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES ON FEMALE INTERSTITIAL CYSTITIS PATIENTS]

(Objectives) We examined the clinical efficacy of dietary manipulation (DM) for female patients with interstitial cystitis (IC) in stable condition who were followed in our hospital. (Patients and methods) This study included 20 female patients with IC in rather stable condition who were followed at our hospital. In cooperation with the nutrition control team, we created a basic IC diet menu for 1 month (total daily calories, 1,500 kcal; protein, 65 g; fat, 40 g; carbohydrate, 220 g; water, 1,000 ml; salt, 7 g). Data regarding daily food intake and food-related symptoms were collected by detailed interview of each patient conducted by the doctors, nurses, and nutritionists at our hospital. In accordance with the abovementioned nutrition control, we set meal menu to control IC symptoms and advised the patients to reduce the intake of specific food items to the maximum possible extent.The following food items were removed from or restricted in the diet of patients: tomatoes, tomato products, soy, tofu product (seasoning was acceptable), spices (pepper, curry powder, mustard, horseradish, etc.), excessive potassium, citrus, high-acidity-inducing substances (caffeine, carbonate, and citric acid), etc. We evaluated the following factors to determine the efficacy of this diet menu 3 months after the start of the intervention: O'Leary-Sant symptom index (OSSI), O'Leary-Sant problem index (OSPI), urgency visual analogue scale (UVAS) score, (0, no urgency; 10, severe urgency), bladder or pelvic pain VAS (PVAS) score, (0, no pain; 10, worst possible pain), and numerical patient-reported quality of life (QOL) index (0, highly satisfied; 6, highly dissatisfied). (Results) OSSI and OSPI improved from 11.7 to 10.1 (p<0.0001), and from 10.7 to 8.8 (p=0.01), respectively. The UVAS score significantly reduced from 6.4 to 4.8, and the PVAS score significantly improved from 6.5 to 4.8 (p<0.0001). The patient-reported QOL index significantly improved from 5.1 to 3.9 (p<0.0001). (Conclusion) Although repeated notes were taken and patients who were followed up for a long term were consulted on the meal, as appropriate, at the time of visit, DM was found to alleviate the symptoms of IC. DM as a systematic treatment modality for IC should be attempted more aggressively because of its non-invasiveness, without alterations to the other IC treatments.

Leukotriene D4 receptor antagonist montelukast alleviates protamine sulphate-induced changes in rat urinary bladder

What's known on the subject? and What does the study add? The mastocytosis in detrusor muscle and the leaky epithelium in interstitial cystitis were the most studied features. In this study the leaky epithelium was shown using the ruthenium red staining in electron microscopy and uroplakin distribution in light microscopy besides the mast cell concentration in detrusor muscle using tryptase immunohistochemistry.

OBJECTIVE

• To study the effects of montelukast (ML), a leukotriene receptor antagonist which has been shown to be effective in inhibiting the action of cysteinyl-containing leukotrienes, on protamine sulphate (PS)-induced changes in rat urinary bladder.

MATERIALS AND METHODS

• Wistar female rats were catheterized and intravesically infused with PBS (control group) or PS (PS group) dissolved in PBS twice in 24 h. • In the PS-applied and ML-treated group (PS + ML group) after the 10 mg/kg PS instillation, ML was injected i.p. twice daily for 3 days. • The urinary bladder was investigated for general morphology under a light microscope. • Tryptase immunohistochemistry was used to observe mast cell distribution and activation. Uroplakin distribution was also identified with immunohistochemistry.

RESULTS

• Alterations of glycosaminoglycan (GAG) and urothelial permeability were seen with ruthenium red (RR) staining techniques under a transmission electron microscope, and topographical changes of luminal urothelial structure were seen with a scanning electron microscope. • Biochemically malondialdehyde (MDA) and gluthatione (GSH) concentrations were analysed. In the PS group, there was degenerated urothelium with irregular uroplakin distribution, increased inflammatory cell infiltration, increased number of both granulated and activated mast cells, irregularity of GAG and penetration of RR into the intercellular spaces and dilated tight junctions. • In PS + ML group, there was relatively regular uroplakin distribution, a decrease in inflammatory cell infiltration, a decreased number of both activated and granulated mast cells in the mucosa, regular GAG and no penetration of RR into the intercellular areas, and regular tight junctions in most regions. • The significant decrease in MDA and the increased GSH concentrations in the PS + ML group was in accordance with the histological findings.

CONCLUSION

• Montelukast appears to have a protective function in the bladder injury model via the anti-inflammatory effects of this leukotriene receptor antagonist.

Taurine ameliorates stress-induced degeneration of the urinary bladder

We studied the potential effects of taurine, a free radical scavenger, on chronic water avoidance stress (WAS)-induced degeneration of the mucosa of the urinary bladder in experimental rats. Wistar albino rats were exposed to WAS for 2h/day, for 5 days (WAS group). Before exposing them to WAS, taurine (50mg/kg) (WAS+taurine group) was injected intraperitonally into the animals. Samples of urinary bladder were then investigated by light and scanning electron microscopy. Lipid peroxidation and gluthathione levels were also measured in the urinary bladder. In the WAS-only group, inflammatory cell infiltration, increased number of mast cells in the mucosa and ulcerated areas were observed. In the WAS+taurine group, relatively normal urothelial topography with microvilli, moderate inflammatory cell infiltration and decreased numbers of mast cells in the mucosa were observed. The increased lipid peroxidation and decreased glutathione levels in WAS rats were reversed by taurine treatment. We conclude that taurine protects against WAS-induced oxidant urinary bladder injury, and thus may be a possible therapeutic agent against interstitial cystitis, the symptoms of which are aggravated by stress conditions.

An aqueous garlic extract alleviates water avoidance stress-induced degeneration of the urinary bladder

OBJECTIVE

To investigate the role of aqueous garlic extract (AGE) on the water-avoidance stress (WAS)-induced degeneration of the urinary bladder in a rat model.

MATERIALS AND METHODS

Wistar albino rats were exposed to WAS for 2 h/day for 5 days (WAS group), after which, AGE (1 mL/kg) was injected intraperitoneally into the rats (WAS + AGE group). Urinary bladder samples were investigated with both light and scanning electron microscopy, and lipid peroxidation and glutathione levels were also measured in the samples.

RESULTS

In the WAS group there was inflammatory cell infiltration, more mast cells and ulcerated areas in the mucosa. In the WAS + AGE group there was relatively normal urothelial alignment, moderate inflammatory cell infiltration and fewer mast cells in the mucosa. The increased lipid peroxidation and decreased glutathione levels in WAS rats were reversed by AGE treatment.

CONCLUSIONS

These results show that AGE has a protective effect on WAS-induced degenerative changes in the urinary bladder.

Protective effects of taurine on protamine sulfate induced bladder damage

The present study was designed to investigate the putative protective effects of taurine on protamine sulfate (PS) induced bladder injury. Wistar albino female rats were catheterized and intravesically infused with phosphate buffered solution (control group) or PS (PS group) dissolved in phosphate buffered solution. In the PS + taurine (PS+Tau) group, after the PS instillation, taurine (50 mg/kg) was injected intraperitoneally for 3 days. Histopathological changes were investigated by light and scanning electron microscopy. Tissue samples were also obtained to determine bladder malondialdehyde (MDA) (a biomarker of oxidative damage) and glutathione (GSH) (a biomarker of protective oxidative injury) levels. In the PS group ulcerated areas, an irregular mucus layer, inflammatory cell infiltration, and increased number of mast cells were observed. In the PS+Tau group, a relatively normal urothelial topography, glycosaminoglycan layer, and decreased number of mucosal mast cells and inflammatory cells were observed. Increased MDA levels as a result of PS induction lead us to propose that free radicals may have a critical role in this injury. The significant decrease in MDA and increase in GSH levels in the PS+Tau group compared to PS group was in accordance with morphological findings. Based on the results, taurine treatment significantly prevented PS induced degenerative morphological and biochemical changes of urinary bladder mucosa.

Aqueous Garlic Extract Inhibits Protamine Sulfate-Induced Bladder Damage

This morphological and biochemical study aims to investigate the antioxidant effects of chronic administration of aqueous garlic extract (AGE) on protamine sulfate (PS)-induced bladder injury. Wistar albino female rats were catheterized and intravesically infused with phosphate-buffered solution (control group) or PS (PS group) dissolved in phosphate-buffered solution. In the PS + AGE group after the PS instillation, AGE (1 ml/kg, i.p., corresponding to 250 mg/kg) was injected intraperitoneally for 3 days. Bladder morphology was investigated by light and scanning electron microscopy. Tissue samples were also obtained to determine bladder malondialdehyde (MDA) and glutathione levels. In the PS group, ulcerated areas, an irregular mucus layer, inflammatory cell infiltration and an increased number of mast cells were observed. In the PS + AGE group a relatively normal urothelial topography, glycosaminoglycan layer and a decreased number of mucosal mast cells and inflammatory cells were observed. Increased MDA levels as a result of PS induction led us to propose that free radicals may have a critical role in this injury. The significant decrease in MDA and increase in glutathione levels in the PS + AGE group was in accordance with morphological findings. Based on the results, AGE treatment significantly prevented PS-induced degenerative morphological and biochemical changes of urinary bladder mucosa.

Painful bladder syndrome/interstitial cystitis

Painful bladder syndrome (PBS) is the term used to refer to a chronic symptom complex of urinary frequency and bladder 'pressure', discomfort or pain in the absence of any other reasonable cause for these symptoms (such as infection). Interstitial cystitis (IC) is the established term used by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) consensus workshop for which a research definition was formulated in the late 1980s. Opinion varies regarding not only definition but also the usefulness of diagnostic investigations such as urodynamic assessment and the potassium sensitivity test. There are still controversies concerning the most basic investigation of cystoscopy in PBS/IC. New developments in the study of PBS/IC include the identification of a potential urinary biomarker, antiproliferative factor (APF), which is produced by urothelial cells in IC and thought to inhibit proliferation. In addition, condition-specific validated questionnaires should aid evaluation, and a growing number of randomised controlled trials should enable clinicians to use evidence-based therapeutic options.

The ameliorating effect of melatonin on protamine sulfate induced bladder injury and its relationship to interstitial cystitis

PURPOSE

The pineal hormone melatonin was recently shown to have free radical scavenging ability and it reduces lipid peroxidation. In this morphological study we investigated the effects of melatonin on protamine sulfate (Sigma Chemical Co., St. Louis, Missouri) induced bladder injury.

MATERIALS AND METHODS

Albino Wistar female rats were catheterized and intravesically infused with phosphate buffered solution (control group) or protamine sulfate (bladder injury group) dissolved in phosphate buffered solution. In the protamine sulfate plus melatonin group after protamine sulfate instillation melatonin was injected intraperitoneally. Bladder morphology was investigated by light and electron microscopy. Tissue samples were also obtained to determine bladder malondialdehyde levels.

RESULTS

In the bladder injury group ulcerated areas, an irregular glycosaminoglycan layer, increased number of mast cells, vacuole formation, dilated perinuclear cistern, formation of pleomorphic and uniform microvilli, and dilated urothelial intercellular spaces were observed. In the bladder injury plus melatonin group a relatively normal urothelial topography, glycosaminoglycan layer and decreased number of mucosal mast cells, some dilatation between intercellular areas, less uniform microvilli and in most areas regular tight junctions were observed.

CONCLUSIONS

Increased malondialdehyde levels as a result of protamine sulfate induction lead us to propose that free radicals may have a critical role in this injury. The significant decrease in malondialdehyde levels in the protamine sulfate plus melatonin group was in accordance with morphological findings. Thus, melatonin appears to exert a urothelial protective activity in a bladder injury model.

Interstitial cystitis: the painful bladder syndrome

Interstitial cystitis (IC) is an enigmatic and frustrating condition to manage as a physician and to cope with as a patient. Many patients are declared as drug addicted and neurotic. Social status and number of sexual partners showed no correlation with incidence. Patients report moderate to excruciating pain in the suprapubic or vaginal area, urgency and frequency (up to 50 micturitions/d), and disruption of their social life. Diagnosis of IC is made by exclusion. Different pathophysiologic mechanisms have been proposed: changes in epithelial permeability, pelvic floor dysfunction, mastocytosis, activation of c-fibers, and increase of nerve growth factors and bradykinin. No single theory can explain IC.

Intravesical hyaluronic acid in the treatment of refractory interstitial cystitis

OBJECTIVES

On the assumption that interstitial cystitis (IC) is the result of a defective mucous lining of the bladder epithelium, a study was carried out to investigate the activity of hyaluronic acid (HA) in the treatment of IC. HA is an important glycosaminoglycan (GAG) present in all connective tissues, including the GAG layer of the vesical mucosa. It exhibits a variety of pharmacologic properties that enhance its appeal for the therapy of IC.

METHODS

A total of 25 patients, with the characteristic picture of IC and refractory to other medical treatments, participated in a trial of HA. Patients received 40 mg of HA intravesically on a weekly basis for 4 weeks, then monthly. Response to therapy was evaluated by symptom score, voiding diaries, and visual analog scales.

RESULTS

An initial positive (complete+partial) response of 56% at week 4 increased to 71% by week 12. This response was maintained until week 20; beyond week 24 there appears to be a moderate decrease in the effectiveness of the medication. There was no significant toxicity attributable to the presence of HA in the bladder.

CONCLUSIONS

The response of refractory IC patients to the intravesical administration of HA was gratifying. In the past, many therapies for IC that were initially considered promising failed the test of a controlled study. Further studies will establish the effectiveness of this particular preparation of HA in the treatment of IC.

Interstitial cystitis: a critique of current concepts with a new proposal for pathologic diagnosis and pathogenesis

Interstitial cystitis (IC) has continued to be an unresolved problem in clinical urology despite intense investigation over the past 16 or more years. Its etiology and pathogenesis are still undetermined, and its pathologic diagnosis is essentially one of exclusion, with no specific or clear criteria. In this review, current concepts of the etiology/pathogenesis and pathology are critically analyzed, new pathologic observations summarized, and a proposal of neurogenic inflammation as the primary pathogenetic factor is presented in the context of all currently available information. The popular postulate attributing IC to a deficient or defective glycosaminoglycan urothelial surface layer is not substantiated by morphologic, experimental, clinical, or therapeutic observations. Although the consensus seems to discount an infectious etiology, there is sufficient evidence that a microbial factor-short of a bona fide clinical infection-may have a role. Both autoimmunity and mast cell infiltration also appear to have a role, despite the lack of evidence that either is involved as the primary etiologic factor. Claims that the so-called feline urologic syndrome may represent a natural animal model of IC are shaky. As it now stands, there is no natural or induced animal model that duplicates IC as it occurs in humans. No specific or diagnostic light microscopic pathologic features are provided by either routine histopathology or immunohistochemistry. Increasingly, it has been recognized that detrusor mast cell count has little or no diagnostic value. On the other hand, electron microscopy has provided important new observations: (a) presence of mast cells, activated by piecemeal degranulation, in close proximity to intrinsic nerves-particularly in suburothelium: (b) distinctive pathologic changes in urothelium, suburothelium, and muscularis in biopsy samples obtained after diagnostic bladder hydrodistension; (c) constant associated changes in venules, capillaries, and neural elements in the same biopsy samples; and (d) diffuse involvement of bladder wall, with the most evident and profound pathologic changes in posthydrodistension biopsy samples obtained from cystoscopically obvious lesions (glomerulations). These features are sufficiently distinctive to allow definitive pathologic diagnosis of IC, and provide a firm basis for primary involvement of neurogenic inflammation in its pathogenesis. A proposal is presented regarding the mechanisms invoked by neurogenic inflammation. This proposal revolves around sensory nerve excitation, the release of neuropeptides, and activated differential secretion of potent mast cell mediators. This proposal can account for the heterogeneity and variability of observed pathologic features, and upholds the tacit acceptance of IC as a disease of pluricausal etiology and multifactorial pathogenesis.

[Light- and electron-microscopic studies of the structure of normal bladder epithelium in female swine]

A light- and electron-microscope investigation was performed to examine the normal structure of the porcine urinary bladder. Tissue biopsies were studied obtained from 10 healthy female pigs (four weanling pigs, six sows). The bladder wall showed a typical stratification consisting of a tunica (t.) mucosae, t. submucosae, t. muscularis and t. serosa. The mucosa consisted of an epithelium transitionale, a lamina propria, and a lamina muscularis mucosae. The urothelium was composed of a basal layer, one or more intermediate layer(s), and a superficial layer. The urothelial cells of all layers were connected by desmosomes, while tight junctions linked adjacent superficial cells. Surface cells were lined by a layer of mucus, which is believed to provide an important barrier against bacterial infection. The surface of the superficial cells was also characterized by numerous irregularly arranged microplicae. By contrast, intermediate cells, which are assumed to be immature cell forms, showed microvilli-like structures. When desquamation of superficial cells takes place, differentiation of underlying intermediate cells is accompanied by merging of microvilli to form microplicae. The morphology of the bladder surface structures may play an important role in the ability of bacteria to adhere to the urothelium.

Is interstitial cystitis an infectious disease?

Interstitial cystitis (IC) is manifest by years of urinary frequency, urgency, and bladder pain and on cystoscopy, is diagnosed by petechial hemorrhages or ulcers. The etiology is unknown; the prominent theories are that IC is an autoimmune disease or is linked to increased permeability of the bladder mucosa. Although sought, no infectious agent has ever been identified. The disease has many characteristics of a chronic infection and the author's opinion is that an infectious disease has not been properly ruled out. To do so would require culture of bladder epithelium (not just urine) using special culture and non-culture techniques such as polymerase chain reaction. Infection can easily be integrated into the autoimmune and permeability theories of IC pathogenesis. A possible analogue for this disease is chronic gastritis in which Helicobacter pylori has been identified as an etiological agent.

Interleukin-6 and interstitial cystitis

We analyzed the presence of the cytokine interleukin-6 in urine samples from interstitial cystitis patients. Interleukin-6 was significantly elevated in patients with interstitial cystitis (169.29 +/- 90.81 pg./ml. versus 34.8 +/- 6.35 pg./ml. in controls). Representative urine samples were analyzed with specific antibody to interleukin-6 and greater than 80% of the biological activity was neutralized. These cytokine measurements were then compared with clinical parameters and interleukin-6 levels correlated positively with the pain scores. Studies on the potential cellular origin of interleukin-6 showed increased levels in spontaneously voided urine but not in ureteral urine, which was collected during cystoscopy, suggesting that interleukin-6 is the product of activated cells in the bladder. This finding is supported by in situ hybridization analyses, which showed that interleukin-6 messenger ribonucleic acid expressing cells are located in the interstitium and epithelial layer, and within blood vessels. The implications of these findings for interstitial cystitis pathogenesis are discussed.

Treatment of interstitial cystitis with intravesical heparin

OBJECTIVE

To control the symptoms of interstitial cystitis with chronic self-administered intravesical heparin and determine whether the drug's continued use can sustain remission.

PATIENTS AND METHODS

A total of 48 patients were selected to undergo intravesical heparin therapy, 10,000 units in 10 ml sterile water, three times per week for 3 months. For patients who attained a good clinical remission, therapy was available for up to a further 9 months.

RESULTS

At 3 months 27 of 48 patients (56%) attained good clinical remissions. All were offered continuous therapy and 23 elected for an additional 3 months. Twenty of the 23 continued in remission. Sixteen of these patients elected to have a further 6 months of therapy (12 months total) and 15 of 16 remained in remission.

CONCLUSION

In over half of the patients studied, intravesical heparin controls the symptoms of interstitial cystitis with continued improvement even after one year of therapy.

Bladder permeability in interstitial cystitis is similar to that of normal volunteers: direct measurement by transvesical absorption of 99mtechnetium-diethylenetriaminepentaacetic acid

Bladder permeability was directly measured with the radionuclide used clinically for detecting vesicoureteral reflux (99mtechnetium-diethylenetriaminepentaacetic acid, 99mTc-DTPA) in 10 interstitial cystitis patients diagnosed according to National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases criterion and compared to 9 sex matched, symptom-free, normal volunteers. After functional bladder capacity was determined (capacity at which the patient demands fluid inflow to stop), the bladder was emptied and 5 mCi. 99mTc-DTPA in 10 ml. of saline were infused followed by normal saline to 80% of functional capacity. This was done to normalize the patients to the same low bladder pressure, since previous studies of rabbits indicated that bladder permeability is low and not significantly different at 20% and 60% of anesthetized bladder capacity (defined as the volume producing an intravesical pressure of 20 cm. water). Radioactivity of 1 ml. serum specimens taken at 0, 2, 15 and 30 minutes after radionuclide infusion was determined in a gamma counter, corrected for radioactive decay and converted to per cent of instilled dose per whole body based on blood volume estimated from body weight for each individual. There was considerable interindividual variability in the absorption between the patients and the volunteers. Analysis of variance of these data showed no statistically significant difference between the patients and controls at any time sampled. These results indicate that while some interstitial cystitis patients have a more permeable bladder than others, the same is true for normal, symptom-free volunteers. Thus, the concept of increased bladder permeability in interstitial cystitis is not supported by this direct measurement of bladder permeability.

A model for the function of glycosaminoglycans in the urinary tract

Investigations into the antibacterial defense mechanisms of the urinary tract revealed an important function for cell surface glycosaminoglycans (GAG), that of a generalized antiadherent activity. This activity was found to prevent bacterial, protein, and ionic adherence to the cell membrane. A model was developed to explain mechanically the activity of sulfated polysaccharides at the bladder surface. The model predicted injurious effects of quaternary amines and also that the mucus would be the so-called blood-urine barrier. It also led to the hypothesis that exogenous polysaccharides may be important in treating bladder disease such as infection and interstitial cystitis. For the first clinical test of these concepts, a polysaccharide was employed in several double-blind studies and was shown to ameliorate significantly the symptoms of interstitial cystitis. These discoveries suggest new methods to manipulate the microenvironment between the transitional cell surface and the urine, leading to novel therapies in regulating disease of the genitourinary tract. They also stress the importance of understanding the mechanisms by which GAGs exert their effect in the urinary tract and how they are produced, maintained, and even inactivated (e.g., by urinary substances such as protamine).

Effect of repeated instillation of interstitial cystitis urine on the rabbit urinary bladder

One theory for the etiology of interstitial cystitis (IC) proposes toxic substances in the urine. This hypothesis was tested in our laboratory by infusing urine into the bladders of rabbits twice weekly for six weeks. For the first study rabbits were treated by one-hour biweekly intravesical exposure to urine from a symptomatic interstitial cystitis patient, a normal volunteer, or physiologic saline. For the second study, animals were exposed to both a high and a low molecular weight fraction of urine pooled from 7 interstitial cystitis patients, 7 normal female volunteers, and physiologic saline. At the end of six weeks the animals were cystoscoped and the bladder was removed the following day for histologic and contractile studies. Post-distention glomerulations were observed in 3 of the 4 whole IC urine-treated animals and an ulcer identical to the classic "Hunner's ulcer" was seen in one of these animals. Post-distention petechial hemorrhages were also noted in all 5 of the high molecular weight IC urine-treated animals but in none of the others, suggesting a difference between IC and normal urine. These IC urine-treated groups also showed the greatest degree of histologic changes including edema and plasma cell infiltrates in the lamina propria, submucosa and perivascular tissue. However, there was no statistically significant difference in bladder capacity, micturition patterns, or contractile response of bladder strips. These results indicate that there are substances with nominal molecular weight greater than 10 kD in interstitial cystitis urine that induce changes in the rabbit bladder that resemble bladders of interstitial cystitis patients.

The bladder mucus (glycosaminoglycan) layer in interstitial cystitis

The thin mucus or glycosaminoglycan layer of the bladder may be implicated in the pathogenesis of interstitial cystitis. We developed a specific anti-mucus, antisera stabilization technique to study the ultrastructural morphological appearance of the layer, and have used this technique to compare the surface morphology of 10 control and 10 interstitial cystitis patients. The electron micrographs demonstrate the ultrastructural characteristics of the pathological changes seen in interstitial cystitis but they did not show any significant difference in the morphological appearance of the mucus or glycosaminoglycan layer between the 2 groups.

Failure of combined supratrigonal cystectomy and Mainz ileocecocystoplasty in intractable interstitial cystitis: is histology and mast cell count a reliable predictor for the outcome of surgery?

Eight women with severe intractable interstitial cystitis were treated with supratrigonal cystectomy and Mainz ileocecocystoplasty. The preoperative evaluation consisted of symptom analysis, cystometry, cystoscopy and bladder pathological findings. Seven patients had increased mast cell density. Median followup was 10 months. The symptoms resolved in 2 patients but recurred in 6 shortly after the operation. Voiding could not be established in 4 patients. Self-catheterization was difficult and painful. Ultimately, cystectomy and urinary diversion were performed in 5 patients and is scheduled in 1. The 2 cured patients had a small contracted bladder preoperatively while they were under anesthesia, while all 6 failed cases had a large bladder capacity. Postoperative biopsies from the trigone showed no difference in the amount of fibrosis, the degree of degenerative changes in the muscle and mast cell density between the 2 cured patients and the 6 who failed to improve. The mast cell density and the histological status of the trigone cannot be used as predictors of the outcome of supratrigonal cystectomy. The role of the mast cells in interstitial cystitis is reviewed. Combination of supratrigonal cystectomy and a Mainz augmentation cystoplasty cannot be recommended in patients with intractable interstitial cystitis and a large bladder capacity.