Risk of Autoimmune Diseases in Patients With Interstitial Cystitis/Bladder Pain Syndrome: A Nationwide Population-Based Study in Taiwan

Innovative applications of natural polysaccharide polymers in intravesical therapy of bladder diseases

Natural polysaccharide polymers, characterized by their remarkable biocompatibility, biodegradability, and structural versatility, hold great promise for intravesical therapy in treating of bladder diseases. Conditions such as bladder cancer and interstitial cystitis compromise drug efficacy by affecting the permeability of the bladder wall. Traditional therapeutic approaches are often hindered by physiological challenges, including rapid drug clearance and the intrinsic permeability barrier of the bladder. Polysaccharides like hyaluronic acid (HA) and chitosan (CS) have emerged as promising materials for intravesical drug delivery systems (IDDS), owing to their ability to repair tight junctions in the bladder wall, mitigate inflammation, and enhance permeability. This review provides a comprehensive overview of the mechanisms through which polysaccharide-based natural polymers regulate bladder wall permeability and highlights their advancements in delivery platforms, including nanoparticles, hydrogels, floating systems, and composite materials. By improving drug retention, enhancing bioavailability, and promoting patient adherence, these materials offer a solid foundation for the development of innovative therapeutic strategies for bladder diseases.

Causal role of common autoimmune diseases in interstitial cystitis/bladder pain syndrome: Mendelian randomization (MR) study

Observational studies suggest that interstitial cystitis/bladder pain syndrome (IC/BPS) indices might be influenced by autoimmune diseases (AIDs), though it is difficult to infer causal relationships based on observational data due to risk of residual confounding. We utilized Mendelian randomization (MR) to explore causal relevance of multiple AIDs on IC/BPS. Our bidirectional two-sample MR analysis was based on summary statistics from the most recent and comprehensive genome-wide association studies. This particular approach was used to delve into the relationships of cause and effect between IC/BPS and a group of 14 AIDs. We examined a range of AIDs such as ulcerative colitis, Crohn disease, celiac disease, Sjogren syndrome, rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, primary biliary cirrhosis, psoriasis, asthma, eczema, ankylosing spondylitis, type 1 diabetes, and primary sclerosing cholangitis. Our primary analytical approach involved using the inverse variance weighting method to establish causal relationships across various AIDs and IC/BPS conditions. Furthermore, we carried out additional examinations, such as utilizing the weighted median technique, MR-Egger regression, MR-PRESSO, and evaluating reverse causality, in order to strengthen the dependability of our results. Our findings indicate a strong association between genetically predicted asthma and the risk of developing IC/BPS with a weighted odds ratio of 1.692, a confidence interval of 1.147 to 2.496, and P = .008, while the Cochran Q test P = .589 and the MR-Egger intercept test P = .554, MR-PRESSO global test P = .600. No evidence was found for causal relationships between other AIDs and IC/BPS. Individuals with asthma show an increased vulnerability to IC/BPS according to our findings. More randomized controlled trials are necessary to validate these results. These results underscore the importance for healthcare providers to assess the potential risk in asthma patients, offering a novel genetic perspective on studying interstitial cystitis.

IC/BPS is not associated with bladder cancer: a nationwide propensity score matched cohort study in Taiwan

PURPOSE

Previous studies have reported an increased risk of bladder cancer (BC) in IC/BPS patients. In this study, we re-examined the BC risk in a population based IC/BPS cohort to assess the potential detection bias caused by some IC/BPS patients diagnosed who might already have co-existing BC.

METHODS

We performed a retrospective cohort study based on a Research Database by extracting IC/BPS patients diagnosed within years 2002-2013. The patients in the study cohorts were identified based on at least 2 IC/BPS diagnoses and excluded patients with BC occurred before IC/BPS diagnosis. The primary outcome was BC events detected. Propensity scores (PSs) were calculated for matching IC/BPS cohort with non-IC/BPS cohort on a 1:1 basis. Cox proportional hazard regression analysis was then used to compare hazard ratios of BC development between 2 cohorts.

RESULTS

By excluding patients with BC diagnosed within 1 year after IC/BPS diagnosis, the study cohort was insignificantly different from the PS-matched control (Model 1, p = 0.219) but significantly different from the non-PS-matched control (Model 2, p < 0.001). However, when including patients with BC diagnosed within 1 year after IC/BPS diagnosis, the study cohort was significantly different from both PS-matched (Model 3, p = 0.002) and non-PS-matched (Model 4, p < 0.001) controls, indicating that excluding patients with BC diagnosed within 1 year after IC/BPS diagnosis and adopting PS matching method greatly reduce the BC detection bias.

CONCLUSIONS

IC/BPS is not associated with BC. The detection bias of previous studies may result from inadequate recruitments of study cohorts or improper matching of control cohorts.

A genome-wide cross-trait analysis identifying shared genetic basis and causal relationships between Hunner-type interstitial cystitis and autoimmune diseases in East Asian populations

PURPOSE

Epidemiological studies have demonstrated the clinical link between Hunner interstitial cystitis (HIC) and autoimmune diseases (ADs), suggesting potential shared genetic bases for their comorbidity. We aimed to investigate the shared genetic architecture and causal relationships between HIC and ADs.

METHODS

We conducted a genome-wide cross-trait study with ~170000 individuals of East Asian ancestry to investigate the shared architecture between HIC and ADs. Bidirectional Mendelian randomization (MR) was used to assess potential causal relationships and a multi-trait analysis of GWAS (MTAG) was conducted to identify their associated pleiotropic loci. Fine-mapping analysis narrowed candidate gene susceptibility loci and colocalization analysis was performed to identify shared variants at specific locus. Lastly, transcriptome-wide association (TWAS) and functional analysis were utilized to explore potential shared gene-tissue associations.

RESULTS

Through bidirectional MR analysis, we observed a positive causal effect of AIH(ORIVW=1.09, PIVW=1.00×10-3) and RA (ORIVW=1.47, PIVW<1.00×10-4) on HIC and a negative causal effect of UC on HIC (ORIVW=0.89, PIVW< 1.00×10-4). Furthermore, we unveiled a robust positive causal effect of HIC on T1D(ORConMix=1.05, PConMix=1.77×10-3). Cross-trait meta-analysis identified a total of 64 independent SNPs associated with HIC and ADs. Functional analysis revealed that the identified variants regulated gene expression in major tissues belonging to the autoimmune system.

CONCLUSIONS

Our findings might offer insights into the shared underlying etiology of HIC and ADs.

Definition Change and Update of Clinical Guidelines for Interstitial Cystitis and Bladder Pain Syndrome

The clinical guidelines for interstitial cystitis (IC) and bladder pain syndrome (BPS) have been revised by updating our previous guidelines. The symptoms of IC and BPS, collectively called as hypersensitive bladder (HSB) symptoms, are virtually indistinguishable between IC and BPS; however, IC and BPS should be considered as a separate entity of disorders. We define IC as a bladder disease with Hunner lesions, usually associated with HSB symptoms and bladder inflammation, and BPS as a condition with HSB symptoms in the absence of Hunner lesions and any confusable diseases. Pathophysiology totally differs between IC and BPS. IC involves immunological inflammation probably resulting from autoimmunity, while BPS is associated with the interaction of multiple factors such as neurogenic inflammation, exogenous substances, urothelial defects, psychological stress, and neural hyperactivity. Histopathology also differs between IC and BPS. IC is associated with severe inflammation of the whole bladder accompanied by plasma cell infiltration and urothelial denudation, while BPS shows little pathological changes. Management should begin with a differential diagnosis of IC or BPS, which would require cystoscopy to determine the presence or absence of Hunner lesions. The patients should be treated differently based on the diagnosis following the algorithm, although pain management would be common to IC and BPS. Clinical studies are also to be designed and analyzed separately for IC and BPS.

Beyond the urothelium: Interplay between autonomic nervous system and bladder inflammation in urinary tract infection, bladder pain syndrome with interstitial cystitis and neurogenic lower urinary tract dysfunction in spinal cord injury-ICI-RS 2023

INTRODUCTION

Inflammation and neuronal hypersensitivity are reactive protective mechanisms after urothelial injury. In lower urinary tract dysfunctions (LUTD), such as urinary tract infection (UTI), bladder pain syndrome with interstitial cystitis (BPS/IC) and neurogenic LUTD after spinal cord injury (SCI), chronic inflammation can develop. It is unclear how the protective reactionary inflammation escalates into chronic disease in some patients.

METHODS

During its 2023 meeting in Bristol, the International Consultation on Incontinence-Research Society (ICI-RS) reviewed the urothelial and inflammatory changes after UTI, BPS/IC and SCI. Potential factors contributing to the evolution into chronic disease were explored in a think-tank.

RESULTS

Five topics were discussed. (1) Visceral fat metabolism participates in the systemic pro-inflammatory effect of noradrenalin in BPS/IC and SCI. Sympathetic nervous system-adipocyte-bladder crosstalk needs further investigation. (2) Sympathetic hyperactivity also potentiates immune depression in SCI and needs to be investigated in BPS/IC. Gabapentin and tumor necrosis factor-α are promising research targets. (3) The exact peripheral neurons involved in the integrative protective unit formed by nervous and immune systems need to be further identified. (4) Neurotransmitter changes in SCI and BPS/IC: Neurotransmitter crosstalk needs to be considered in identifying new therapeutic targets. (5) The change from eubiosis to dysbiosis in SCI can contribute to UTI susceptibility and needs to be unraveled.

CONCLUSIONS

The think-tank discussed whether visceral fat metabolism, immune depression through sympathetic hyperactivity, peripheral nerves and neurotransmitter crosstalk, and the change in microbiome could provide explanations in the heterogenic development of chronic inflammation in LUTD. High-priority research questions were identified.

Latest insights into the pathophysiology of bladder pain syndrome/interstitial cystitis

PURPOSE OF REVIEW

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a common medical problem in both sexes affecting people of all ages. Patients might report overactive bladder symptoms with additional bladder pain at maximum bladder filling, during and after micturition. This review aims to highlight pathophysiological mechanisms associated with this disease.

RECENT FINDINGS

Latest literature exposes different pathophysiological mechanisms such as impaired urothelial barrier function, alteration of urothelial factors and cytokines, chronic inflammation, vascular lesions, neurogenic inflammation and processes in the central nervous system leading to central sensitization. According to the involved mechanisms, BPS/IC may be arranged in clusters according to the clinical phenotype thus helping in clinical decision-making and treatment. Moreover, patients with BPS/IC suffer from other comorbidities such as fibromyalgia, irritable bowel syndrome, chronic pain and functional syndromes and psychosomatic diseases making the management challenging for medical professionals.

SUMMARY

Bladder pain syndrome/interstitial cystitis is a complex heterogeneous medical condition involving different pathomechanisms leading to bladder pain and dysfunction, consequently, impairing quality-of-life in affected individuals. However, these mechanisms are still not fully understood, so that patient treatments often remain unsatisfactory. For this reason, continuing research is important to understand the underlying pathomechanisms to discover biomarkers and treatment targets eventually improving diagnostic and therapeutic measures of BPS/IC.

Risk of uveitis in autoimmune diseases patients treated with hydroxychloroquine: A population-based retrospective cohort study

OBJECTIVE

Uveitis is a common manifestation of various autoimmune diseases and can lead to severe visual impairment. Hydroxychloroquine (HCQ) is an antimalarial drug that is also used to treat autoimmune diseases. The aim of this study was to investigate the association between HCQ use and the incidence of uveitis in patients with autoimmune diseases, as well as to identify potential risk factors for the development of uveitis in this study.

METHODS

We conducted a population-based cohort study using a nationwide database to investigate the incidence of uveitis in patients with autoimmune diseases who received HCQ treatment. We selected non-HCQ comparison cohort at a 1:1 ratio by propensity score matching on age, sex, index date, urbanization, income, comorbidities, and medications. The data were analyzed using Cox proportional hazards models, and propensity score matching (PSM) was used to reduce selection bias.

RESULTS

Our study included 15 822 patients with autoimmune diseases. After 1:1 PSM, there were 4555 individuals in both the HCQ group (n = 4555) and the non-HCQ group (n = 4555). The multiple Cox proportional hazard regression analysis was used for the estimation of adjusted hazard ratios on uveitis. After PSM, the adjusted hazard ratio for the HCQ group was 0.74 (95% CI = 0.58-0.95). These findings suggest that HCQ may play a protective role in reducing the risk of uveitis in patients with autoimmune diseases, including rheumatoid arthritis, Sjogren's syndrome, and systemic lupus erythematosus groups. The Kaplan-Meier survival curves also showed a significantly lower incidence of uveitis in the HCQ group (log-rank = 0.0229) after PSM.

CONCLUSION

HCQ use is associated with a lower incidence of uveitis in patients with autoimmune diseases. Further studies are needed to confirm this association and to investigate the underlying mechanisms.

The Model of Interstitial Cystitis for Evaluating New Molecular Strategies of Interstitial Regeneration in Humans

Given the recent evidence in the clinical application of regenerative medicine, mostly on integumentary systems, we focused our interests on recent bladder regeneration approaches based on mesenchymal stem cells (MSCs), platelet-rich plasma (PRP), and hyaluronic acid (HA) in the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) in humans. IC/BPS is a heterogeneous chronic disease with not-well-understood etiology, characterized by suprapubic pain related to bladder filling and urothelium dysfunction, in which the impairment of immunological processes seems to play an important role. The histopathological features of IC include ulceration of the mucosa, edema, denuded urothelium, and increased detection of mast cells and other inflammatory cells. A deeper understanding of the molecular mechanism underlying this disease is essential for the selection of the right therapeutic approach. In fact, although various therapeutic strategies exist, no efficient therapy for IC/BPS has been discovered yet. This review gives an overview of the clinical and pathological features of IC/BPS, with a particular focus on the molecular pathways involved and a special interest in the ongoing few investigational therapies in IC/BPS, which use new regenerative medicine approaches, and their synergetic combination. Good knowledge of the molecular aspects related to stem cell-, PRP-, and biomaterial-based treatments, as well as the understanding of the molecular mechanism of this pathology, will allow for the selection of the right and best use of regenerative approaches of structures involving connective tissue and epithelia, as well as in other diseases.

Progress and challenges in intravesical drug delivery

INTRODUCTION

Intravesical drug delivery (IDD) has gained recognition as a viable approach for treating bladder-related diseases over the years. However, it comes with its set of challenges, including voiding difficulties and limitations in mucosal and epithelial penetration. These challenges lead to drug dilution and clearance, resulting in poor efficacy. Various strategies for drug delivery have been devised to overcome these issues, all aimed at optimizing drug delivery. Nevertheless, there has been minimal translation to clinical settings.

AREAS COVERED

This review provides a detailed description of IDD, including its history, advantages, and challenges. It also explores the physical barriers encountered in IDD, such as voiding, mucosal penetration, and epithelial penetration, and discusses current strategies for overcoming these challenges. Additionally, it offers a comprehensive roadmap for advancing IDD into clinical trials.

EXPERT OPINION

Physical bladder barriers and limitations of conventional treatments result in unsatisfactory efficacy against bladder diseases. Nevertheless, substantial recent efforts in this field have led to significant progress in overcoming these challenges and have raised important attributes for an optimal IDD system. However, there is still a lack of well-defined steps in the workflow to optimize the IDD system for clinical settings, and further research is required to establish more comprehensive in vitro and in vivo models to expedite clinical translation.

Th1/17 polarization and potential treatment by an anti-interferon-γ DNA aptamer in Hunner-type interstitial cystitis

Hunner-type interstitial cystitis (HIC) is a rare, enigmatic inflammatory disease of the urinary bladder with no curative treatments. In this study, we aimed to characterize the unique cellular and immunological factors specifically involved in HIC by comparing with cystitis induced by Mycobacterium bovis bacillus Calmette-Guérin, which presents similar clinicopathological features to HIC. Here, we show that T helper 1/17 +polarized immune responses accompanied by prominent overexpression of interferon (IFN)-γ, enhanced cGAS-STING cytosolic DNA sensing pathway, and increased plasma cell infiltration are the characteristic inflammatory features in HIC bladder. Further, we developed a mouse anti-IFN-γ DNA aptamer and observed that the intravesical instillation of the aptamer significantly ameliorated bladder inflammation, pelvic pain and voiding dysfunction in a recently developed murine HIC model with little migration into the blood. Our study provides the plausible basis for the clinical translation of the anti-IFN-γ DNA aptamer in the treatment of human HIC.

Genome-wide association study identifies risk loci within the major histocompatibility complex region for Hunner-type interstitial cystitis

Hunner-type interstitial cystitis (HIC) is a rare, chronic inflammatory disease of the urinary bladder with unknown etiology and genetic background. Here, we conduct a genome-wide association study of 144 patients with HIC and 41,516 controls of Japanese ancestry. The genetic variant, rs1794275, in the major histocompatibility complex (MHC) region (chromosome 6p21.3) is associated with HIC risk (odds ratio [OR] = 2.32; p = 3.4 × 10^-9). The association is confirmed in a replication set of 26 cases and 1,026 controls (p = 0.014). Fine mapping demonstrates the contribution to the disease risk of a completely linked haplotype of three human leukocyte antigen HLA-DQβ1 amino acid positions, 71, 74, and 75 (OR = 1.94; p = 5 × 10^-8) and of HLA-DPβ1 amino acid position 178, which tags HLA-DPB1∗04:02 (OR = 2.35; p = 7.5 × 10^-8). The three HLA-DQβ1 amino acid positions are located together at the peptide binding groove, suggesting their functional importance in antigen presentation. Our study reveals genetic contributions to HIC risk that may be associated with class II MHC molecule antigen presentation.

INTERSTITIAL CYSTITIS AS A PLAUSIBLE CAUSE OF OVERACTIVE BLADDER IN SYSTEMIC SCLEROSIS: A HYPOTHESIS

Patients with chronic inflammatory disease of the bladder, known as interstitial cystitis (IC), tend to have autoimmune diseases, such as Sjogren’s syndrome, systemic lupus erythematosus (SLE), rheumatoid arthritis and, rarely, systemic sclerosis (SSc). SLE patients with IC are prone to present with overactive bladder (OAB) symptoms. Lower urinary tract involvement is less usual in SSc but OAB symptoms are quite common among SSc patients with lower urinary tract involvement. The underlying mechanisms of lower urinary tract involvement, including OAB, in SSc could be as follows: i) vasculopathy, ii) fibrosis and/or sclerosis of bladder wall, iii) systemic sclerosis-associated myopathy, and iv) autonomic dysfunction. However, the role of IC leading to OAB is unclear. This hypothesis suggests that in patients with SSc, OAB may be associated with IC.

Monoclonal Antibody Therapy for the Treatment of Interstitial Cystitis

An emerging theory regarding the potentially autoimmune nature of painful bladder syndrome/interstitial cystitis (PBS/IC) had led to several studies being conducted to assess the possible therapeutic effect of immunotherapeutic options for PBS/IC. This review presents the available evidence regarding the potential autoimmunity-based pathogenesis of PBS/IC and focuses on a main representative of the immunotherapeutic modalities for PBS/IC, aiming to summarize, evaluate, and present available data regarding the potential therapeutic role of monoclonal antibodies for PBS/IC patients. A non-systematic narrative and interpretative literature review was performed. The monoclonal antibodies included in the review were the anti-tumor necrosis factor-α (anti-TNF-α) agents adalimumab, which showed no difference compared to placebo, and certolizumab pegol, which showed statistically important differences in all outcome measures compared to placebo at the 18-week follow-up visit. Anti-nerve growth factor (anti-NGF) agents were also reviewed, including tanezumab, which showed both positive and negative efficacy results compared to placebo, and fulranumab, the study of which was discontinued owing to adverse events. In summary, monoclonal antibody therapy remains to be further researched in order for it to be proposed as a promising future treatment option for PBS/IC.

Biomarkers in the Light of the Etiopathology of IC/BPS

In this review, we focused on putatively interesting biomarkers of interstitial cystitis/bladder pain syndrome (IC/BPS) in relation to the etiopathology of this disease. Since its etiopathology is still under discussion, the development of novel biomarkers is critical for the correct classification of the patients in order to open personalized treatment options, on the one hand, and to separate true IC/BPS from the numerous confusable diseases with comparable symptom spectra on the other hand. There is growing evidence supporting the notion that the classical or Hunner-type IC (HIC) and the non-Hunner-type IC (NHIC) are different diseases with different etiopathologies and different pathophysiology at the full-blown state. While genetic alterations indicate close relationship to allergic and autoimmune diseases, at present, the genetic origin of IC/BPS could be identified. Disturbed angiogenesis and impairment of the microvessels could be linked to altered humoral signaling cascades leading to enhanced VEGF levels which in turn could enhance leucocyte and mast cell invasion. Recurrent or chronic urinary tract infection has been speculated to promote IC/BPS. New findings show that occult virus infections occurred in most IC/BPS patients and that the urinary microbiome was altered, supporting the hypothesis of infections as major players in IC/BPS. Environmental and nutritional factors may also influence IC/BPS, at least at a late state (e.g., cigarette smoking can enhance IC/BPS symptoms). The damage of the urothelial barrier could possibly be the result of many different causality chains and mark the final state of IC/BPS, the causes of this development having been introduced years ago. We conclude that the etiopathology of IC/BPS is complex, involving regulatory mechanisms at various levels. However, using novel molecular biologic techniques promise more sophisticated analysis of this pathophysiological network, resulting in a constantly improvement of our understanding of IC/BPS and related diseases.