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The autoimmune features of interstitial cystitis are reviewed. Despite some controversy, interstitial cystitis should be grouped to the connective tissue diseases but as a separate entity.
We report a case of intractable hemorrhagic cystitis due to cyclophosphamide therapy for Wegener's granulomatosis. Conservative treatment, including bladder irrigation with physiological saline and instillation of prostaglandin F2 alpha, failed to totally control hemorrhage. We then used hyperbaric oxygen at an absolute pressure of 2 atm, 5 days a week for 8 consecutive weeks. The bleeding ceased completely by the end of treatment and the patient remained free of hematuria thereafter. No side effect was noted during the course of therapy. In future, this form of therapy can offer a safe alternative in the treatment of cyclophosphamide-induced hemorrhagic cystitis.
Six female patients with radiation cystitis, induced by previous pelvic radiation to uterus cancer, were treated with hyperbaric oxygenation (30-35% of oxygen concentration at 2 atmospheric absolute pressures for 90-120 min daily from 20 to 61 days with the average of 45 +/- 7 days, mean +/- standard error). Except in 1 patient symptoms and cystoscopic findings were improved. No side effects were found. Recurrence of radiation cystitis never occurred during the follow-up period (1.0 +/- 0.1 years). Hyperbaric oxygenation treatment in this pressure environment appears to have a beneficial effect of this disorder.
Prolonged bladder distension continues to be recommended for the treatment of detrusor instability and other bladder conditions. We have reviewed our experience of the technique. A total of 45 patients have undergone 50 procedures. Only 1 of 29 patients with detrusor instability had sustained improvement. 6 of 7 patients with interstitial cystitis noted improvement, sustained in 3. All the other patients noted some improvement. There was a 20% complication rate. 33 (75%) of the living patients returned questionnaires with 27% feeling that the operation was worthwhile. We feel that prolonged distension of the bladder is unhelpful in the treatment of patients with detrusor instability. Its place in the management of patients with interstitial cystitis and irritative symptoms remains controversial. The place of simple bladder distension should be considered.
Haemorrhagic cystitis following radiotherapy is fortunately relatively uncommon. When it does present it represents a therapeutic challenge. We have managed 14 patients with haemorrhagic cystitis of varying severity with sodium pentosanpolysulphate. Complete control of haematuria was achieved in 10 patients and partial control in 3 patients. This medication is effective, safe and merits further investigation.
Eosinophilic cystitis is an unusual bladder lesion of unclear etiology first described in 1960. It usually causes irritative voiding symptoms and hematuria and in its rare tumor-like appearance the disease may mimic an invasive bladder neoplasm. In the report herein, a case of an 11-year-old boy with a tumor-forming eosinophilic cystitis is presented which was mistaken for an infiltrative vesical malignancy until the histopathological study was completed. The principal clinical findings, differential diagnosis, etiology, pathogenesis and treatment modalities of this inflammatory disease are discussed.
Eosinophilic cystitis is an uncommon inflammatory disease of the urinary bladder characterized by irritative urinary symptoms and eosinophilia of the involved tissue and often of the peripheral blood. Parasitic bladder infiltration has been suggested as the etiologic agent, but review of the literature revealed only one case in which this was proven. A 3.5-year-old boy with eosinophilic cystitis was extensively investigated, but there was no evidence of parasitism. Several immunologic reactions may cause eosinophilia in both tissues and peripheral blood, but no specific allergen could be found in this patient.
A study is described in which 205 women aged 18 to 60 years presenting with symptoms of cystitis and for whom there was no clear clinical evidence of a bacterial infection were treated with a 48-hour course of sodium citrate in the form of Cymalon granules. Significant bacteriuria was present in forty-three (21.3%) of the 202 patients for whom assessment was possible. Continuing or assumed bacteriuria was evident in twenty-one patients after treatment for whom an antibacterial agent was indicated. The average pre-treatment symptom score was higher for those with initial bacteriuria, than those without. In patients with persisting bacteriuria, symptom severity remained unchanged or worsened. In patients with pre-treatment bacteriuria whose symptoms improved, the bacteriuria was cleared. In those patients who were abacteriuric initially, symptoms were relieved in about 80% of cases. It is concluded that a 48-hour course of sodium citrate can provide good symptomatic relief for most women with cystitis for whom there is no definite clinical evidence of a bacterial infection. Failure to respond adequately is very suggestive evidence of persisting bacteriuria for which a course of antibacterial therapy is indicated.
Interstitial cystitis (IC) is a syndrome consisting of severe refractory bladder symptoms of unknown etiology. The disease tends to affect Caucasian women with a mean age of 40 years, with 25% of patients under the age of 30. Few population based epidemiological studies of IC have been performed. We analyzed a case of interstitial cystitis in a 42-year-old non-smoker woman. In two biopsy samples the presence of viral DNA of human polyomavirus BK (BKV), human herpes virus type 1 and type 2 (HHV- 1 and HHV-2), adenovirus, human papillomavirus (HPV) and bacterial DNA (Chlamydia trachomatis and Mycoplasma genitalium) were evaluated by means of polymerase chain reaction (PCR). Both samples resulted positive only for BKV and HPV DNA. HPV genotyping revealed the presence of HPV-66 that is associated with a high risk of cancer development. Thus the finding of a viral co-infection could support the hypothesis of the multi-factorial origin of this pathology.
When adenovirus causes haemorrhagic cystitis in immunocompromised patients, vidarabine is used for its treatment because therapeutic choice is limited. Although vidarabine has been reported to be effective for these patients, its therapeutic basis has not yet been established. Vidarabine dose-dependently inhibited viral replication as assessed by a yield reduction assay. Viral protein synthesis was dose-dependently inhibited by vidarabine but not at all by acyclovir, and the degree of inhibition by vidarabine was different for each of the viral proteins, ranging from 0-40% of the untreated control. These results indicated the specificity and mechanism of action of vidarabine against adenovirus. The concentration of vidarabine and its metabolite in the bladder is suggested to exhibit effective anti-adenoviral activity in suppressing the replication of adenovirus. Thus, our results support vidarabine therapy as a possible candidate for adenovirus-induced haemorrhagic cystitis in immunocompromised patients.
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.
BACKGROUND: Interstitial cystitis (IC) is a chronic bladder disorder of unknown etiology. Antiproliferative factor (APF), a peptide found in the urine of IC patients, has previously been shown to decrease incorporation of thymidine by normal bladder epithelial cells. This study was performed to determine the effect of APF on the cell cycle of bladder epithelial cells so as to better understand its antiproliferative activity. METHODS: Explant cultures from normal bladder biopsy specimens were exposed to APF or mock control. DNA cytometry was performed using an automated image analysis system. Cell cycle phase fractions were calculated from the DNA frequency distributions and compared by two-way analysis of variance (ANOVA). RESULTS: APF exposure produced statistically significant increases in the proportion of tetraploid and hypertetraploid cells compared to mock control preparations, suggesting a G2 and/or M phase cell cycle block and the production of polyploidy. CONCLUSIONS: APF has a specific effect on cell cycle distributions. The presence of a peptide with this activity may contribute to the pathogenesis of interstitial cystitis through disruption of normal urothelial proliferation and repair processes.
Pituitary adenylate cyclase-activating polypeptide (PACAP) elicits a transient contraction, sustained increase in the amplitude of spontaneous phasic contractions, and significantly increases the amplitude of nerve-mediated contractions in mouse urinary bladder smooth muscle (UBSM) strips. PACAP immunoreactivity (IR) is increased in micturition reflex pathways following cystitis. PACAP may contribute to altered sensation and bladder overactivity in the chronic bladder inflammatory syndrome, interstitial cystitis.
We examined the possibility of continuing oxazaphosphorine therapy in patients with previously documented cyclophosphamide- or ifosfamide-induced hematuria by concomitant use of the uroprotective agent, mesna. Twenty-six patients with oxazaphosphorine-induced hematuria received additional cyclophosphamide or ifosfamide with mesna. Twelve, who had previously experienced hematuria with ifosfamide, received a median of 3.5 more cycles of ifosfamide/mesna. One patient developed further hematuria (grade 1). Of seven patients who experienced acute hematuria with cyclophosphamide, one experienced further hematuria after an additional course of cyclophosphamide with mesna, but none of the other six patients developed further hematuria when administered either cyclophosphamide/mesna (two) or ifosfamide/mesna (four). Seven patients who had chronic cyclophosphamide-induced hematuria had further oxazaphosphorine with mesna without worsening of their hematuria. Mesna is an effective uroprotective agent that prevents recurrent acute hemorrhagic cystitis, or worsening of chronic hemorrhagic cystitis, in patients receiving further oxazaphosphorine after previous ifosfamide- or cyclophosphamide-induced hematuria.
UNLABELLED: We investigated the effect of epidural local anesthetic blockade on urinary substance P levels in five patients suffering from painful flare-ups of interstitial cystitis. Urine was collected in 24-h intervals commencing at the onset of an epidural bolus of 0.25% bupivacaine followed by maintenance epidural infusions of 0.05% bupivacaine. Substance P was measured by radioimmunoassay. After initiation of the epidural infusion, urinary substance P levels increased and then declined in all patients. All patients reported a decrease in pain intensity. We hypothesize that acute release, followed by depletion, of substance P from bladder sensory nerve endings accounts for the transient increase of peptide levels in urine and may contribute to the decrease in pain intensity during a 3-day epidural infusion. IMPLICATIONS: Substance P levels in urine initially increased and then declined in a series of 5 patients who achieved pain control by epidural local anesthetic infusion during a flare-up of interstitial cystitis.
Interstitial cystitis (IC) is a chronic inflammatory disorder of the bladder that is notoriously difficult to manage and can result in considerable morbidity. It very likely overlaps with painful bladder syndrome, but they are different conditions. The aetiology remains obscure, and the definition and diagnostic criteria are debated. The diagnosis of IC is one of exclusion, frequently based on symptoms and cystoscopy findings. Typical symptoms include frequency, urgency, dysuria and lower abdominal, bladder, vaginal, urethral or perineal pain, in the absence of bacterial cystitis. Voiding often relieves the suprapubic discomfort, and drinking alcohol- and caffeine-containing drinks frequently exacerbates it. Many treatments have been tried, with little sustained success. Proposed systemic treatments include anti-histamines, heparin, amitriptyline and pentosan polysulfate (a synthetic analogue of glycosaminoglycan which augments the mucous protective layer of the bladder). In many patients symptoms are improved following cysto-distension but the benefits are short-lived. Instillations of dimethyl sulfoxide, hyaluronic acid or chondroitin also show promise. Where treatments have failed and symptom severity is such that the patient's quality of life is poor, a urological opinion should be sought and reconstructive surgery considered. Available options include partial cystectomy, augmentation cystoplasty, and urinary diversion with or without cystectomy.
Pseudotumoral cystitis is an uncommon inflammatory condition which may masquerade as a bladder tumour in children. There are a variety of clinical presentations such as haematuria, dysuria, infection and obstruction. Reported causative factors include infection (bacterial, fungal and parasitic) and allergy. Ultrasound is an excellent imaging modality for demonstrating this intravesical lesion although the spectrum of features is poorly described in the literature. We report our recent experience of four patients with pseudotumoral cystitis and describe the clinical features and ultrasound appearance of this condition in children.
Polypoid cystitis is a rare disease of the urinary bladder in dogs characterized by chronic inflammation, epithelial proliferation, and development of a polypoid mass or masses without histopathologic evidence of neoplasia. The ultrasonographic appearances of eight dogs with polypoid cystitis are described. Ultrasonography confirmed the presence of a bladder mass or masses in all patients. Ultrasonographic findings are mucosal projections and a polypoid to pedunculated mass of variable size and shape. Although a polypoid mass tends to be located in the cranioventral bladder mucosa, the polyps also could arise in the craniodorsal bladder mucosa. Ultrasonographic images are well correlated with contrast radiographic studies and gross morphological appearance. Ultrasound is a non-invasive, very useful diagnostic tool for detecting bladder polyps, but histopathology is required for definitive diagnosis.