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This article reports the progress made in the last several years of investigations into possible pathogenic processes that lead to the development of interstitial cystitis. The evidence presented here asserts that bladder mucin is functionally intact in interstitial cystitis and that the permeability of the afflicted patient's bladder is not greater than normal.
In the author's opinion, infection has not been properly ruled out as a factor in the development of interstitial cystitis. Dismissing infection as a cause would require special techniques to search for microorganisms not only in urine but also in bladder tissue. Infection is not necessarily exclusive of other theories concerning the pathogenesis of interstitial cystitis, such as autoimmunity or increased bladder permeability.
Morphologic changes, including light microscopy and ultrastructural, immunologic, and immunohistochemical findings in interstitial cystitis are described. The results indicate that biopsies are useful as an aid in the diagnosis of interstitial cystitis.
The diagnosis of interstitial cystitis is best based on the techniques necessary to elicit the criteria established at the conferences of the National Institute of Arthritis, Diabetes, Digestive, and Kidney Diseases (NIDDK). Essentially, this requires a thorough patient history, urodynamic evaluation, and cystoscopy carried out under anesthesia with hydrodistention of the bladder and bladder biopsy. Diagnosis of interstitial cystitis is tightly linked to its definition, and until the latter is crystal clear, the former will continue to be murky.
The treatment of interstitial cystitis is difficult and at time frustrating--both for the patient and for the physician. Treatment is hampered by the lack of a clear understanding of its pathophysiology, which makes it difficult to objectively assess disease severity and/or progression. Intravesical therapy appears to be the most successful approach to the relief of symptoms. Clearly, there are drawbacks to intravesical therapy, particularly Clorpactin lavage. Responses to intravesical lavage are variable in duration, unpredictable, and unamenable to objective measurement. Multiple treatments are frequently needed, as with DMSO, and multiple anesthetics may be required for Clorpactin therapy. There have been no double-blind, placebo-controlled studies comparing the mainstays--Clorpactin and DMSO--of intravesical treatment. It is hoped that current research into the pathogenesis and causation of interstitial cystitis will lead to an improved understanding of this disease or syndrome. The introduction of newer, more specific intravesical therapies will surely follow such advances.
DMSO2 is one alternative for treating interstitial cystitis. Research with this compound is very limited, but side effects have been negligible. The drug may hold promise for interstitial cystitis patients, as well as those suffering from painful bladder (urethral) syndrome.
The role of ultrasonographic examination of the bladder has been retrospectively evaluated in 12 patients with hemorrhagic cystitis occurring after BMT. Three sonographic patterns of bladder abnormalities have been observed: type 1, circumscribed thickening of the wall protruding into the lumen (4 patients); type 2, diffuse thickening of the wall (3 patients); type 3, intraluminal lobulated bulky mass reducing the capacity (5 patients). Sonographic follow-up showed a progressive trend of bladder abnormalities: type 3 lesions were always preceded by type 1 or type 2 abnormalities. In 10 of 12 patients the cystoscopic findings proved the correlation between the sonographic aspects and the progressive stages of bladder wall damage. Patients were treated initially by hyperhydration and blood products transfusions in order to stop hematuria. The median duration of bleeding was significantly longer (p < 0.01) in patients showing type 3 lesions (90 days) than in the combined groups with types 1 or 2 lesions (14 days). All 5 patients with type 3 abnormalities failed treatment and required endoscopic removal of clots; hemorrhagic cystitis was the major cause of death in 3 patients in this group. Ultrasonography may therefore be considered an accurate investigation for assessing the extent of bladder damage and monitoring the effectiveness of treatment for this complication.
A total of 117 children with chronic pyelonephritis (CP) aged 4-14 were examined and treated. 57 of them having attendant cystitis received multimodality treatment comprising local intravesicular instillations of chigain controlled by clinical findings, urinalysis, cystoscopy and urinary secretory immunoglobulins SIg A1, SIg A2 and IgG. The drug chigain capable of immune replacement was found to initiate clinical response, positive trends in urinalysis and cystoscopy data, in the levels of secretory urine immunoglobulins. The findings show the need of immune replacement therapy in the complex of modalities to treat children with CP combined with cystitis.
Polypoid cystitis is not uncommon in patients with a permanent urethral catheter. In some cases difficulties are encountered when making the differential or anatomopathological diagnosis from transitional cell carcinoma of the bladder. We report a case of polypoid cystitis mimicking bladder carcinoma in a patient with a permanent urethral catheter.
A 39-year-old female with AML (M2) underwent allogeneic bone marrow transplantation (BMT) on July 8th, 1991. The post transplantation course had been going well until day 85 post BMT, when severe hemorrhagic cystitis with right hydronephrosis and ureter stenosis developed. Adenovirus type 11 was isolated from the urine. She received instillations of prostaglandin E1 (PGE1) directly into the bladder after the appearance of clots in the urine. Complete resolution of hematuria was obtained by two courses of this treatment. PGE1 bladder instillations seem to be effective for the control of hematuria caused by severe hemorrhagic cystitis after BMT.
Eight patients with interstitial cystitis were treated by supratrigonal cystectomy and enterocystoplasty. The indications for this procedure are functionally disabling interstitial cystitis refractory to conservative treatment and associated with severely altered cystomanometric parameters. 6 patients obtained an excellent functional result and 2 patients obtained a poor result, due to sphincter hypotonia responsible for total incontinence in one case.
This multicentre, open, randomized trial, involving 482 patients and conducted by private practitioners, compared the effectiveness and safety of a single 800 mg dose of pefloxacin and of a 10 days' course of norfloxacin 400 mg bid. in the treatment of uncomplicated acute cystitis in women aged over 50 years. Clinical effectiveness was evaluated on days 17-19 and 28-32 respectively, and bacteriological effectiveness on days 15-17 and 26-28 respectively. The median time taken for the symptoms to disappear was 2 days with pefloxacin and 3 days with norfloxacin (P < 0.001). Irrespective of the nature of cystitis and the patients' age, no significant difference could be found in eradication of the pathogens. Undesirable side-effects were recorded in 7.8 percent of patients under pefloxacin and in 8.8 percent of those under norfloxacin (P = 0.68); gastrointestinal disorders were predominant. The acceptability of treatment, as judged by the patients themselves, was regarded as excellent by 55 percent of women treated with single dose pefloxacin and by 37.6 percent of those treated with norfloxacin (P = 0.001).
A case of recurrent emphysematous cystitis in a 44-year-old male diabetic is described. Treatment of the first episode had been effective and demonstrable radiologically. A recurrent episode of cystitis disclosed a neurogenic bladder, which had not been detected previously. The literature on the pathogenesis of this entity is briefly reviewed.
BACKGROUND: Hemorrhagic cystitis (HC) is a major complication of high-dose cyclophosphamide therapy used in the preparative regimen for allogeneic or autologous bone marrow transplantation. Several viruses (adenovirus, cytomegalovirus and polyomavirus BK) have also been implicated in the etiology of HC. No one established method of treatment is as yet available. MATERIALS AND METHODS: HC developed in 10 patients after allogeneic bone marrow transplantation and was BK viruria-associated in all cases. All patients were treated with instillations of prostaglandin E2 (PGE2) directly into the bladder. RESULTS: A complete resolution of hematuria within a short time (5 +/- 1 days) was observed in all cases; in 4/10 patients urine cleared within 24 hours of the initial treatment. Intravesical PGE2 therapy caused no systemic circulatory or respiratory problems, although bladder spasms occurred in all patients. CONCLUSIONS: Intravesical prostaglandin E2 instillation appears to be an effective treatment for hemorrhagic cystitis in bone marrow transplant patients; further studies are required to assess the actual role of BK virus in the pathogenesis of HC in bone marrow transplant patients.
A 45-year-old woman who had been diagnosed as having systemic lupus erythematosus (SLE) at the age of 28 years and who had been in remission developed severe urinary frequency, watery diarrhea, vomiting and weight loss. She also developed acute renal failure and her serological examination was consistent with active SLE. She had a markedly decreased urinary bladder capacity of 20 ml with hydroureteronephrosis. Histopathological study of her urinary bladder biopsy specimen showed mucosal edema, infiltration by lymphocytes and granulocytes, and deposition of IgA in the epithelium and submucosal region. We diagnosed this as a case of lupus cystitis. The patient's symptoms were alleviated by bilateral nephrostomy and corticosteroid therapy. In the present episode the patient showed none of the usual symptoms of SLE. This case and others reported in the literature show that lupus cystitis presents with specific signs and symptoms and therefore, this syndrome may represent a specific clinical manifestation of SLE.
The study covers eighty-seven women, aged 21 to 68 years, presenting chronic recurrent cystitis. In 53 of the total number (60.92 percent) no evidence of intravesical obstruction is found. In the remainder 34 (39.08 percent), following urethral calibration and urodynamic investigations, direct and indirect data pointing to urethral stricture are established. Urethrotomy is done in thirteen women, and dilatation of the urethra (up to 30)-in twenty-one. After the manipulations described, a six-month antibiotic prophylaxis against urinary infection relapse is conducted. It is demonstrated that urethrotomy and dilatation of the urethra lead to normalization of the urodynamic indicators and subjective miction improvement. Within a year, one to several cystitis recurrences are recorded in all women documented.
Presentation of two clinical cases of spontaneous vesical rupture secondary to bacterial cystitis in elderly patients. One corresponds to an intraperitoneal perforation while the second case was extraperitoneal. The patients were, in both cases, diabetic women admitted in emergency due to acute abdomen. We considered that although vesical perforation secondary to bacterial cystitis is a very uncommon process, it should be taken into account in the differential diagnosis of acute abdomen in predisposed patients (diabetic elderly patients with pyuria). In such instances, a retrograde cystography would provide the diagnosis. Although extraperitoneal vesical perforations can be resolved with a vesical catheter or cystostomy, extravasation of the infected urine may result in a perivesical abscess and septic shock. Early surgical management should be considered in these cases.
Salmonellae are frequently isolated from urine during the course of typhoid fever, although cystitis in typhoid is rare. In a young man who had returned from India with severe hemorrhagic cystitis, urine and bone marrow cultures confirmed the diagnosis of typhoid. Full recovery followed treatment with chloramphenicol. This case illustrates an unusual presentation of typhoid fever and the illustrates an unusual presentation of typhoid fever and the diagnostic difficulties occasionally encountered in patients returning from developing countries.