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The finding of Torulopsis glabrata fungal cystitis has become increasingly evident. The presence of indwelling urinary catheters, diabetes mellitus, and prior antibiotic therapy are significant risk factors in its development. Three cases are presented exemplifying the presentation of this disease. A discussion of its diagnosis and a protocol for its management are outlined.
The authors present a case of a fifteen-year-old boy with urgency, suprapubic pain, hematuria, and pyuria with negative routine urine cultures. Cystoscopy revealed gross cystitis, and VCUG showed bilateral reflux and ureteral dilatation. Renal arteriograms, percutaneous renal biopsy, and bladder biopsy also were performed. After finding a positive culture for Ureaplasma, therapy with doxycycline rendered the patient asymptomatic and reflux improved on follow-up VCUG. Ureaplasma urealyticum should be considered in patients with symptomatic pyuria and negative routine cultures. Ureteral reflux, reversible with appropriate therapy, may be part of the infectious process.
Ten patients with biopsy-proved interstitial cystitis were treated with a program of self-administered dimethyl sulfoxide (DMSO) using the technique of intermittent self-catheterization. Nine of the 10 patients responded favorably to the treatment and are on a maintenance program. The technique was well tolerated and without complications.
A case of acute bilateral ureteral obstruction due to severe candidal cystitis is described. The obstruction was due to inflammation and fungal plaque formation in the bladder, rather than the usual intraureteral fungus balls. Percutaneous nephrostomies were required bilaterally for resolution of sepsis and renal failure. The case and its management are presented.
The urodynamic findings in 41 women with proven interstitial cystitis were reviewed. All subjects had pain during bladder filling with sensory instability and limited functional capacity. Despite an average symptom duration of 5.7 years, all women had normal bladder wall compliance during cystometry. Fourteen of 41 women had additional significant urodynamic findings.
Pentosan polysulfate sodium (PPS) was compared with placebo for the symptomatic therapy of interstitial cystitis in a double-blind, multicenter study. A total of 110 patients were enrolled and treated for three months. In this study, overall improvement of greater than 25 percent was reported by 28 percent of the PPS-treated patients and by 13 percent of the placebo-treated patients (p = 0.03). The investigators' overall evaluation provided similar results, 26 percent vs 11 percent in favor of PPS (p = 0.04). Improvement in pain and pressure to urinate also favored PPS over placebo and approached statistical significance (p = 0.07 and 0.08). The incidence of adverse reactions was 6 percent in the PPS-treated group and 13 percent in the placebo-treated group. All adverse reactions were minor, and treatment was discontinued by 1 patient in the PPS group and 2 in the placebo group. In this study, PPS was found to be significantly more effective than, and equally as safe as, placebo.
An encephalopathy and cardiomyopathy developed in a seventeen-year-old girl with chemotherapy-induced renal failure while receiving an intravesical aluminum infusion for hemorrhagic cystitis. Premortem serum and postmortem tissue aluminum levels were markedly elevated. It is likely that her inability to excrete absorbed aluminum contributed to her death. Aluminum infusions should be used with caution in patients with renal failure.
A variant of the interstitial cystitis (IC) syndrome, minimal or no pain or significant pain that has been lessened by another therapy, can be clinically improved by retraining of the individual's voiding pattern. Patients with greater pain but capable of completing this protocol also may be helped. While this group of patients fills the diagnostic criteria of IC and has many of the classic changes, many differ in that they have minimal or no pain, while simultaneously they have a dysfunctional bladder as expected from long-term low-volume voiding. All patients were placed on a protocol which focused on progressively increasing intervals between voids. Fifteen to thirty minutes initially were added to their present voiding time. The same increase was added to the voiding pattern every three or four weeks until an interval of three to four hours between voids was achieved. Twenty-one patients fit the criteria to be entered into this study. Overall 71 percent (15/21) had successful management of their symptoms and reported a 50 percent decrease in their symptoms of urinary urgency, frequency, and nocturia. Nineteen percent (4/21) reported 25 percent decrease in symptoms and 10 percent had no change. Presence of significant pain adversely affects outcome, 3/7 (with pain) improvements versus 12/14 (without pain). For all patients there was a significant increase in bladder capacity (92 mL average before study and 179 mL after) and average daily voids (13.2/day prestudy and 7.4 post-therapy). These differences in voided profiles were statistically significant (p value less than 0.01).
OBJECTIVES: Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder of unknown etiology. We tested the hypothesis that a microorganism would be found at higher prevalence in urine or bladder tissue from women with IC than from control women. METHODS: Urine and bladder tissue were obtained at cystoscopy from 11 IC patients and 7 control subjects. These specimens were cultured for a variety of fastidious and nonfastidious bacteria, mycobacteria, fungi, and viruses. In addition, special staining techniques were used to examine biopsy specimens and cytospun urine, and tissue sections and outgrowths of explanted bladder cells were examined by electron microscopy. RESULTS: Cultures of urine from 6 of 11 IC patients grew five different bacteria (Corynebacterium sp. Klebsiella pneumoniae, Lactobacillus sp, Streptococcus constellatus, and Streptococcus morbillorum), human cytomegalovirus, or Torulopsis glabrata; one of these organisms (Lactobacillus sp) was found in urine from 2 patients. Although contamination by urethral organisms is possible, the prevalence of microorganisms in urine of IC patients (6 of 11) was significantly greater than in urine of control subjects (0 of 7) (P < 0.05). Acridine orange staining revealed rods with appropriate morphology in urine from 4 of the 5 IC patients who had positive bacterial cultures and yeastlike organisms in urine and bladder tissue specimens that grew Torulopsis. Additionally, rodlike organisms were seen in urine from 2 IC patients with negative bacterial cultures and cocci were seen in the urine of 1 control patient. Biopsy specimens from 2 IC patients grew Torulopsis sp or Lactobacillus sp, in agreement with the results of acridine orange staining and culture of urine from these patients; in contrast, specimens from 3 control subjects grew small numbers of Pseudomonas sp or Staphylococcus epidermidis, but no organisms were cultured from urine or seen in acridine orange-stained tissue smears. All other cultures and stains were negative. CONCLUSIONS: These data do not provide evidence that IC is associated with infection or colonization by a single microorganism. However, they do generate the hypothesis that the prevalence of microorganisms, especially bacteria at low concentrations, is greater in the urine of IC patients than of control subjects. If these results are confirmed by other controlled studies, the question of whether the presence of these organisms is a cause or a result of IC should be addressed.
Our experience with the use of Formalin instillation in interactable gross hematuria secondary to radiation cystitis in patients with gynecological malignancies is reported. This study indicates coagulative effect of low concentration of Formalin with minimal side effects as a method to control hemorrhage.
In an open study, 172 male and female adult patients with acute uncomplicated bacterial cystitis were randomly allocated to three treatment groups. Two groups received brodimoprim 200 mg tablets as follows: a single dose of two 200 mg tablets on day 1, followed by one tablet per day on days 2 and 3 (58 patients); or a single daily dose of two tablets, for 2 days (63 patients). The third group received a single dose of pefloxacin, as two 400 mg tablets, for 1 day (51 patients). Complete urinalysis, sediment and urine culture examinations were carried out before treatment and 10 days after the last dose. Evaluation also comprised, at the time of enrolment and 48 h after the last dose, measurement of corporal temperature and assessment of symptoms (dysuria, pollakiuria, strangury, suprapubic pain, burning sensation during urination and urgency) on a 4-point scale. The eradication rate for the pathogen concerned was 98.3% and 96.7% in the groups receiving brodimoprim for 3 and 2 days, respectively, and 92.8% in the pefloxacin group (between-group comparison n.s.). There was significant regression of symptoms (P < 0.001) in the three groups (between-groups comparison n.s.). Mainly gastrointestinal adverse events occurred in 3 patients receiving brodimoprim for 2 days and in 4 patients from each of the other two groups.
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.
We analyzed the incidence, etiology, risk factors, and clinical management of hemorrhagic cystitis (HC) in 102 children who underwent allogeneic stem cell transplantation: 28 from matched siblings, 57 from unrelated donors, and 17 from mismatched relatives. Conditioning regimens consisted of high-dose chemotherapy (n=83) or total body irradiation (n=19). In all children, urine and plasma were prospectively screened for human polyomavirus (HPV; BK virus [BKV] and JC virus [JCV]) or adenovirus (AdV) DNA with a polymerase chain reaction-based assay. Viral DNA was detected in the urine of 56 children (54.9%): BKV in 48 (47%), JCV in 4 (3.9%), and AdV in 4 (3.9%). HC occurred in 26 children (25.5%), and viruria was detected in all of them: BKV in 21 (80.8%), AdV in 4 (14.4%), and JCV in 1 (3.8%). All patients with AdV viruria developed HC. The cumulative incidence of HC in patients with HPV viruria was 0.43. The only significant risk factor for HC in patients with HPV-positive urine was conditioning with high-dose chemotherapy. Twenty-two children were treated with cidofovir, with no significant toxicity. In all treated patients but 1, the clinical symptoms were moderate, and no HC-related death was observed. We conclude that virus-induced HC is a frequent complication after allogeneic hematopoietic cell transplantation. Treatment with cidofovir is feasible, and further studies are warranted to evaluate its activity in HC mediated by BKV or JCV.
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.
OBJECTIVE: We conducted a prospective pilot study to assess the safety and efficacy of hyperbaric oxygen (HBO) for the treatment of interstitial cystitis (IC). METHODS: Six patients underwent 30 sessions of 100% oxygen inhalation in a hyperbaric chamber and were followed up over 15 months. The measures of efficacy were changes in pain and urgency (visual analog scales), alteration in the patient's assessment of overall change in his well-being (Patient Global Assessment Form), and changes in frequency and functional bladder capacity (48-hours voiding log). Evaluation of symptom severity regarding pain and voiding problems was done using the O'Leary-Sant index. RESULTS: Four patients rated the therapeutic result as either excellent or good and assessed their well-being after HBO treatment as improved. Two patients showed only short-term amelioration of some of their symptoms. At 12 months follow-up the baseline functional bladder capacity increased from 37-161 ml (range) to 160-200 ml in the responder group. The 24-hour voiding frequency decreased from 15-27 to 6-11 voids per day, a pain scale improvement from 20-97 mm at baseline to 3-30 mm at 12 months follow-up and an urgency scale improvement from 53-92 mm to 3-40 mm, respectively was observed at 12 month follow-up. The symptom and pain index score decreased from 23-35 at baseline to 3-17 at 12 months follow-up. CONCLUSION: HBO appears to be effective to treat IC patients. Treatment was well tolerated and resulted in a sustained decrease of pelvic pain and urgency, improvement of voiding patterns and increase of functional bladder capacity for at least 12 months.
INTRODUCTION AND OBJECTIVES: According to National Institute of Health (NIH) criteria, a bladder capacity of less than 350 cc is an automatic exclusion for a diagnosis of Interstitial Cystitis (IC). In the present study, patients, showing symptoms of IC and with bladder capacities of <350 and >/=350 cc were tested as to their response to a intravesical hyaluronic acid therapy. METHODS: The study included 48 patients with clinical symptoms of IC and a positive 0.4 M potassium sensitivity test. Maximum bladder capacity (C(max)) was assessed for the 0.9% NaCl solution first and then for the 0.2 M KCl solution. After the NaCl cystometry, patients were separated into two groups: Group I with a C(max) of <350 cc and Group II with a C(max) of >/=350 cc. Both groups were again separated in two further groups as to the respective percentage reduction of C(max) with the 0.2 M KCl solution: Group Ia/IIa (>/=30%) and Group Ib/IIb (<30%). Patients were treated with weekly instillations of 40 mg hyaluronic acid for 10 consecutive weeks. Pre- and post-treatment bladder symptoms were evaluated through their visual analog scale (VAS) scores. RESULTS: With the saline solution, 32 patients had a C(max) of <350 cc (Group I), while 16 patients had a C(max) of >/=350 cc (Group II). Evaluation of VAS scores confirmed a positive response, i.e. symptom relief, to hyaluronic acid therapy, irrespective of bladder capacity. The improvement was particularly evident in patients with a C(max) reduction of >/=30% versus those with a reduction of <30% with the 0.2 M KCl solution (p=0.003). CONCLUSION: The present study demonstrates that patients with typical IC symptoms and a cystometric bladder capacity of >/=350 cc, may have increased potassium sensitivity as a sign of IC and show symptom improvement after hyaluronic acid instillation therapy.
OBJECTIVES: To determine the prevalence of interstitial cystitis (IC) symptoms in an urban female population, to study their impact on quality of life and sexual function, and to identify correlates for IC symptoms. METHODS: Women attending a voluntary health survey project in Vienna underwent a detailed health investigation and completed a questionnaire containing the O'Leary-Sant IC questionnaire. Women with high (> or =12) symptom and problem scores including nocturia (>2) and pain were considered most likely to have IC. RESULTS: A total of 981 women, aged 19 to 89 yr (mean, 49.1+/-14.7 yr), participated in the study. Of these, 57.9% had a low IC symptom score (score 0-3), 25.9% mild IC symptoms (score 4-6), 13.9% moderate symptoms (score 7-11), and 2.3% a high symptom score (score 12-20). The IC problem score revealed a similar pattern. The overall prevalence of IC was 306/100,000 women with the highest value (464/100,000) in middle-aged women (40-59 yr). About two thirds of the women with moderate to high risk for IC reported an impairment of quality of life; 35% reported an effect on their sexual life. In a multivariate analysis, bowel disorders (p=0.016) and psychological stress (p=0.029) were correlated to the probability of IC. CONCLUSION: The prevalence of IC symptoms is higher than previously estimated and substantially affects quality of life and sexuality.
STUDY OBJECTIVE: To estimate the prevalence of bladder-origin pain, intraperitoneal pathology, and vulvar pain in patients undergoing laparoscopy for chronic pelvic pain (CPP). DESIGN: Prospective, observational one-site (Canadian Task Force classification II-2). SETTING: Referral gynecology specialty private practice. PARTICIPANTS: Sixty-four patients undergoing laparoscopy for CPP were prospectively assessed to establish the source of their CPP over a 12-month period. INTERVENTIONS: All patients received an intravesical potassium sensitivity test (PST), cystoscopy with double-fill hydrodistension, a physical examination for vulvar pain, and laparoscopy to assess the presence of peritoneal pathology. The validated pelvic pain/urgency/frequency (PUF) screening questionnaire was given to all patients to assess symptoms. MEASUREMENTS AND MAIN RESULTS: Forty-four patients (69%) were found to have a positive PST indicating pain of bladder origin due to bladder epithelial dysfunction. Cystoscopic findings diagnosed only seven cases of classic interstitial cystitis (11%). Laparoscopic findings revealed biopsy-proven endometriosis in 28% and adhesions in 64%. Vulvar pain was diagnosed on examination in 20%. Assessment of intraperitoneal pathology and bladder-origin pain accurately diagnosed 95% of patients. There was no statistical difference in the prevalence of endometriosis, adhesions, or vulvar pain when groups were stratified to PST-positive or -negative groups. Bladder pain, peritoneal pathology, and vulvar pain are independent risk factors of CPP although a trend of severity was noted in patients who had worse symptoms (increased voids per day, urgency, pain, and PUF scores). Patients with increased symptoms had a higher likelihood of having pain from bladder epithelial damage and intraperitoneal pathology. CONCLUSIONS: The etiology of CPP may arise from multiple sites in the pelvis including the bladder, pelvic peritoneum, and vulva. This study demonstrated that in a group of women undergoing a comprehensive work-up for CPP, the bladder was the predominant pain generator. A work-up for CPP should include an assessment of bladder epithelial function and an assessment for intraperitoneal pathology.