Report On Presentations From The European Society For The Study Of Interstitial Cystitis (ESSIC) Annual Meeting

Main Category: Urology / Nephrology
Article Date: 20 Jun 2008 - 0:00 PDT

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BERKELEY, CA (UroToday.com) - This year's meeting was held in Rome, Italy from June 5-7, 2008.

In just a few short years, the meeting of the ESSIC group has expanded dramatically. Approximately 100 urologists and health care professionals gathered in Rome to discuss a series of presentations regarding bladder pain syndrome / interstitial cystitis (BPS/IC). Before the open meeting, members of ESSIC discussed plans to move ahead with an agenda to increase cooperation internationally to learn more about BPS/IC and improve treatment. The meeting concluded with a course on the disease by members of ESSIC and presentations on analgesia and pain center organization (Andrew Baranowski), central nervous system pain processing (Jean-Jacques Wyndaele), neurophysiological evaluation of the pelvic floor in BPS/IC (Sylvia Malaguti), irritable bowel syndrome (Enrico Corazziari), and vulvar pain syndrome (Leonardo Micheletti). Plans are to put all of these excellent presentations on the ESSIC web site in the near future www.essic.eu.

Antecedent Non-Bladder Syndromes in a Case Control Study of Interstitial Cystitis/Painful Bladder Syndrome

Jack Warren and colleagues from the United States discussed antecedent non-bladder syndromes in a case control study of the disease that has been on-going, concluding that some patients have a systemic syndrome not confined to the bladder. Eleven antecedent syndromes were more often diagnosed in BPS/IC cases, and most syndromes appeared in clusters. Fibromyalgia-chronic widespread pain, chronic fatigue syndrome, sicca, and irritable bowel syndrome comprised the most prominent cluster, and patients with one or more of these syndromes were more likely than controls to have migraine, chronic pelvic pain, depression, and allergy.

Significance of Multidisciplinary Approach to Diagnostics of Causes Of Chronic Pelvic Pain in Women

Dr. Andrey Zaitcev and coworkers from Moscow presented a series of 19 women diagnosed with chronic pelvic pain from endometriosis who were subsequently evaluated for BPS/IC. While 17 of 19 patients were confirmed to have evidence of endometriosis, 6 patients in this series were found to have BPS/IC on the basis of symptoms, cystoscopy, and morphological results, thus enabling proper direction of treatment.

Preliminary Data Concerning Pain and Quality of Life in Patients with BPS/IC YKL-40 in Bladder Biopsies from Patients with BPS/IC â€" A Possible Prognostic Marker for Clinical Outcome? Presentation of Preliminary Findings

Drs. Benedikte Richter and Jorgen Nordling, representing the urology group from Herlev Hospital in Copenhagen, presented 2 interesting papers. In a survey of pain and quality of life, they confirmed what Oravisto wrote 35 years ago. Many patients (60%) experience severe pain at the onset of disease, but pain intensity seemed to weaken through the course of the disease. Through the last month or year about a third felt severe pain. Quality of life seemed to improve over time, although the direct relationship to treatment was not yet determined. Preliminary work on YKL-40, a mammalian glycoprotein, was presented. Elevated concentrations have been found in patients with diseases characterized by inflammation, tissue remodeling, and fibrosis. It shows no or only weak staining in normal adult human bladder tissue. They found it, by immunohistochemistry, in mast cells and macrophages in bladder biopsies of patients with BPS/IC. Further studies are planned.

Surgical Treatment of Intractable Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC)

Two clinical treatment studies presented by Dr. Nordling engendered a lot of interest. In a study with Dr. Thomas Norus, he reviewed results of Bricker ileal conduit without cystectomy for intractable BPS/IC, and reported the largest series in the literature. Between 1999 and 2006 16 patients underwent the surgery. All patients had detrusor mastocystosis, and average bladder capacity under anesthesia was 490cc. Median follow-up was 10 months. Fifteen of 16 patients experienced almost complete relief of symptoms including pain following diversion. One underwent cystectomy for persistent pain, but still without relief. Complications were not insignificant, with 2 episodes of pyocystitis, one abscess, and one abdominal wall hernia. Nevertheless, the 94% success rate in this very difficult and suffering population is encouraging.

Results of a multinational, uncontrolled trial of the Accessa system, a permanently implanted generator device that sends signals to the pelvic floor via a lead implanted in the periurethral area, were then presented by Dr. Nordling. Of 75 subjects receiving test stimulation, 81.3% went on to receive a permanent implant and were followed for a year. Revision was required in 7 patients. Median pain scores decreased by 3 points on a 10 point scale, and Interstitial Cystitis Symptom Index and Problem Index scores decreased by 5 and 6 points respectively. Daytime frequency dropped from 17.5 to 12.8 voids and nocturia diminished from 6.3 to 4.2 voids. Intermittent neuromuscular pelvic floor stimulation may become a new treatment modality in the future.

CISTIC Study Report. Prospective Double-Blind Randomized Controlled Multi- Center Study Investigating the Efficacy of Hyaluronan in BPS/IC

It is unfortunately rare to learn details of large, negative studies sponsored by pharmaceutical companies, but in a superb and thoughtful presentation, results of the 5 year CISTIC study on intravesical hyaluronan, which involved 130 BPS/IC patients in 20 European and North American centers, were reported by Dr. Claus Riedl of Baden, Austria. Patients were treated with weekly instillations of hyaluronan or placebo in a 3:1 randomization for 8 weeks. Patient Global Assessment at week 9 was the primary endpoint. The projected size of the study was calculated with an estimate of efficacy of about 60% for treatment versus 30% for placebo. The 60% threshold was obtained. However, the placebo response in 30 patients was an astounding 80%. These patients received the alkalinized vehicle used in the active group. The way the study was powered, there appeared to be no statistical difference in terms of the primary end point between the hyaluronan and the control group. Controls used a significantly higher rate of concomitant medications and had a higher rate of bladder specific adverse events. Their disease duration was shorter than in the active treatment group. The presentation emphasized the difficulty designing studies in this population.

Bladder Pain Syndrome/Interstitial Cystitis and Vulvodynia: Two Aspects of One Syndrome

Our host, Dr. Mauro Cervigni, and colleagues from Rome discussed BPS/IC and its relationship to vulvodynia. He studied 90 female patients who met NIDDK criteria. They were evaluated for vulvodynia with vulvoscopy, colposcopy, psychological evaluation, and vaginal cultures. 45.5% of women were not sexually active, 13 because of pain. Of the 49 sexually active women, all had dyspareunia. After treatment for BPS/IC 15 of 49 women showed remission of dyspareunia and pelvic pain.

Statistical Analysis of Symptoms, Endoscopy and Urothelial Morphology in Fifty-Eight Bladder Pain Syndrome/Interstitial Cystitis Female Patients

Dr. Zamecnik and coworkers from Prague reported on a statistical analysis of symptoms, endoscopy, and urothelial morphology in 58 BPS/IC female patients. They found intravesical treatment to be more effective than oral therapy. Age, disease duration, and time to diagnosis did not reflect treatment outcome. Symptom severity did seem to higher in older patients. Overall, they were unable to predict disease course based on endoscopic findings, mast cell counts, and symptom scores.

Urodynamics and Interstitial Cystitis/Painful Bladder Syndrome

Dr. Whitmore from Philadelphia did a retrospective study of her urodynamic data in BPS/IC patients. She concluded that symptom severity was significantly associated with urodynamic parameters. These included earlier first sensation, first urge, strong desire, and lower maximum cystometric capacity. Urodynamic pain and Likert pain scores correlated in a subset of patients, and she urged that we assess pain on bladder filling during urodynamics.

Evaluation of the Efficacy of Intravesical Chondroitin Sulphate in BPS/IC

Dr. Arunkalaivanan and colleagues from Birmingham, UK studied the effects of 2% chondroitin sulphate when administered intravesically for BPS/IC in 25 women weekly for 4 weeks and then fortnightly for a month and then monthly if there was an initial response. Eighteen patients were evaluable and results were equivocal. The Pelvic Pain , Frequency, and Urgency (PUF) scale showed no significant improvement. Visual analogue values for satisfaction improved from 2.8 +/- 0.8 to 10 after the treatment cycle.

Potassium Channel Kv1.3 and Kv1.6 Expression in the Bladder of Patients with Bladder Pain Syndrome/Interstitial Cystitis: A Controlled Study

Daha and coworkers from Vienna investigated the expression of potassium channels Kv1.3 and Kv1.6 in bladder tissues of patients with BPS/IC and reported that overall, immunoreactivity for both was stronger in detrusor smooth muscle celles than in urothelial cells in both groups. When specifically detrusor muscle cells were examined, immunostaining for both markers decreased considerably in specimens from BPS/IC patients compared to a control group.

GRC 6211, the New TRPV1 Oral Antagonist Diminishes Pain in the Rat Model of BPS/IC

Dinis and colleagues from Porto, Portugal researched the new TRPV1 oral antagonist GRC 6211 in the rat model of BPS/IC. GRC 6211 had an analgesic effect in rats with bladder inflammation induced by cyclophosphamide. This study suggests that intravesical vanilloid therapy may be effective in relieving lower urinary tract symptoms, and future trials in humans with BPS/IC are a goal of their research.

Next spring the European Society for the Study of Interstitial Cystitis is planning a meeting in Gothenburg, Sweden, and readers are directed to their website (http://www.essic.eu) for details in the future.

Reported by UroToday.com Contributing Editor Philip M. Hanno, MD, MPH

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