Bladder Pain Syndrome / Interstitial Cystitis (BPS/IC) - Exclusive Report From 2008 Asian IC Guideline Meeting

Main Category: Urology / Nephrology
Also Included In: Pain / Anesthetics
Article Date: 15 Jan 2009 - 3:00 PDT

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HUALIAN, TAIWAN (UroToday.com) - The annual Asian Interstitial Cystitis Meeting was devoted to the subject of developing an Asian IC Guideline for publication next year. Participants came from Korea (Young Ho Kim, Jeong Gu Lee, JY Hong, Kim Duk Yoon), Japan (Yukio Homma, Tomohiro Ueda, Takaaki Ito, Hikaru Tomoe, Mineo Takei) Taiwan (Shing-Hwa Lu, Ming Hui Lee, YC Chuang and Dr. Wang) and the United States (this correspondent). The meeting was organized by Dr. Alex Lin and hosted by Dr. HC Kuo who practices in the host city.

Dr. Yukio Homma, Professor and Chair of Urology at the University of Tokyo, led off the meeting with a report on the status of the Asian Guidelines and discussion of a draft guidelines he had developed along with members of the committee based on previous meetings and consultations. The report is still in a nascent stage, but the main points of discussion are worth highlighting.

The term interstitial cystitis for the syndrome is considered inappropriate as it indicates inflammation in the interstitum, which is often not present. The names bladder pain syndrome or painful bladder syndrome are inappropriate because of the high proportion of patients who are "painless" (or perhaps do not complain of pain would be more accurate). In Asia it appears they have concerns about the term pain, and worry that patients with the disorder would be misdiagnosed if they did not admit to pain, even if pain were redefined as "pain, pressure, or discomfort". The discussion centered on keeping the designation "IC", but using it to refer to:

1. patients with bladder hypersensitivity, urinary frequency, and/or bladder pain and
2. bladder pathology proven endoscopically by Hunner's ulcer and/or mucosal bleeding after overdistention and
3. exclusion of confusable diseases (infection, malignancy, calculi, etc.)

The most controversy was engendered by condition #2 with regard to whether mucosal bleeding or glomerulations should be justification for the "IC" designation, or whether only ulcerative disease would get such a designation. Further consultation among members on this point is planned.

The guidelines may propose a new symptom syndrome, "hypersensitive bladder syndrome" or "HBS", previously described by Homma.(1) This is a symptom syndrome comprising bladder hypersensitivity, usually associated with urinary frequency, with or without bladder pain. It is designed to capture patients who complain of pain and those who do not.

The published Asian guideline will incorporate levels of evidence and discuss etiology, epidemiology, diagnosis, and treatment, and can be expected sometime in 2009. In late 2009 or early 2010 it is expected that the American Urological Association guideline will also be published. At that point a process of harmonization among Europe (ESSIC guideline(2;3), North America, and Asia can more readily be accomplished.

Dr. Tomoe then discussed the finding of Hunner's lesions. She proposed that the finding of ulceration is important, especially from a therapeutic standpoint. While hydrodistention may have efficacy in ulcerative and nonulcerative disease, cauterization or resection is a valuable therapeutic modality in the former instance only. Other treatments may also prove more valuable in one type of disease or the other.

Japanese urologists believe the frequency of Hunner's ulcer is about 40%, 4 times higher than reported in the general literature. Dr. Tomoe suggests that the low frequency of Hunner's lesion is a result of overlooking the small vulnus on endoscopy. She believes that some of these small lesions can be easily missed after hydrodistention.

Dr. Ueda then discussed narrow band imaging (NBI), a specialized cystoscopic technology allowing for identification of angiogenic markers of Hunner's lesions without the need for hydrodistention or anesthesia.(4) He reported on 52 patients with symptoms of BPS/IC who were examined. Thirty-seven were found to have ulcers by conventional cystoscopy, and were also recognized by narrow band imaging as capillary-rich brownish areas. In 13 cases, NBI positive areas without ulcer coincided with petechial hemorrhages and glomerulations upon hydrodistention under anesthesia. Further studies are required to ascertain the true specificity of positive NBI findings, but the sensitivity appears quite high.

The meeting concluded with a proposal from Dr. Lin for a collaborative Asian survey on BPS/IC associated disorders including fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and vulvodynia.

The Asian Interstitial Cystitis Society will be in close communication throughout the next several months in order to finalize their guidelines and publish them. Future meetings in Japan and Korea are being planned. This productive group is interested in more integration with European and American efforts in searching for answers and coordinating efforts to optimize therapy for this syndrome.

References
1. Homma Y. Lower urinary tract symptomatology: Its definition and confusion. International Journal of Urology 2008;15(1):35-43.
2. Nordling J, Anjum FH, Bade JJ, Bouchelouche K, Bouchelouche P, Cervigni M, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol 2004 May;45(5):662-9.
3. van de Merwe JP, Nordling J, Bouchelouche P, Bouchelouche K, Cervigni M, Daha LK, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol 2008 Jan;53(1):60-7.
4. Ueda T, Nakagawa S, Okamura K, Tanoue H, Yoshida H, Yoshimura N. New cystoscopic diagnosis for interstitial cystitis/painful bladder syndrome using narrow band imaging system. International Journal of Urology 2008;1-5. doi: 10.1111/j.1442-2042.2008.02179.x

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

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