Pelvic Pain in Urology

Urethral syndrome: response to alpha-adrenergic blocking agents.
Sinha D, Arunkalaivanan A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 1;:1-2.

Urethral syndrome patients have irritative bladder symptoms in the absence of any objective urological findings. While not life threatening, it can have a severe disruptive effect on the quality of life. Attempts at symptom control are not always effective because of lack of clarity about the underlying aetiology. We describe a case of a 27-year-old patient whose irritative bladder symptoms showed response to alpha-adrenergic blocking agents on two separate occasions during the course of her treatment.

Inconsistent localization of gram-positive bacteria to prostate-specific specimens from patients with chronic prostatitis.
Krieger JN, Ross SO, Limaye AP, Riley DE
Urology 2005 Oct;66(4):721-5.

OBJECTIVES: To determine the rate of gram-positive localizations and whether repetitive cultures demonstrate consistent localization of gram-positive bacteria in patients with chronic prostatitis symptoms. METHODS: We repeated localization cultures at different visits for untreated patients with chronic prostatitis symptoms. RESULTS: A total of 470 patients with chronic prostatitis had lower urinary tract localization cultures done. Ten-fold increases in the concentrations of gram-positive bacteria were noted when the postprostatic massage (VB3) or expressed prostatic secretions cultures were compared with first-void urine (VB1) cultures from 29 patients (6%). This was comparable to the 7% rate of gram-negative chronic bacterial prostatitis. We studied 49 patients who had undergone 130 repeated localization studies (median 2, range 2 to 4). Repeatedly negative studies were found in 20 patients, including 19 who each had undergone two studies and 1 who had undergone four studies. Of 9 patients who each had undergone three or four studies, 9 demonstrated localization of at least one gram-positive species. Of the 29 patients with gram-positive localizations, 27 (94%) did not have consistent localization of the gram-positive species. CONCLUSIONS: Patients with chronic prostatitis demonstrated localization of gram-positive bacteria, but the results were seldom reproducible in untreated patients. Gram-positive localizations may represent nonpathogens, transient bacterial colonization of the lower urinary tract, or intermittent shedding of prostatic pathogens. The limitations of traditional cultures highlight the need for better diagnostic approaches and improved recommendations for antimicrobial therapy.

Quality of life and psychological factors in chronic prostatitis/chronic pelvic pain syndrome.
Ku JH, Kim SW, Paick JS
Urology 2005 Oct;66(4):693-701.

Long-term results of amitriptyline treatment for interstitial cystitis.
van Ophoven A, Hertle L
J Urol 2005 Nov;174(5):1837-40.

PURPOSE: We performed a prospective, open label study to examine the safety and efficacy of the long-term administration of the tricyclic antidepressant amitriptyline in patients with interstitial cystitis (IC). MATERIALS AND METHODS: A total of 94 patients were stratified into 2 groups, namely a National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) group of those who fulfilled NIDDK criteria for IC and a nonNIDDK group of those who presented with characteristic IC symptoms but met at least 1 NIDDK exclusion criterion. Amitriptyline was received strictly at bedtime following an established self-titration protocol without a limitation of the maximum daily dose. Patients reporting improvement in a global response assessment questionnaire were considered treatment responders. Further efficacy measures were changes in pain and urgency, functional bladder capacity and frequency. Changes in the O'Leary-Sant IC index and rating of overall satisfaction with the therapeutic outcome were also reported. RESULTS: Mean study followup +/- SD was 19.0 +/- 12.5 months. The response rate was 64% (60 patients). The overall mean dose was 55 mg (range 12.5 to 150). Side effects occurred in 79 patients (84%), including dry mouth in 79% and weight gain in 59%. Patient overall satisfaction with the therapeutic result was excellent or good in 43 (46%). The dropout rate was 31% (29 patients) after a mean treatment period of 6 weeks at a mean dose of 70 mg. Nonresponse to treatment was the primary reason for dropout in all cases, while side effects contributed to dropout in 25 (86%). Improvement in the various IC symptoms was statistically significant compared with baseline. CONCLUSIONS: Long-term administration of amitriptyline is a feasible, safe and effective treatment for IC, provided that the drug is used judiciously to minimize adverse effects. The therapeutic response to amitriptyline was uniformly observed in patients fulfilling NIDDK criteria and in those with the pure clinical diagnosis of IC.

Menstrual cycle affects bladder pain sensation in subjects with interstitial cystitis.
Powell-Boone T, Ness TJ, Cannon R, Lloyd LK, Weigent DA, Fillingim RB
J Urol 2005 Nov;174(5):1832-6.

PURPOSE: Using psychophysical methods we compared the effect of the menstrual cycle on bladder sensation in subjects with the diagnosis of interstitial cystitis (IC) and in controls. MATERIALS AND METHODS: Female participants with normal menstrual cycles, including 7 with IC and 8 healthy controls, were recruited into this study. They completed daily diaries related to bladder pain and other body pain, and tracked daily micturition frequency. In a subset formal psychophysical testing of thermal and ischemic pain was performed at 2 times of the menstrual cycle, corresponding to the luteal and follicular phases. Cystometrograms were performed at the same time. RESULTS: Subjects with IC had higher pain scores and frequency than controls throughout the entire menstrual cycle. Pain scores were highest in the perimenstrual period in subjects with IC and controls. Micturition frequency was highest in the perimenstrual period in subjects with IC. Cystometric evaluation of a first need to void and the evocation of bladder pain demonstrated that lower intravesical volume and pressure were necessary to evoke bladder pain during the follicular period than during the luteal period in subjects with IC, although there was no effect on the first need to void. CONCLUSIONS: These findings are consistent with clinical lore that suggests a perimenstrual flare in pain in subjects with IC. To our knowledge it also demonstrates for the first time a menstrual cycle effect on bladder sensory function in subjects with IC. This suggests a potential role of gonadal hormones on bladder sensory processing and, therefore, a potential role for hormonal modulation as a therapeutic modality in this patient population.

Increased prevalence of interstitial cystitis in women with detrusor overactivity refractory to anticholinergic therapy.
Minaglia S, Ozel B, Bizhang R, Mishell DR Jr
Urology 2005 Oct;66(4):702-6.

OBJECTIVES: To estimate the prevalence of interstitial cystitis in women with detrusor overactivity refractory to anticholinergic medication using the potassium sensitivity test (PST). METHODS: Women with complaints of urinary frequency, urgency, and/or urge incontinence of 3 months' duration or longer were referred to the urogynecology clinic. Between October 2003 and June 2004, 47 consecutive women were diagnosed with phasic, idiopathic detrusor overactivity after evaluation by history, physical examination, urinalysis, urine culture, urodynamic testing, and cystoscopy. Refractory detrusor overactivity was defined as a 50% or less improvement in urinary urgency, frequency, and/or urge incontinence episodes while taking anticholinergic medications. All women were offered the PST. RESULTS: All 47 women were included in the study; 18 (38.3%) had only detrusor overactivity incontinence and 29 (61.7%) also had concomitant urodynamic stress incontinence. Additionally, 19 women (40.4%) had pelvic pain. Of the 47 women, 31 agreed to undergo the PST. Of the 31 women, 25 had positive and 6 had negative PST result. Of the 31 women, 25 did not respond to therapy with one or more anticholinergic medications, and 24 (96%) of these 25 had had a positive PST. The remaining 6 women responded to treatment with oxybutynin, and only 1 (16.7%) had had a positive PST (P = 0.0002). The odds ratio of a positive PST for women in whom anticholinergic therapy failed compared with women in whom it did not was 120.0 (95% confidence interval 6.4 to 2257.5; P = 0.0002). CONCLUSIONS: These preliminary findings suggest that there is a high prevalence of interstitial cystitis in women with detrusor overactivity that does not respond to anticholinergic medication.

International Consultation on IC - Rome, September 2004/Forging an International Consensus: progress in painful bladder syndrome/interstitial cystitis. Report and abstracts.
Hanno P, Keay S, Moldwin R, Van Ophoven A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun;16 Suppl 1:S2-S34.

Painful bladder syndrome/interstitial cystitis.
Rosamilia A
Best Pract Res Clin Obstet Gynaecol 2005 Sep 19;.

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.

Interstitial cystitis: a primary care perspective.
Rosenberg M, Parsons CL, Page S
Cleve Clin J Med 2005 Aug;72(8):698-704.

Interstitial cystitis is more common than previously thought and is often diagnosed only when pain, frequency, and urgency become continuous and severe. Its diagnosis is straightforward, and effective therapies are available. Physicians should keep the diagnosis of interstitial cystitis in mind for all patients presenting with pelvic pain or urinary symptoms.

Prevalence of clinically confirmed interstitial cystitis in women: a population based study in Finland.
Leppilahti M, Sairanen J, Tammela TL, Aaltomaa S, Lehtoranta K, Auvinen A
J Urol 2005 Aug;174(2):581-3.

PURPOSE: Interstitial cystitis (IC) is a clinical condition occurring predominantly in women that is characterized by irritative voiding symptoms, including urinary frequency, urgency and pain. To our knowledge its etiology is unknown and little is known about its occurrence. We evaluated the prevalence of IC in women in Finland. MATERIALS AND METHODS: A total of 2,000 participants were randomly selected from the Finnish population register. Urinary symptoms were evaluated using the validated O'Leary-Sant IC symptom and problem index questionnaire. Women with moderate or severe symptom scores (7 or higher) without any urinary tract infection during the last month were invited to undergo clinical examination. RESULTS: Of the 1,331 respondents 32 had moderate or severe symptoms involving a suspicion of IC, of whom 21 underwent clinical evaluation. Three women were found to have probable IC and 4 had possible IC. Thus, the prevalence of clinically confirmed probable IC in women was 230/100.000 (95% CI 100 to 360) and that of possible/probable IC was 530/100.000 (95% CI 140 to 910). Considering the lack of information on 8 patients with urinary symptoms the corrected estimates were 300/100,000 (95% CI 120 to 770) and 680/100,000 women (95% CI 360 to 1,300), respectively. CONCLUSIONS: Our results based on a large and representative population, and clinically confirmed diagnoses indicate that IC is substantially more common than previously thought.

Prevalence of interstitial cystitis symptoms in a managed care population.
Clemens JQ, Meenan RT, O'Keeffe Rosetti MC, Brown SO, Gao SY, Calhoun EA
J Urol 2005 Aug;174(2):576-80.

PURPOSE: We calculated the prevalence of symptoms typically associated with interstitial cystitis (IC) in men and women in a managed care population in the Pacific Northwest. MATERIALS AND METHODS: International Classification of Diseases-9 based queries of the Kaiser Permanente Northwest, Portland, Oregon database were used to identify subjects with IC exclusion criteria, who were excluded from further analysis. A total of 10,000 questionnaires, including 5,000 for women and 5,000 for men, were mailed to subjects with codes indicating bladder symptoms and to those with none of the codes. The questionnaires included questions about the presence of IC symptoms and the O'Leary-Sant interstitial cystitis questionnaire. IC symptoms were defined in 2 ways, that is as 1) pelvic pain at least 3 months in duration plus urgency or frequency at least 3 months in duration and 2) the same criteria plus pain increasing as the bladder fills and/or pain relieved by urination. RESULTS: The prevalence of IC symptoms according to definitions 1 and 2 was 11.2% and 6.2% in women, and 4.6% and 2.3% in men, respectively. Symptoms were long-standing (duration greater than 1 year in 80% of cases) and bothersome (severity score 5 or greater in greater than 50%). Mean O'Leary-Sant interstitial cystitis questionnaire scores were 15.94 in subjects with definition 1 IC symptoms, 18.97 in those with definition 2 IC symptoms and 6.69 in those with no IC symptoms (p <0.001). Symptoms were most common and most severe in subjects previously diagnosed with IC. CONCLUSIONS: The prevalence of IC symptoms is 30 to 50-fold higher in women and 60 to 100-fold higher in men than the prevalence of a coded physician diagnosis of IC in the same population. Although these findings are not conclusive, they imply that IC may be significantly under diagnosed.

Re: Daha LK, Riedl CR, Lazar D, Hohlbrugger G, Pfluger H. Do Cystometric Findings Predict the Results of Intravesical Hyaluronic Acid in Women with Interstitial Cystitis? Eur Urol 2005; 47: 393-7.
Gupta SK
Eur Urol 2005 Jun 30;.

What is the pain of interstitial cystitis like?
Fitzgerald MP, Brensinger C, Brubaker L, Propert K
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 2;.

To describe the characteristics of pain experienced by patients with interstitial cystitis (IC) in terms of pain site, severity, and character, we performed a secondary analysis of data from the IC database (ICDB), which was a prospective, longitudinal, cohort study of IC patients. We analyzed the cross-sectional baseline data from 629 patients who had a completed baseline symptom questionnaire. Patients answered questions about whether they had pain or discomfort associated with urinary symptoms over the past 4 weeks and if so, about the location, characteristics, intensity, and frequency of their pain. Logistic regression examined associations between pain location and the presence of urinary symptoms. Analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC, USA) and considered significant at the 5% level. Five hundred and eighty-nine (94%) patients with a mean age of 45 years (SD 14 years) reported baseline pain or discomfort associated with their urinary symptoms. The most common baseline pain site was lower abdominal (80%), with urethral (74%) and low back pain (65%) also commonly reported. The majority of patients described their pain as intermittent, regardless of the pain site. Most patients reported moderate pain intensity, across all pain sites. There was a statistically significant link between pain in the urethra, lower back, and lower abdomen, and urinary symptoms. Patients with IC report pain at several sites other than the bladder, possibly arising from the previously well-described myofascial abnormalities of pelvic floor and abdominal wall present in patients with IC and other chronic pelvic pain syndromes.

Absence of bacterial and viral DNA in bladder biopsies from patients with interstitial cystitis/chronic pelvic pain syndrome.
Al-Hadithi HN, Williams H, Hart CA, Frazer M, Adams EJ, Richmond DH, Tincello DG
J Urol 2005 Jul;174(1):151-4.

PURPOSE: We examined bladder biopsies from women with interstitial cystitis/chronic pelvic pain syndrome (IC/CPPS) for the presence of bacterial and viral DNA sequences using polymerase chain reaction. MATERIALS AND METHODS: Bladder biopsies were taken during cystoscopy from patients under investigation for IC/CPPS, or controls undergoing colposuspension for stress incontinence. Biopsies were snap frozen to -70C. After DNA extraction, polymerase chain reaction (PCR) using specific primers for the hypoxanthine-guanine phosphoribosyl transferase gene confirmed the presence of human DNA. PCR for bacterial and viral gene sequences was performed using specific primers. Positive reactions were repeated to confirm the signal. RESULTS: A total of 92 patients with IC/CPPS (12 who met the National Institute of Diabetes and Digestive and Kidney Diseases criteria and 80 who did not) and 91 controls were recruited. PCR for hypoxanthine-guanine phosphoribosyl transferase gene was positive in all samples. PCR for the 16S ribosomal RNA gene, as well as for adenovirus, cytomegalovirus, herpes simplex virus types I and II, human papillomavirus (all subtypes) and Chlamydia trachomatis were negative in all samples. CONCLUSIONS: IC/CPPS is not associated with persistence of viral and bacterial DNA in the bladder. A chronic infective etiology for the condition is excluded by these findings.

Risk factors for painful bladder syndrome in women seeking gynecologic care.
Kennedy CM, Bradley CS, Galask RP, Nygaard IE
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 2;.

The aim of this cross-sectional study was to report risk factors for painful bladder syndrome in women. We surveyed 645 women presenting for care to general gynecology clinics and a vulvar specialty clinic using a standardized questionnaire and validated outcome measures. We used two definitions for painful bladder syndrome, based on the O'Leary-Sant interstitial cystitis symptom and problem indices. Of those women surveyed, 29.5% met broader criteria and 8.5% met more restrictive criteria for painful bladder syndrome. After adjusting for confounders, bladder pain was significantly associated with current smoking, irritable bowel syndrome, and a generalized pain disorder. Tobacco use, the only modifiable association noted on multivariate analysis, has not been previously identified to our knowledge.

Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men.
Anderson RU, Wise D, Sawyer T, Chan C
J Urol 2005 Jul;174(1):155-60.

PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT). MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with a pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom Index. Patient reported perceptions of overall effects of therapy were documented on a global response assessment questionnaire. RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptom scores, as assessed by the PPSS. In those at the 50% or greater improvement level median scores decreased 69% and 80% for pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy. CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy.

Argument for the use of the potassium sensitivity test in the diagnosis of interstitial cystitis.
Parsons CL.
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 2;.

International Consultation on IC - Rome, September 2004 / Forging an International Consensus: Progress in Painful Bladder Syndrome / Interstitial cystitis.
Hanno P.
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun;16 Suppl 1:S2-S34.

INTRODUCTION: Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC).
Cervigni M.
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun;16 Suppl 1:S1.

Intravesical heparin and peripheral neuromodulation on interstitial cystitis.
Baykal K, Senkul T, Sen B, Karademir K, Adayener C, Erden D.
Urol Int 2005;74(4):361-4.

INTRODUCTION: We wanted to evaluate the therapeutic effect of intravesical heparin and peripheral neuromodulation on patients with interstitial cystitis. MATERIALS AND METHODS: From March 2002 to August 2003, 8 female and 2 male subjects conform to the NIDDK criteria and not responsive to the previous conventional treatments were included in the study. Wisconsin pain scores, maximal cystometric capacities, and night and day voiding frequencies were determined and these studies were repeated in the 2nd and 12th months of the treatment with 10,000 units intravesical heparin and peripheral neuromodulation. Frequency of the treatment was once a week during first 8 weeks, once in 2 weeks in the following 8 weeks, and once in 3 weeks four times. Then, it was decreased to once a month. RESULTS: The mean follow-up period was 13 months (12-16 months). Day and night voiding frequency were significantly better in the 2nd and 12th months, when compared to pretreatment values. The Wisconsin pain scores were 62.5 +/- 13.9% and 62.8 +/- 15.2% in the 2nd and the 12th months, respectively. The average increase in the maximum cystometric capacity was 54.8 +/- 27.4% and 52.5 +/- 31.6% in the 2nd and the 12th months, respectively. CONCLUSIONS: Intravesical heparin and peripheral neuromodulation combination seems to be an alternative for patients with interstitial cystitis not responsive to other treatments.

Chronic Scrotal Pain Syndrome: Management among Urologists in Switzerland.
Strebel RT, Leippold T, Luginbuehl T, Muentener M, Praz V, Hauri D.
Eur Urol 2005 Jun;47(6):812-6. Epub 2005 Jan 18.

INTRODUCTION AND OBJECTIVES: Management of patients presenting with chronic or recurrent pain located in the scrotum is often very challenging. Evidence-based literature and clinical practice guidelines for the management of chronic scrotal pain syndrome (CSPS) are not available. We assessed the current perception and management of chronic scrotal pain syndrome by urologists in Switzerland. METHODS: In July 2004, all the members of the Swiss Society of Urology received a questionnaire focusing on diagnostic and treatment practices for the management of chronic scrotal pain syndrome. The questionnaire consisted of 6 topics concerning practice setting, incidence, aetiology, diagnostics, therapy and treatment success rate. RESULTS: 103 questionnaires were completed (63%). All but 2 (2%) responding Swiss urologists see a mean of 6.5 new patients per month (range 1-30). 79% of Swiss urologists consider CSPS to be infectious or post-infectious in nature. Furthermore, a history of vasectomy, psychosomatic disorders, chronic prostatitis, neuromuscular disorders, a history of inguinal surgery, and idiopathic aetiology were mentioned in decreasing order. The most commonly used examinations are urinalysis in 96% and ultrasound in 93%. Additional assessments include blood sampling, duplex ultrasound, assessment for coexisting chronic prostatitis, and referral to an Orthopaedist, Rheumatologist or Psychiatrist. The predominant medication prescribed for CSPS is a non-steroidal anti-inflammatory agent given for a mean of 15.5 days. An antibiotic trial is prescribed by 82% for a mean of 20.5 days. 74% consider epididymectomy the treatment option of choice in recurrence. Inguinal orchiectomy is performed by 7%, microsurgical spermatic cord denervation is performed by 6% of surgeons. Mean estimated recurrence rate after conservative treatment is 48% and thus higher than after epididymectomy with 18%. CONCLUSIONS: Chronic pain located in the scrotum is a common clinical condition in Switzerland. Most urologists consider an infection or post-infectious alterations as the predominant aetiology for CSPS. Consequently, an antibiotic trial in combination with an anti-inflammatory agent is prescribed as first-line therapy. Recurrence rates for conservative treatment are estimated high which is in contradiction to the presumed aetiology. Therefore, further evaluation of this poorly described disease complex is required.

Validation of Spanish version of Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale.
Minaglia S, Ozel B, Nguyen JN, Mishell DR Jr
Urology 2005 Apr;65(4):664-9.

OBJECTIVES: To translate the previously described Pelvic Pain and Urgency/Frequency (PUF) questionnaire into Spanish using a back-translation technique and to validate the Spanish version in a group of bilingual women with symptoms consistent with interstitial cystitis or painful bladder syndrome. METHODS: Bilingual women with complaints of urinary urgency/frequency and/or pelvic pain were randomized to complete initially either the Spanish version or the original English version of the PUF questionnaire followed by the questionnaire in the other language. To evaluate retest reliability, subjects completed the Spanish version a second time 1 week later. Demographic information, including age, ethnic origin, and primary language, was obtained. Paired t tests and Wilcoxon signed rank tests for total PUF score, its two domain scores, and each item were used to assess the difference between the Spanish and English versions. Test and retest reliability of the Spanish version was similarly assessed. Agreement between the Spanish and English versions was assessed by weighted kappa statistics and 95% confidence intervals for each item. P values less than 0.05 were considered significant, and kappa values greater than 0.7 were considered to indicate good agreement. RESULTS: No statistically significant difference was found in the mean or median scores (ie, item, symptom, bother, total) between the English and Spanish versions. Good agreement between English and Spanish versions in all eight items was demonstrated by weighted kappa statistics. The Spanish version demonstrated retest reliability among total scores and seven of eight items when administered 1 week later. CONCLUSIONS: The Spanish PUF questionnaire is a valid and reliable instrument for the evaluation and treatment of patients with interstitial cystitis or painful bladder syndrome.

Early hyperbaric oxygen therapy improves outcome for radiation-induced hemorrhagic cystitis.
Chong KT, Hampson NB, Corman JM
Urology 2005 Apr;65(4):649-53.

OBJECTIVES: To assess the clinical factors that affect the efficacy of hyperbaric oxygen (HBO2) therapy in treating radiation-induced hemorrhagic cystitis. HBO2 therapy is an effective treatment for radiation-induced hemorrhagic cystitis, with reported response rates ranging from 76% to 100%. METHODS: The data from patients with radiation-induced hemorrhagic cystitis treated at our institution between May 1988 and December 2001 were reviewed retrospectively. All patients received HBO2 therapy at 2.36 atm absolute pressure, with 90 minutes of 100% oxygen breathing per treatment. The outcome was assessed after at least 12 months of follow-up. We evaluated patient demographics, types of pelvic malignancy and radiotherapy, total radiation dose, onset and severity of hematuria, and prior intravesical management. Clinical improvement was defined as the absence of, or reduction in, macroscopic hematuria. RESULTS: A total of 60 patients (55 men and 5 women), mean age 70 years, received an average of 33 HBO2 treatments (range 9 to 63). Of the 60 patients, 48 (80%) had either total or partial resolution of hematuria. When treated within 6 months of hematuria onset, 96% (27 of 28) had complete or partial symptomatic resolution (P = 0.003). All 11 patients with previous clot retention had clinical improvement if treated within 6 months of hematuria onset (P = 0.007). Prior intravesical chemical instillation did not affect the clinical outcome. Patients who had undergone primary, adjuvant, or salvage external beam pelvic radiotherapy showed response rates of 81%, 83%, and 78%, respectively (P = 0.950). CONCLUSIONS: Our results show that delivery of HBO2 therapy within 6 months of hematuria onset is associated with a greater therapeutic response rate. Treatment efficacy was independent of prior intravesical therapy and the timing of radiotherapy.

Is the potassium sensitivity test a valid and useful test for the diagnosis of interstitial cystitis?
Hanno P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 15;.

[Management of acute prostatitis, based on a series of 100 cases]
Auzanneau C, Manunta A, Vincendeau S, Patard JJ, Guille F, Lobel B
Prog Urol 2005 Feb;15(1):40-4.

OBJECTIVES: To evaluate the current diagnostic and therapeutic management of acute prostatitis. MATERIAL AND METHODS: The authors report a series of 100 consecutive patients with a diagnosis of acute prostatitis managed between January 1999 and December 2003. They analysed the clinical and laboratory data and imaging findings leading to the diagnosis of acute prostatitis and then the modalities of treatment and follow-up of these patients. RESULTS: The median age was 56.5 years (range: 19-86 years). In 77% of cases, the initial septic syndrome was considered to be severe. Prostatic tenderness was detected on digital rectal examination in 68% of cases. In 76% of cases, the micro-organism responsible was Escherichia coli. 8% of patients had positive blood cultures. All patients presented laboratory signs of inflammatory syndrome, with elevated C Reactive Protein (CRP) in most cases. Renal and bladder ultrasound was performed in 49% of cases and CT was performed in 16% of cases. 92% of patients were treated with fluoroquinolones, as monotherapy in 34% of cases. The duration of prescription ranged from 2 weeks to 6 weeks. No aetiology was detected in 48% of cases, 8% were considered to be iatrogenic and 44% were associated with incomplete bladder emptying. CONCLUSION: Acute prostatitis, rapidly treated by aggressive and adapted antibiotics has a rapidly favourable outcome. Elevation of CRP and the presence of leukocyturia on urine dipsticks are almost constant and, when they are normal, the diagnosis of acute prostatitis should be questioned. Imaging is not required in the absence of diagnostic doubt and any suspicion of progression to abscess. The duration of antibiotic therapy varies from prescriber to prescriber reflecting the various guidelines. Guidelines on this subject are contradictory and further effort is required to achieve homogenization and application of these guidelines.

Clinical characterization of the prostatitis patient in Italy: a prospective urology outpatient study.
Rizzo M, Marchetti F, Travaglini F, Trinchieri A, Nickel JC
World J Urol 2005 Feb;23(1):61-6. Epub 2004 Nov 17.

A prospective multi-center Italian urology outpatient survey, undertaken to determine the prevalence of prostatitis in Italy, provided an ideal opportunity to identify and characterize the typical prostatitis patient presenting to Italian urologists. A total of 70 urologists, representing a cross section of urologic centers in Italy, counted and recorded the overall total male patients reported in the clinic and the overall total patients diagnosed with prostatitis over a 5 week period in late 2001. Data on demographics, previous diagnoses, symptoms (frequency and severity), quality of life, physical examination and laboratory data were prospectively collected. A total of 1,148 patients were identified with prostatitis (12.8%). Of these, 1,074 patients had complete data and could be included in this characterization analysis. The mean age of the prostatitis patients was 47.1 years (range 16-83); two thirds had experienced their first symptom within the last year. A family history of prostatitis was reported by 20.4%. The most common urinary diseases were benign prostatic hyperplasia (17.4%), recurrent urinary tract infection (11.2%) and urinary calculogenesis (11.1%), while the most common concurrent diseases were diabetes (7.2%) and depression (6.8%). The most frequently reported and most severe symptoms at the time of evaluation were irritative voiding symptoms, perineal and suprapubic pain and discomfort. Over three quarters of the patients were dissatisfied with their quality of life. Bacteria were cultured in 15.6%, 17.7% and 14.0% of expressed prostatic secretions, urine specimens after prostatic massage and semen specimens, respectively. Prostatitis is a common outpatient diagnosis, comprising over 10% of male outpatient visits to urologists in Italy. This comprehensive characterization of the typical prostatitis patient diagnosed in routine urological outpatient practice can be employed to generate hypothesis-driven studies in diagnosis and treatment.

A randomized controlled trial of intravesical bacillus calmette-guerin for treatment refractory interstitial cystitis.
Mayer R, Propert KJ, Peters KM, Payne CK, Zhang Y, Burks D, Culkin DJ, Diokno A, Hanno P, Landis JR, Madigan R, Messing EM, Nickel JC, Sant GR, Warren J, Wein AJ, Kusek JW, Nyberg LM, Foster HE
J Urol 2005 Apr;173(4):1186-91.

PURPOSE: We compared intravesical bacillus Calmette-Guerin (BCG) to placebo instillations in patients with treatment refractory interstitial cystitis (IC). MATERIALS AND METHODS: Subjects who met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC, and reported at least moderate pain and frequency for a minimum of 6 months before study entry, were randomized to 6 weekly double-blinded intravesical instillations of either BCG or placebo, and then followed for a total of 34 weeks. The primary outcome was a patient reported global response assessment at week 34, supplemented with medications for IC during weeks 31 to 34. Secondary outcomes included a 24-hour voiding diary, pain, urgency, validated IC symptom indexes and adverse events. The target sample size was 260 participants, designed to detect a difference in response rates between placebo and BCG of 30% and 50%, respectively. RESULTS: A total of 265 participants were randomized and 17 (6%) patients withdrew from study. The response rates for the primary outcome were 12% for placebo and 21% for BCG (p = 0.062). Small improvements were observed for all secondary outcomes, some more so with BCG, but these differences were of borderline statistical significance. Although a large number of adverse events were reported in the BCG arm, there was no statistically significant difference between the treatment arms in overall adverse event rates. CONCLUSIONS: Although the BCG safety profile was acceptable, the response rate for the primary outcome was low. Effective medical treatment for patients with moderate to severe interstitial cystitis remains elusive.

Abnormal urinary potassium metabolism in patients with interstitial cystitis.
Parsons CL, Greene RA, Chung M, Stanford EJ, Singh G
J Urol 2005 Apr;173(4):1182-5.

PURPOSE: If most patients with interstitial cystitis (IC) have epithelial leakage allowing urinary K to penetrate the interstitium and provoke symptoms, urinary K should be lower in untreated patients than in healthy subjects and it should increase with successful heparinoid treatment. This study tested these hypotheses. MATERIALS AND METHODS: Na, K and creatinine (Cr) were determined in spot urine samples from new, symptomatic, untreated patients with IC meeting all National Institute of Diabetes and Digestive and Kidney Diseases clinical diagnostic criteria, returning patients with IC reporting 50% or greater symptom improvement after 4 or greater months of oral heparinoid therapy and control subjects, and in 24-hour urine samples from new untreated patients and controls. RESULTS: In spot urine specimens of 37 new patients with IC K-to-Cr ratios were significantly lower than in 18 controls (0.51 vs 0.88 mg/mg Cr, p = 0.001). A total of 50 successfully treated patients with IC had significantly higher K-to-Cr ratios than those in 37 new patients (0.66 vs 0.51 mg/mg Cr, p = 0.025). Na-to-Cr ratios in the 3 groups were not significantly different. In 24-hour urine specimens 30 new patients had lower average K (31.0 vs 46.2 mEq/l, p = 0.01) and lower K-to-Cr ratios (0.43 vs 0.52 mg K/mg Cr, p = 0.01) than in 47 controls, while Na was not significantly different. CONCLUSIONS: Our finding of lower urinary K in new, untreated patients supports the concept of abnormal epithelial permeability and K absorption in IC. Higher urinary K in successfully treated vs untreated patients may reflect decreasing urinary K absorption due to mucosal repair and a resulting decrease in epithelial permeability. K/mg Cr appears accurate for normalizing urinary K.

Prospective, randomized, double-blind study of safety and tolerability of intravesical resiniferatoxin (RTX) in interstitial cystitis (IC).
Chen TY, Corcos J, Camel M, Ponsot Y, Tu LM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 8;.

Objective: To determine the safety and tolerability of intravesical resiniferatoxin (RTX) in interstitial cystitis (IC) patients. Materials and Methods: IC patients were instilled with 50 cc of test solution containing either placebo, 0.05 muM or 0.10 muM RTX in the bladder. Plasma concentration of RTX and its degradant resiniferonol 9-, 13-, 14-orthophenylacetate was measured. Immediate post-treatment blood sampling and cystoscopy were performed. Symptoms were evaluated before treatment, at 4- and at 12-week follow-ups, using VAS indicator for pain, voiding diary, and O'Leary's IC symptom/problem indices. Results: Among 22 patients observed (ten in 0.10 muM RTX, eight in 0.05 muM RTX, and four in placebo groups), the most commonly reported adverse event was pain during instillation (80.0%, 87.5%, and 25.0%). No serious adverse events were reported. Conclusions: Use of intravesical RTX in IC patients is associated with important tolerability issues but safe at 0.10 muM and 0.05 muM.

Correlation between 2 interstitial cystitis symptom instruments.
Sirinian E, Azevedo K, Payne CK
J Urol 2005 Mar;173(3):835-40.

PURPOSE: Two statistically validated interstitial cystitis (IC) symptom instruments have been used in clinical research. In this study we report what is to our knowledge the first direct comparison of the University of Wisconsin Symptom Instrument (UWI) with the O'Leary-Sant instruments, that is the IC Symptom Index (ICSI) and IC Problem Index (ICPI). MATERIALS AND METHODS: A convenience sampling of 107 patients with IC evaluated at the urology clinic at our institution from March through August 2000 were asked to complete ICSI, ICPI and UWI. The scores were analyzed and graphed. RESULTS: Mean ICSI, ICPI and UWI scores +/- SD were 12.6 +/- 4.3, 10.5 +/- 3.8 and 25.5 +/- 10.8, respectively. UWI and ICSI scores correlated at r = 0.80 (p <0.01) and ICSI/ICPI scores correlated at r = 0.83 (p <0.01). ICSI and ICPI contain 4 symptom-problem pairs. There are relevant differences in the correlation of symptom severity (ICSI question) and its associated problem (ICPI question). The symptom of urgency correlated best with the associated problem (r = 0.84), followed by nocturia (r = 0.82), pain (r = 0.70) and frequency (r = 0.68). CONCLUSIONS: The ICSI and UWI symptom instruments correlate strongly in a large population of patients with IC. The data presented will aid in interpreting the literature. A relatively poor correlation between pain symptom-problem pairs in the O'Leary-Sant instruments is probably an artifact of wording. The word pressure appears in ICPI but not in ICSI. We suggest using parallel wording of the pain symptom-problem pair containing the identical phrase, burning, pain, discomfort or pressure, to improve the ICSI/ICPI correlation and more accurately reflect the clinical condition.

Efficacy of prednisone for severe refractory ulcerative interstitial cystitis.
Soucy F, Gregoire M
J Urol 2005 Mar;173(3):841-3; discussion 843.

PURPOSE: We know that bladder inflammation has been noted in some patients with interstitial cystitis (IC). Studies with corticotherapy were performed about 50 years ago. Since that time few studies have been done with corticotherapy. We evaluated the efficacy of prednisone in patients with chronic severe IC with Hunner's ulcers unresponsive to first line therapies. MATERIALS AND METHODS: A prospective study was performed on 14 patients with evidence of ulcerative IC between 1998 and 2003. The patients received 25 mg of prednisone daily for 1 to 2 months and the dose was then tapered to the minimum required for relief of symptoms. Efficacy was evaluated with the O'Leary symptom and problem index and a 6-point pain scale. RESULTS: Of the 14 patients 9 (64%) were still using prednisone at the end of the study with an average followup of 16 months. In these 9 patients a 38% reduction (p <0.005) in the total score of the O'Leary index was observed. Pain was decreased by 88% (p = 0.0001). There were 5 patients who dropped out of the study due to lack of improvement or side effects. Overall results for the whole cohort included a reduction of 22% (p <0.02) of the total score of O'Leary index and a 69% improvement in pain control (p <0.001). CONCLUSIONS: These results suggest that a trial of prednisone should be considered in patients with severe ulcerative IC otherwise unresponsive to conventional treatment. Improvement in pain control was particularly impressive in this group of patients.

Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis.
Parsons CL
Urology 2005 Jan;65(1):45-8.

OBJECTIVES: To test the efficacy of a new intravesical therapeutic solution in relieving urgency/frequency and pain in interstitial cystitis (IC). METHODS: A solution of 40,000 U heparin, 8 mL 1% lidocaine (80 mg; group 1) or 2% lidocaine (160 mg; group 2), and 3 mL 8.4% sodium bicarbonate was administered intravesically in patients with newly diagnosed IC with significant frequency, urgency, and pain. Using the Patient Overall Rating of Improvement of Symptoms, the response to treatment was evaluated within 20 minutes of instillation in all patients, after 24 to 48 hours in group 2, and after three treatments per week for 2 weeks in group 2 patients who elected to receive additional instillations. Significant symptom relief was defined as 50% or greater symptom improvement. RESULTS: After one instillation, 35 (75%) of 47 patients in group 1 (1% lidocaine) and 33 (94%) of 35 in group 2 (2% lidocaine) reported significant immediate symptom relief. The difference in the response rates was statistically significant (P <0.01). In group 2, 50% of the subjects experienced at least 4 hours of symptom relief from the single instillation, and 16 (80%) of 20 reported significant sustained symptom relief after 2 weeks of treatment. CONCLUSIONS: Intravesical treatment with combined heparin and alkalinized lidocaine immediately reduced the pain and urgency of IC in most patients treated for newly diagnosed IC. Symptom relief lasted beyond the duration of the local anesthetic activity of lidocaine, suggesting the solution suppresses neurologic upregulation. In IC treatment, this new intravesical solution may be helpful in the interval before heparinoid therapy reaches its full effect.

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