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3rd ESSIC Meeting, Baden, Austria, 16-18 June 2005  

Summary of the Meeting by Jørgen Nordling

Scientific and other presentations
Thursday June 16th

The first day starting at 2.30 p.m. was devoted to scientific and other presentations.

Mauro Cervigni gave an extensive and very informative presentation on international activities in the field of PBS/IC during the last years with special focus on the successful international MICA conference in Rome in 2004.

This was followed by an advanced theory of the pathophysiological course of IC by Gero Hohlbrugger. An original noxa to the bladder (cold, psychological stress, medication, infection, autoimmune dysregulation, allergic responses or neuroinflammation etc.) might result in damage to the urothelial cells resulting in inhibition of glycosaminoglycan (GAG) expression. A deficit of GAG provokes sympathetic hyperactivity in the sense of a repair impulse and is most likely the essential inducer of the inflammatory cascades also causing epithelial hyperpermeability. At this stage a potassium test would be positive. If the noxa and/or sympathetic hyperactivity cannot be brought under control e.g. by GAG substitution therapy, the process continues. With time (years) this process “burns out” and the nerves become insensitive and non-reacting. At this stage, the potassium test becomes negative. A highly interesting and promising theory.

Jean-Jacques Wyndaele followed with his presentation on “non-infectious, non-malignant diseases and IC” emphasizing that many confounding diseases or conditions might cause chronic pelvic pain. Pain might come from joints, other organs, fascia, muscles or nerves. Also many bladder diseases such as chemical irritation, immunological (eosinophilic, plasma cell cystitis, isolated vasculitis), bladder endometriosis, sarcoidosis, nephrogenic adenomas, cystitis glandularis and non-malignant hisiocytosis might cause bladder pain. Even more disorders such as infravesical obstruction, urethral diverticulum, bladder calculi, bladder lymphangioma and detrusor overactivity might cause bladder hypersensitivity. Bowel diseases such as constipation, irritable bowel disease, spastic colon, radiation colitis, prolapse, rectal ulcer and congenital cysts might cause pelvic pain. Furthermore, it has been shown recently (Gastroenterology 2005;128:1953-64), that there is evidence of bidirectional cross-sensitization of the colon and LUT.

Claus Riedl presented data on epidemiology of IC in Austria. The O’Leary-Sant symptom and bother score was given to 1143 women and men. 176 persons had felt bladder pain or burning during the last month, but it was only a medium or big problem in 71. This gives a “prevalence” of 6.2-15% of PBS in Austria, a surprisingly high figure.

Dara Lazar found very high figures of sexual dysfunction in females with IC defined by a positive potassium test. Most frequent was hypoactive sexual desire disorder (65%) followed by sexual arousal disorder (40%) and dyspareunia (30%). 52% were unhappy/disappointed with their sex life and 70% reported feelings of guilt. 50% stated feelings of inadequacy and inferiority due to IC.

Gero Hohlbrugger reminded us of the vesico-urethral reflex causing sphincter spasm in IC patients due to the increased sensory input from the bladder. The following outflow obstruction should not be treated surgically but by pelvic floor relaxation therapy.

Claus Riedl had looked at the modified potassium test in IC and non-IC patients. Mean ΔCmax was 43% in the IC group and 3.7% in the non-IC group. The test could not be used to diagnose IC, but to identify IC patients who would benefit from GAG-layer substitution therapy.

Lukas Daha showed that in 13 IC patients with positive clinical effects from GAG-layer substitution therapy the modified potassium test normalized, which was not the case in 10 non-responder patients.

Jukka Sairanen reported on an exciting study from Finland on the effect of cyclosporine A on IC patients. The study was a prospective, randomized unblinded study comparing cyclosporine A (CyA) with Pentosan Polysulfate Sodium (PPS) 100 mg. tid. Symptom score decreased by 15 points from 29.4 in the CyA group, but only by 3.1 points from 30.2 in the PPS group. The same highly significant differences could be demonstrated for pain VAS and frequency. According to the Global Response Assessment (GRA), 24/32 responded in the CyA group versus 6/32 in the PPS group. Highly promising results, but a proper blinded placebo controlled study is still needed.

Arndt van Ophoven reported long-term results of amitriptyline treatment demonstrating very good results including in the longer term.

Gustav Kiss reported on the experience with sacral nerve stimulation in Innsbruck. This is still a controversial issue, but the results in 6 patients in Innsbruck were promising.

Jørgen Nordling reported on the last 5 years’ results on urinary diversion for PBS in Herlev. Eleven patients had received a urinary diversion (Bricker bladder) without cystectomy. Ten became pain-free. The eleventh had a cystectomy, but was not rendered pain-free by that either. One patient had a cystectomy due to recurrent pyocystos. The conclusion was that while urinary diversion might be a good option in severely debilitated patients, cystectomy is not necessary during the same procedure.

Claus Riedl had collected treatment data from 7 ESSIC members. GAG substitution was used by 6 (hyaluronic acid/PPS/heparin), amitriptyline by 4 and antihistamines by 3. Hydrodistension was used as a treatment was by 2 as well as EMDA, SANS/PTNS, DMSO and gabapentin/pregabalin. The discussion ended with a treatment algorithm, which was approved by the Society.

Criteria for the diagnosis of PBS/IC

Friday 17th was almost totally dedicated to discussion on criteria for the diagnosis of PBS/IC.

The day was superbly directed by Joop van de Merwe, who will provide a more comprehensive review of the day and the future in due course.

The day started with a review by Jørgen Nordling on the results from NIH ICDB study followed by Joop van de Merwe on the design of diagnostic criteria.

Claus Riedl, Magnus Fall, Martina Tinzl, Thomas Horn, Nigel Phillips, Mauro Cervigni, Martin Häusler and Jean-Jacques Wyndaele gave reviews on the potassium test, cystoscopy, markers, morphology, physiology of the GAG-layer, gynaecological aspects, endometriosis and non-infectious/non-malignant diseases in the bladder and pelvis.

This was followed by an extremely interesting and productive session on confusable diseases, chaired by Joop van de Merwe.

During the final discussion, it was decided that ESSIC should for the time being accept and support the ICS definition of PBS (painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary tract infection or other obvious pathology). ESSIC decided that the last sentence does not include pathology typical of interstitial cystitis. The diagnosis of interstitial cystitis could not be made unless typical cystoscopic (glomerulations, Hunner’s vulnus) or morphological (mononuclear inflammatory cells including mast cell infiltration and granulation tissue) were demonstrated. Since the cystoscopic and morphological changes in the bladder are changeable over time, a patient with typical symptoms but without objective findings should be reinvestigated after a period of time. Until cystoscopic and/or morphological findings are demonstrated, the patient should be diagnosed as having PBS.


Course for regional physicians on final day

Saturday June 18th

A course on PBS/IC was held for interested physicians from the region.

Nomenclature, diagnosis and differential diagnosis as well as treatment were addressed during a comprehensive programme. This extremely successful course was attended by about 25 physicians from as far afield as Prague and Budapest.

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