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Diagnosis of PBS/IC

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  1. Diagnosis of PBS/IC Sang-Kuk Yang Konkuk University

  2. Diagnosis : NIDDK • NIDDK criteria • developed at 1987 NIDDK conference  revised in 1988 • developed to standardize criteria for entrance into research protocols • inclusion criteria • must have glomerulation or Hunner’s ulcers on hydrodistention • exclusion criteria • bladder capacity >350cc • phasic involuntary contractions • duration of symptoms < 9months • Frequency < 8/day • Age < 18 years Hanno PM et al. J Urol 1999;161:553-7

  3. Diagnosis : NIDDK ICDB • NIDDK ICDB criteria • Broaden criteria – include IC-like patients • Unexplained urgency or frequency or pelvic pain of 6 months • baseline cystoscopy : not mandatory • less strict than the NIDDK criteria  NIDDK criteria : too restrictive for clinical use  ICDB criteria : led to increasing numbers of patients being diagnosed Hanno PM et al. J Urol 1999;161:553-7

  4. Definition of ICS • Painful bladder syndrome  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 infection or other obvious pathology • Interstitial cystitis : subset of PBS  a specific diagnosis and requires confirmation by typical cystoscopic and histologic features “Without specific definition of bladder lesion” Abrams P et al. Neurourol Urodyn 2003;21:167-78

  5. Disparity in Prevalence data Prevalence varys Widely depending upon Definition and methodology

  6. Multifactorial etiology of PBS/IC

  7. PBS becoms BPS ? Interstitial cystitis Bladder pain syndrome Urological Pelvic pain syndrome Chronic pelvic pain

  8. Diagnosis : Clinical History • Symptoms Pelvic pain : essential • Typical suprapubic pressure sensation • Pain should be brodened to “pressure” and “ discomfort” • Pain in lower abdomen, low back, inguinal area, vagina, urethra, scrotum or testes, multiple locations • Pain with/after intercourse in vagina, penile shaft can last for days. • Dysuria • Over 50% with constant pain – severity is highly variable • Pain characterized as spasms, worse in upright position, worse with emotional stress

  9. Diagnosis : Clinical History • Symptoms Frequency / Urgency  Frequency : May be presenting Symptom  Urgency : Confused with OAB Sx  often develops gradually – not noticed immediately  8~60 voids/day  nocturia - variable

  10. Diagnosis : Problem • Symptoms Problems • the diagnosis of PBS/IC is clinical and based on symptomatology • PBS/IC is a diagnosis of exclusion. • there is no evidence to qualify or quantify the symptoms to include or exclude patients from the diagnosis of PBS/IC.

  11. Differential Diagnosis

  12. Diagnosis : Sx index • Clinical symptom scales  evaluate the severity of symptomatology monitor disease progression or regression • O’Leary/Sant symptom index = ICSI • University of Wisconsin • Pelvic pain (VAS) and Urgency/Frequency Scale Problems • None shown to be of value for diagnosis

  13. Diagnosis : PE • Physical examination • abdominal, pelvic and neurological exam findings • suprapubic tenderness to deep palpation on bimanual exam • bladder base and urethra tender in females • spasticity of levator muscles • males with normal genitalia and DRE • exam must R/O : active vaginitis, urethral diverticulum, CaP, POP

  14. Diagnosis • Hydrodistention under cystoscopy • Method • should be done under anesthesia to allow sufficient distention • irrigant should be 80~100 cmH2Oabove bladder to avoid rupture • distention held at capacity for 1~2 mins, then drained • Positive findings • glomerulations • Hunner’s ulcer • Fissures and Fibrosis that bleeds • Important to R/O – CIS, papillary bladder cancer

  15. Diagnosis : Hydrodistention • Hydrodistention under cystoscopy Problems • cystoscopic findings (Hunner’s ulcer, glomerulations) are not well described and classified • glomerulations not specific for IC – seen in most inflammations • glomerulations absent in up to 20% of patients with classic symptoms • no correlation between degree of glomerulations and symptoms  research into treatment results and prognosis as related to cystoscopic findings is needed. • only Hunner’s ulcers – diagnostic for IC

  16. Glomerulation in ureter stone patient

  17. Diagnosis : Cystoscopy • Hydrodistention under anesthesia Glomerulation Hunner’s ulcer

  18. Diagnosis : PST • Potassium sensitivity test (PST, Parsons test) • Saline vs 0.2 M KCl infusion : 500 cc • positive test may indicate increased permeability and/or increased neural activity. • easy to perform – office procedure Problems • not recommended as diagnostic tool – inflammatory diseases like radiation and bacterial cystitis, malignancy have positive test. • not physiologic of concentration of KCl • Low sensitivity (69.5%) low specificity (50%, positive, chronic prostatitis, gynecologic pain) Parsons CL et al. Neurourol Urodyn 1994;13:515-20, Chambers GK et al. J Urol 1999;162:699-701

  19. Diagnosis : UDS OAB PBS/IC Pain

  20. Overlapping Sx of PBS with OAB Kirkemo A et al. Urology 1997; 49 suppl 1:76-80

  21. Diagnosis : Bladder biopsy • Bladder biopsy • confirm diagnosis and for DDx • pathologic findings are not well described and classified • therapeutic benefit from accompanying hydrodistention • Fibrosis – prognostic value • research purposes Problems • costs and complications • No pathognomonic findings Sant GR etl al. Urology 2001;57 suppl 1:82-8

  22. Diagnosis : Clinical markers • Antiproliferative factor (APF) • unique protein found only in urine of IC patients • APF is expressed solely in the bladder epithelium of IC patients with no expression evident in normal human bladder epithelial cells. • APF activity and altered levels of HB-EGF and EGF identified in IC urine are related • APF up-regulates bladder epithelial cell production of EFG and down-regulates production of HB-EGF in vitro Erickson DR et al. Urology 2001;57 suppl 1:15-21, Erickson DR et al. J Urol 2007;177:556-60

  23. Diagnosis : Clinical markers • Antiproliferative factor (APF) Implications • APF may cause the epithelial thinning or ulceration seen in IC • urine APF may be useful as a diagnostic biomarker for IC, and as a disease parameter for treatment studies • agents that inhibit APF production or activity may potentially be useful for the treatment of IC

  24. When Suspect IC/PBS ? Pain, Frequency/Nocturia and Urgency AND Physical exam excludes Vaginitis, Urethral or Vulvar lesion or Infection AND UA is negative for Hematuria AND Urine culture during symptoms is Negative AND No Hx of Neurological problem, Pelvic trauma, Malignancy of recent Pelvic Surgery

  25. Beset with Problem • Lack of uniform definition PBS/IC • Unknown etiology • Uncertain pathophysiology • Lack of standardized methodology • Lack of readily available diagnostic marker

  26. What is Needed ? • Evidence-based, symptom-specific definition • Studies on true incidence, prevalence, natural history, risk factor • Validate diagnostic marker • Ability to differentiate PBS/IC from myriad of other causes of voiding dysfunction and bladder pain

  27. Thank You !