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AUA 2015 Recap
In between manning the ICA booth in the Urology Care Foundation’s (UCF) Patient Advocacy Hub, ICA staff attended the presentations. Here’s a recap of some of the most IC-relevant courses, presentations, lectures, and poster sessions.
A psychometric analysis of pain and urinary symptoms in patients with interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome: Findings from MAPP Research Network
Griffith, James (Chicago, IL); Griffith, James; Edwards, Todd; Hong, Barry; Sutcliffe, Siobhan; Pontari, Michel; Afari, Niloofar; Krieger, John; Lloyd, Robert; Tu, Frank; Williams, David; Patrick, Donald; Kim, Jayoung; Naliboff, Bruce; Lai, Henry; Bradley, Catherine; Mullins, Chris; Landis, Richard
It has become apparent to clinicians that improved approaches are needed to better characterize the course of interstitial cystitis/bladder pain syndrome (IC/BPS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). These conditions are collectively referred to as urologic chronic pelvic pain syndromes (UCPPS). The purpose of this research was to examine the number of factors among a large set questionnaire items, which helps to understand the symptom structure of pelvic pain, as well as to create simple indices to characterize changes in symptoms. The researchers found that UCPPS can be measured using two simple indices. Two meaningful factors are evident (pain versus urinary symptoms), and these two factors show differential relationships with important comorbidities, such as depression. Future analyses within MAPP will characterize symptom changes over time and study their relationship with other comorbid symptoms and biomarkers.
Comparison of baseline urologic symptoms in men and women with interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome
Clemens, J. Quentin (Ann Arbor, MI); Clauw, Daniel J.; Kreder, Karl J.; Krieger, John N; Kusek, John W; Lai, H. Henry; Rodriguez, Larissa V.; Williams, David; Hou, Xiaoling; Stephens, Alisa; Landis, J. Richard
It’s a common knowledge in the IC community that the clinical features characteristic of IC are similar to those of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). However, no studies have directly compared the clinical characteristics of these syndromes in men and women. NIH established the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) network in part to apply novel phenotyping strategies to these conditions. The purpose of this study was to test one of the hypotheses of the MAPP network, that IC and CP/CPPS represent the same underlying condition. There have been many studies that have described symptoms of patients with either IC or CP/CPPS, yet this was the first study to prospectively recruit men and women with both urologic pain syndromes and to compare these syndromes using the same instruments. Their findings confirm the similarities between these syndromes. However, additional information about the pathophysiology of these symptoms is needed to determine if these common urologic pain syndromes truly represent the same underlying condition.
One highlight of AUA2015 was a presentation by Drs. J. Curtis Nickel, Dan Shoskes and Michel Pontari. In their lecture, they chronicled the cases of two men struggling with pelvic pain. Their main point of emphasis was that urologists should not assume that all pelvic pain cases in men are the result of prostate infection. Consequently, not every case should be treated with antibiotics. Instead, they explained that a provider should assess and then treat ALL of the conditions contributing to pelvic pain using the UPOINT Diagnostic System (urinary, psychosocial, organ-specific, infection, neurologic or non-bladder, and tenderness of pelvic floor). When they do so, they showed that 77% of patients have symptom improvement. In fact, some see a complete resolution of their symptoms. The UPOINT Diagnostic System represents a very significant change in the way physicians treat patients, and the doctors urged urologists to expand their examination and look beyond the prostate and the bladder to the pelvic floor muscles. Importantly, Dr. Nickel concluded the presentation by encouraging doctors, despite their reservations, to treat pelvic pain patients.
Canadian Journal of Urology study highlights the benefits of heparin and alkalinized lidocaine combination formulation for the relief of interstitial cystitis symptoms
A recent study highlighted the benefits of a heparin and alkalinized lidocaine combination formulation for the relief of interstitial cystitis symptoms as well as demonstrated that a combination of heparin and alkalinized lidocaine formulation yielded higher lidocaine absorption versus lidocaine alone. The report, conducted by a team of researchers led by C. Lowell Parsons, MD stated the instillation resulted in significantly better relief of interstitial cystitis (IC) symptoms including relief of pain and urinary urgency, as compared to alkalinized lidocaine alone. In addition, a separate study also concluded that the combination heparin and alkalinized lidocaine produced higher lidocaine absorption than unalkalinized lidocaine alone.
Long-term efficacy and safety of onobotulinumtoxinA in patients with neurogenic detrusor overactivity: Analysis among patients who completed 4 years of treatment
This study investigated the safety and efficacy of intradetrusor injection of onabotulinumtoxinA in patients with neuropathic bladder dysfunction. The results showed that around 90% of patients had greater than a 50% reduction in incontinence episodes per day and over time, there was no decrease in the effect of the onobotulinumtoxinA. Therefore, this study provides clinicians with a good sense of the long-term efficacy of onabotulinumtoxinA for neurogenic bladder. It also allows for explaining to patients that they can expect around 1.5 injections per year and that the effectiveness of the injections does not decay over time.
Does asymptomatic bacteriuria increase the risk of urosepsis or modify intra-detrusor botulinum toxin A (BoNTA) efficacy?
The investigators of this study hypothesized that asymptomatic bacteriuria – the occurrence of bacteria in the urine without causing symptoms – does not increase the risk of sepsis or modify the efficacy of onabotulinumtoxinA. In the end, results showed that positive cultures were not associated with hematuria (blood in the urine) or urosepsis (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream). However, positive cultures at the time of injection were associated with a 15.9 times increase in the odds of symptomatic urinary tract infection. In addition, bladder capacity was found to be unchanged in patients with positive cultures at the time of injection. During the question and answer period, the audience noted that this study filled a knowledge gap in the practical use of botulinum toxin in a population with a high prevalence of positive cultures.
Crossfire: Controversies in Urology: Neuromodulation should be the first choice over botulinum toxin for idiopathic detrusor overactivity
Dr. Dirk De Ridder opened the session by reviewing the evidence in the European Association of Urology guidelines for urinary incontinence. The guidelines give onabotulinumtoxinA injection and Sacral Neuromodulation a Grade A recommendation for refractory detrusor overactivity. Both therapies have been proven effective, and the debaters set out to educate the audience on the subtleties of choosing between the two. Their main points were:
Pros (In favor of neuromodulation):
- Should be the preferred treatment for refractory idiopathic overactive bladder.
- Some studies show that nearly twice as many patients are completely dry with sacral neuromodulation compared to botulinum toxin.
- Incidence of heavy leaks are also more significantly lessened.
- Neuromodulation offers patients the benefits of continued voiding efficiency with improved voided volumes and without the risk for needing to catheterize.
- Neuromodulation can lead to improvements in related pelvic floor symptoms, including constipation and fecal incontinence.
- Neuromodulation is restorative, with proven effectiveness and safety after over 20-years of use.
- Neuromodulation can be used as a comprehensive treatment for pelvic floor disorders including pain and defactory symptoms.
- Neuromodulation has a favorable adverse event profile with a lack of urinary retention and urinary tract infection risk compared with botulinum toxin injection.
- When a trial of neuromodulation does not work for a patient, they may then immediately be transitioned to a regimen of botulinum toxin, whereas patients who have undergone botulinum toxin may not return to baseline for 6-9 months, causing a delay in treatment with neuromodulation.
Cons (In favor of botulinum toxin):
- In cost-effectiveness comparisons of both therapies, the cost of office-based botulinum toxin injection makes it more accessible.
- Botulinum toxin has high rates of persistence.
- Botulinum toxin has high patient acceptance rates.
- Patients and providers have very minimal burden with office-based botulinum toxin injection.
- Even the most severe adverse effects of requiring catheterization after injection are temporary and do not degrade the quality of life improvements offered by this treatment.
- AUA/SUFU guidelines indicate that botulinum toxin is a “Standard” for third line therapies for refractory overactive bladder as sacral neuromodulation is considered a “Recommendation.”
This conversation was rewarding for all attendees as the noted experts in the field of voiding dysfunction and incontinence clearly defined the issues clinicians face in choosing between these two therapies.
Does the interstitial cystitis symptom and problem index reliably measure overactive bladder symptoms?
Gilleran, Jason (Royal Oak, MI); Killinger, Kim A.; Bartley, Jamie; Boura, Judith A.; Peters, Kenneth M.
The validated Interstitial Cystitis Symptom and Problem Index (ICSI-PI) reliably measures symptoms and associated bother in patients with interstitial cystitis. In this study, researchers attempted to evaluate whether the ICSI-PI reliably measures overactive bladder (OAB) symptoms in patients with OAB and without incontinence (OAB wet/dry). It was determined that even though pain is not a component of the OAB syndrome, the ICSI-PI appears to reliably measure voiding symptoms and bother in patients with OAB.