Trigonal Injection of Botulinum Toxin A in Patients with Refractory Bladder Pain Syndrome/Interstitial Cystitis

Transcription

1 EUROPEAN UROLOGY 58 (2010) available at journal homepage: Platinum Priority Pelvic Pain Editorial by George A. Barbalias on pp of this issue Trigonal Injection of Botulinum Toxin A in Patients with Refractory Bladder Pain Syndrome/Interstitial Cystitis Rui Pinto a,b, Tiago Lopes a,bárbara Frias b,c, André Silva a,b, João Alturas Silva a,b, Carlos Martins Silva a,b,c,célia Cruz b,c, Francisco Cruz a,b,c, *, Paulo Dinis a,b,c a Department of Urology, Hospital de São João, Portugal b Faculty of Medicine, University of Porto, Portugal c Institute of Histology and Embryology (Faculty of Medicine of Porto) and Instituto de Biologia Molecular e Celular, University of Porto, Portugal Article info Article history: Accepted February 23, 2010 Published online ahead of print on March 6, 2010 Keywords: Bladder pain syndrome Interstitial cystitis Botulinum toxin NGF BDNF Bladder trigone Pain Abstract Background: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease without an effective treatment, characterized by pain during bladder filling. Most nociceptive bladder afferents course in the trigone. Objective: To evaluate efficacy and tolerability of trigonal injection of botulinum toxin A (BoNTA) in patients with BPS/IC. Urine concentration of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) were also evaluated. Design, setting, and participants: Women with refractory BPS/IC were included in an open, exploratory study. Intervention: Under sedation, 100 U of BoNTA (Botox) were injected in 10 trigonal sites (10 U per 1 ml saline). Retreatment was allowed 3 mo after injection. Measurements: Pain, urinary frequency, O Leary-Sant score (OSS), quality of life, (QoL), and urodynamic testing at 1 and 3 mo and every 3 mo thereafter. Urine NGF and BDNF were assessed at the same points. Patients who were retreated were evaluated every 3 mo. Results and limitations: All patients reported subjective improvement at 1- and 3-mo follow-up. Pain, daytime and nighttime voiding frequency, OSS, and QoL improved significantly. Bladder volume to first pain and maximal cystometric capacity more than doubled. Treatment remained effective in >50% of the patients for 9 mo. Retreatment was also effective in all cases, with similar duration. A significant, transient reduction in urinary NGF and BDNF was observed. No cases of voiding dysfunction occurred. The low number of patients and the lack of a placebo arm are obvious limitations of this study. Conclusions: Trigonal injection of BoNTA is a safe and effective treatment for refractory BPS/IC. # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Hospital S. Joao, Faculty of Medicine of Porto and IBMC of Porto, Porto, Portugal. Fax: address: cruzfjmr@med.up.pt (F. Cruz) /$ see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 EUROPEAN UROLOGY 58 (2010) Introduction The International Continence Society (ICS) has defined painful bladder syndrome as the complaint of suprapubic pain related to bladder filling accompanied by other symptoms such as daytime and nighttime voiding frequency in the absence of a proven urinary infection or other obvious pathology [1]. The European Society for the Study of Interstitial Cystitis (ESSIC), in an attempt to use a consistent pain syndrome terminology, has preferred the term bladder pain syndrome (BPS). BPS is defined as pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder, accompanied by at least one other urinary symptom such as a persistent urge to void or increased daytime and nighttime voiding frequency [2]. The definition of interstitial cystitis (IC) should probably be restricted to cases that include typical cystoscopic and histologic features [1,2]. In this paper, the designation BPS/IC will be used. The etiology of BPS/IC is unknown. Therefore, BPS/IC management is directed to pain relief, as bladder pain is believed to drive both voiding frequency and nocturia. Botulinum toxin A (BoNTA) has been shown to decrease noxious input [3,4]. The analgesic effect of BoNTA presumably results from decreased neuropeptide release at peripheral extremities [5], and glutamate, substance P, and calcitonin gene-related peptides from the central endings of bladder sensory nerves [5]. In the first case, neurogenic inflammation is prevented, and in the second, nociceptive transmission becomes inhibited at the spinal cord. Most nociceptive bladder afferents are concentrated in the trigone [6]. This may suggest that previous studies that injected the entire bladder of BPS/IC patients with BoNTA [7,8] placed most of the neurotoxin far from the nociceptive fibers and increased the risk of decreasing detrusor contractility. The hazard of vesicoureteral reflux after trigonal BoNTA is nonexistent [9]. Therefore, we undertook a pilot study evaluating the effectiveness, safety, and duration of treatment/retreatment of BPS/IC patients with BoNTA applied exclusively to the trigone. Additionally, the urine concentration of two neurotrophic factors known to influence the activity of nociceptive afferent fibers nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) was assessed. The urinary levels of NGF were previously shown to be increased in BPS/IC patients [10]. However, BDNF, an equally ubiquitous neurotrophin, has never been investigated in this disease. 2. Material and methods Twenty-six women with BPS/IC gave written informed consent to receive BoNTA, a practice that has been approved by the ethics committee of our institution in refractory cases. Patients were informed about the possible complications of BoNTA administration, including the necessity of occasional self-catheterization. All patients had experienced symptoms for >6 mo and had undergone cystoscopy with hydrodistension and bladder biopsy under general anesthesia. Previous unsuccessful treatments included oral pentosan polysulphate, amitriptyline, intravesical heparinoids, and intravesical dimethyl sulfoxide. Two patients had had intravesical Fig. 1 Location of trigonal injection sites. Each site was injected with botulinum toxin A, 10 U per 1 ml saline. resiniferatoxin 2 yr previously. Pregnancy, neurologic diseases, urinary tract infections (UTIs), aminoglycoside use, bladder outlet obstruction, detrusor overactivity, urinary incontinence, bladder stones, and previous pelvic radiotherapy were exclusion criteria. All patients were evaluated by history, physical examination, serum biochemistry, urinalysis, urine culture and cytology, and imaging assessing the upper and lower urinary tracts. Pain intensity was scored using a 10-point visual analog scale (VAS). Patients provided a 3-d voiding frequency volume chart [11], and the O Leary-Sant score (OSS) was used to assess symptoms and problems. Quality of life (QoL) was evaluated using question 8 of the International Prostate Symptoms Score. Pressure-flow studies (Dantec Dynamics Ltd., Bristol, England), followed ICS directives. A 6-French dual-channel catheter was used, infusing saline at room temperature (25 ml/min). Bladder volumes for first sensation/pain of bladder filling, maximum cystometric capacity, maximum urinary flow rate during voiding phase (Q max ), bladder contractility index, and postvoid residual (PVR) volume were assessed. BoNTA (Allergan, Irvine, CA, USA) was injected under light sedation through a 23-gauge needle (Coloplast A/S, Humlebaek, Denmark) inserted 3 mm into the trigonal wall underneath cystoscopic control. A total of 100 U was distributed throughout 10 sites (10 U per 1 ml saline, Fig. 1). Patients received prophylactic ciprofloxacin; specifically, 500 mg twice a day for 3 d. After 2 wk, PVR volume and muscle weakness were assessed. Urine was collected for culture. Patients were further evaluated at 1 and 3 mo and every 3 mo thereafter using VAS for pain, a 3-d voiding chart, OSS, QoL, and urodynamic investigations, as performed at baseline. Patients could ask for retreatment after the 3-mo visit if they reported symptom reappearance and OSS and VAS confirmed a return to baseline values. Urinary NGF and BDNF were also measured in the last 10 patients, at baseline and at 1, 3, and 6 mo after BoNTA injection. Urine samples were collected at a full bladder sensation, immediately put on ice, and centrifuged (3000 rpm; 10 min at 4 8C). The supernatant was collected in 1.5-ml tubes and stored at 80 8C. NGF and BDNF concentrations were determined by ELISA (Emax Immunoassay System, Promega, Madison, WI, USA), with a minimum sensitivity of 3.9 pg/ml and 7.8 pg/ml, respectively, following the manufacturer s instructions. Briefly, 96-well plates were coated with anti-ngf/bdnf polyclonal antibodies. Urine or NGF/BDNF standards were added to each well, and plates were incubated. After several washes, anti-ngf/bdnf monoclonal antibodies were added, and plates were again incubated. After thorough washes, the amount of bound monoclonal antibody was detected using immunoglobulin G horseradish peroxidase-conjugated antibody. The unbound conjugate was washed out, followed by a 10-min incubation with a 100 ml substrate solution at room temperature. Hydrochloric acid was added to terminate the reactions. Color change was measured with a Synergy HT Microplate Reader (Bio-Tek Instruments, Winooski, VT, USA)

3 362 EUROPEAN UROLOGY 58 (2010) Table 1 Classification of patients according to European Society for the Study of Interstitial Cystitis criteria [2] Bladder pain syndrome classification Biopsy X (not done) A (normal) B (inconclusive) C (positive) Cystoscospy with hydrodistension X (not done) (normal) (glomerulations) (Hunner s lesion) Table 2 Data at baseline and after first and second treatments First treatment baseline First treatment, first month First treatment, third month Second treatment baseline Second treatment, third month Pain visual analog scale (0 10) * * * Daytime frequency * * * Nighttime frequency * * * O Leary-Sant score for symptoms (0 20) * * * O Leary-Sant score for problems (0 16) * * * Quality of life (0 6) * * * Bladder volume for first sensation/pain (ml) * * * Maximum cystometric capacity (ml) * * * Bladder contractility index (P det Q max +5Q max ) Maximum urinary flow rate (ml/s) Postvoid residual volume (ml) * p < at 450 nm. All samples were run in duplicate, and values were averaged. NGF and BDNF levels were normalized to the urinary concentration of creatinine. Results are presented as mean values plus or minus standard deviations. A paired t test was used for intragroup comparisons. A Wilcoxon test for nonparametric data was used for multiple comparisons. Kaplan-Meyer plots were applied to the duration of treatment. A p value of <0.05 was considered statistically significant. Analysis of data was performed using IBM SPSS v.18.0 for the Macintosh (SPSS Inc., an IBM Company, Chicago, IL, USA). 3. Results Patients had a mean age of yr. All patients had typical cystoscopic findings, and the majority had positive findings in bladder samples. The ESSIC classification for all 26 patients is presented in Table 1. Symptoms were present for 5 2 yr. Table 2 shows VAS value, daytime and nighttime voiding frequency, OSS and QoL scores, and urodynamic parameters at baseline. No patient had detrusor overactivity. After 2 wk of treatment, no patients reported voiding difficulties, high PVR, or UTI. Urine cultures were all negative. Sixteen patients were followed for 2 yr. The last 10 cases had a follow-up of 6 mo. At 1-mo and 3-mo follow-up, voiding difficulties namely, hesitancy, a weak or intermittent stream, or high PVR (Table 2) were not observed. UTIs did not occur. A marked decrease in OSS symptoms and problems at 1 and 3 mo was observed (Fig. 2). In addition, pain intensity, daytime and nighttime voiding frequency, and QoL decreased significantly, whereas bladder volume to first pain sensation and maximum cystometric capacity increased significantly (Table 2). Bladder contractility Fig. 2 O Leary-Sant score for symptoms (0 20) and problems (0 16) at baseline and after first treatmen. *=p < 0.05.

4 EUROPEAN UROLOGY 58 (2010) Fig. 3 Kaplan-Meyer plot for duration of first and second treatment. The two curves overlap in most of their extension (in the first treatments, 10 patients currently have only 6-mo follow-up). index, Q max, and PVR were not changed (Table 2). At 6-mo follow-up, 3 of 26 patients requested retreatment. At 9 mo, 4 of 13 patients made the same request. At 12-mo follow-up, nine patients that reached this visit were retreated. Considering only the patients followed-up to retreatment (16 for the first treatment and 16 for the second treatment), the average duration of clinical improvement was mo after the first treatment and after retreatment. Sixteen patients were retreated. Before reinjection, OSS symptom and problem score, VAS, daytime and nighttime voiding frequency, and QoL were slightly inferior to baseline values at presentation. Although not accompanied by hydrodistension, the appearance of the mucosa was similar to baseline at reinjection cystoscopy. A significant improvement was nevertheless detected in all these parameters at the 3-mo visit (Table 2). No cases of voiding dysfunction were reported. Five UTIs were detected. All 16 patients were observed at the 6-mo visit, and 2 asked for a third BoNTA injection. At the 9-mo visit, 5 of the 14 remaining patients Fig. 5 Urine concentration (pg/mg) of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) at baseline and after treatment. *=p < also asked for retreatment. At 12 mo, all the remaining nine patients asked for a third injection (Fig. 3). OSS applied to normal individuals shows combined scores below 14 [12]. Using this criteria, all patients had a combined OSS score below 14 after the first treatment, and only one had a score above that cut off after the second treatment (Fig. 4, Table 2). NGF changed from pg/mg at baseline to , , and pg/mg after 1, 3, and 6 mo, respectively ( p < 0.05 at first and third months). BDNF changed from to , , and , respectively, at the same time points ( p < 0.05 at the first month) (Fig. 5). At 1 mo, a strong correlation was found between the absolute decrease in NGF and BDNF concentration and the absolute decrease of pain intensity in the VAS (Fig. 6). 4. Discussion Fig. 4 O Leary-Sant symptom and problem combined score of all patients distributed by tertiles after first and second treatment. A score <14 is found in normal subjects [11]. This work showed that trigonal injection of BoNTA improved lower urinary tract symptoms, including pain and frequency, in the entire cohort. More than half the patients reported symptom improvement during at least the first 9 mo of treatment. At 1-yr follow-up, all patients requested retreatment, which was as effective and safe during a similar period of time. At reinjection, the

5 364 EUROPEAN UROLOGY 58 (2010) Fig. 6 Correlation between the absolute decrease of urinary concentration of nerve growth factor (D NGF) and brain-derived neurotrophic factor (D BDNF) and absolute decrease of pain intensity (D VAS; VAS = visual analog scale) at 1-mo follow-up. R 2 = multivariate coefficient of determination. cystoscopic appearance of the mucosa was similar to that at baseline. As interim cystoscopies were not planned, we do not know whether BoNTA treatment improved mucosa appearance in parallel with symptom regression. The trigone contains a dense suburothelial network of nociceptive fibers [6] that participate in pain generation and neurogenic inflammation [4,5,13]. This network is markedly increased in BPS/IC patients [14]. BoNTA blocks the release of neurotransmitters from those fibers [5]. In addition, BoNTA reduces TRPV1 trafficking from the cytoplasm to the cell membrane of sensory neurons [15]. As a consequence, a marked analgesic effect of BoNTA can be expected. BoNTA also decreases adenosine triphosphate (ATP) release from the bladder [16], providing an additional explanation for the analgesic effect. ATP is released from urothelial cells [17,18] and causes pain after binding purinergic receptors in suburothelial sensory fibers [19]. Urothelium from BPS/IC patients [20] releases more ATP than control urothelium. The mechanism leading to ATP release impairment is, however, unclear. Urothelium, in contrast to sensory nerves, does not express SV2 or SNAP-25 [21], precluding the direct action of BoNTA. Future studies will elucidate this phenomenon. BoNTA reduces the urine concentration of NGF [10], a neurotrophic agent essential for the growth and maintenance of a large subset of nociceptors. As NGF has noxious effects [22], its reduction in the urine can also contribute to a decrease in bladder pain. The present study confirmed NGF reduction but added the novel information that BDNF, another ubiquitous neurothrophin with nociceptive activity [23], is also decreased upon BoNTA treatment. NGF is released from urothelial [24] and smooth muscle cells [25], whereas BDNF immunoreactivity was observed in urothelial cells [26] and in sensory fibers [23]. Themechanismfor such a decrease is unknown, and any explanation at this time can be considered only speculative. It is, however, interesting to observe that whole bladder [10] or trigonal injections (as done in this study) might cause a similar neurothrophin decrease. However, this decrease might be the consequence of sensory fiber concentration in the trigone. Previous studies with BoNTA in BPS/IC patients have reported conflicting results. Giannantoni [7] injected 200 U of BoNTA in 20 sites in 15 patients. However, only 60 U were applied in the trigone, helping to explain the short antinociceptive effect observed. Pain recurred in 73% of the patients at 5 mo. Kuo et al. [8] injected 100 or 200 U in 40 sites in the posterior and lateral walls, combined with hydrodistension. Curiously, 71% of the patients still showed improvement at 6 mo, 55% at 12 mo, and 30% at 24 mo. This surprisingly long-lasting effect might be attributable to hydrodistension. However, the treated population might also differ between the Kuo et al study [8] and this one. Pain was less intense and occurred at bladder volumes of 150 ml in the Kuo et al study [8]. In ours, pain appeared at volumes of <50 ml. Furthermore, no cases of ulcerative disease were included by Kuo et al. [8]. Thus, patients enrolled in our study might have had a more severe form of BPS/IC and therefore responded to BoNTA for shorter periods. The use of a common classification system such as the ESSIC model might help in future comparisons [2,27]. Restraining BoNTA to the trigone might have prevented voiding dysfunction, a result often reported by other studies that injected the whole bladder [7,8]. As a fixed part of the bladder, predominantly innervated by sympathetic nerves, the human trigone does not contract during voiding [28]. Although some BoNTA could have diffused from the trigone to the lateral walls, in fact, there was no clinical or urodynamic evidence of poor emptying. Stress urinary incontinence eventually caused by BoNTA diffusion to adjacent sphincteric structures did not occur. Although UTIs were not observed after the first treatment, five patients developed UTIs after reinjection. This is a concern, as UTIs might worsen BPS/IC symptoms [29]. The duration of clinical improvement was comparable to that reported in detrusor overactivity [3,30]. Nevertheless, BPS/IC being a chronic disease, retreatments are foreseeable. In patients retreated through the duration of this study, BoNTA has remained effective. This is an important consideration for BPS/IC patients, because BoNTA injections have no curative effect. Although reinjections every 8 10 mo might constitute a major burden to patients and health systems, detrusor overactivity is being managed cost effectively with repeated injections for >8 yr[3,30]. 5. Conclusions Trigonal injection of 100 U BoNTA improves BPS/IC symptoms without significant complications. Reinjections remain effective. The low number of patients and the lack of

6 EUROPEAN UROLOGY 58 (2010) a placebo arm are obvious limitations of this study. Therefore, placebo-controlled dose-escalating studies are warranted. Author contributions: Francisco Cruz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Dinis, F. Cruz, Pinto. Acquisition of data: Pinto, Lopes, Frias, J.A. Silva, C.M. Silva. Analysis and interpretation of data: Pinto. Drafting of the manuscript: Pinto. Critical revision of the manuscript for important intellectual content: F. Cruz, Dinis, C. Cruz. Statistical analysis: Pinto. Obtaining funding: Dinis, F. Cruz. Administrative, technical, or material support: None. Supervision: Dinis, F. Cruz. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: F. Cruz is a consultant with Allergan, Astellas, and Recordati. Funding/Support and role of the sponsor: This work was funded by INComb FP7 HEALTH project no and the Portuguese Association of Urology. References [1] Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21: [2] Van de Merwe JP, Nordling J, Bouchelouche P, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol 2008; 53:60 7. [3] Apostolidis A, Dasgupta P, Denys P, et al. Recommendations on the use of botulinum toxin in the treatment of lower urinary tract disorders and pelvic floor dysfunctions: a European consensus report. Eur Urol 2009;55: [4] Chuang YC, Yoshimura N, Huang CC, et al. Intravesical botulinum toxin A administration produces analgesia against acetic acid induced bladder pain response in rats. J Urol 2004;172: [5] Rapp DE, Turk KW, Bales GT, et al. Botulinum toxin type A inhibits calcitonin gene-related peptide release from isolated rat bladder. J Urol 2006;175: [6] Avelino A, Cruz C, Nagy I, et al. Vanilloid receptor 1 expression in the rat urinary tract. Neuroscience 2002;109: [7] Giannantoni A, Porena M, Costantini E, et al. Botulinum A toxin intravesical injection in patients with painful bladder syndrome: 1-yr follow-up. J Urol 2008;179: [8] Kuo HC, Chancellor MB. Comparison of intravesical botulinum toxin type A injections plus hydrodistension with hydrodistension alone for the treatment of refractory interstitial cystitis/painful bladder syndrome. BJU Int 2009;1:1 5. [9] Karsenty G, Elzayat E, Delapparent T, et al. Botulinum toxin type A injections into the trigone to treat idiopathic overactive bladder do not induce vesicoureteral reflux. J Urol 2007;177: [10] Liu HT, Tyagi P, Chancellor MB, et al. Urinary nerve growth factor level is increased in patients with interstitial cystitis/bladder pain syndrome and decreased in responders to treatment. BJU Int 2009;104: [11] Nordling J, Anjum FH, Bade JJ, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol 2004;45: [12] O Leary MP, Grannum RS, Floyd JF, et al. The Interstitial Cystitis Symptom Index and Problem Index. Urology 1997;49: [13] Dinis P, Charrua A, Avelino A, et al. Intravesical resiniferatoxin decreases spinal c-fos expression and increases bladder volume to reflex micturition in rats with chronic inflamed urinary bladders. BJU Int 2004;94: [14] Mukerji G, Yiangou Y, Agarwal SK, et al. Transient receptor potential vanilloid receptor subtype 1 in painful bladder syndrome and its correlation with pain. J Urol 2006;176: [15] Morenilla-Palao C, Planells-Cases R, García-Sanz N, et al. Regulated exocytosis contributes to protein kinase C potentiation of vanilloid receptor activity. J Biol Chem 2004;279: [16] Khera M, Somogyi GT, Kiss S, et al. Botulinum toxin A inhibits ATP release from bladder urothelium after chronic spinal cord injury. Neurochem Int 2004;45: [17] Birder LA, Barrick SR, Roppolo JR, et al. Feline interstitial cystitis results in mechanical hypersensitivity and altered ATP release from bladder urothelium. Am J Physiol Renal Physiol 2003;285: [18] Charrua A, Reguenga C, Cordeiro JM, et al. Functional transient receptor potential vanilloid 1 is expressed in human urothelial cells. J Urol 2009;182: [19] Cockayne DA, Hamilton SG, Zhu QM, et al. Urinary bladder hyporeflexia and reduced pain-related behaviour in P2X3-deficient mice. Nature 2000;407: [20] Sun Y, Keay S, De Deyne PG, et al. Augmented stretch activated adenosine triphosphate release from bladder uroepithelial cells in patients with interstitial cystitis. J Urol 2001;166: [21] Coelho A, Dinis P, Pinto R, et al. Distribution of the high-affinity binding site and intracellular target of botulinum toxin type A in the human bladder. Eur Urol 2010;57: [22] Dyck PJ, Peroutka S, Rask C, et al. Intradermal recombinant human nerve growth factor induces pressure allodynia and lowered heat pain threshold in humans. Neurology 1997;48: [23] Merighi A, Salio C, Ghirri A, et al. BDNF as a pain modulator. Prog Neurobiol 2008;85: [24] Koltzenburg M, Torebjörk HE. Pain and hyperalgesia in acute inflammatory and chronic neuropathic conditions. Lancet 1995; 345:1111. [25] Clemow DB, Steers WD, Tuttle JB. Stretch-activated signaling of nerve growth factor secretion in bladder and vascular smooth muscle cells from hypertensive and hyperactive rats. J Cell Physiol 2000;183: [26] Pinto R, Frias B, Allen S, et al. Sequestration of BDNF by intravenous delivery of TrkB-Ig2 reduces bladder overactivity and noxious input in animals with chronic cystitis. Neuroscience 2010;166: [27] Fall M, Oberpenning F, Peeker R. Treatment of bladder pain syndrome/interstitial cystitis 2008: can we make evidence-based decisions? Eur Urol 2008;54: [28] Shafik A. Role of the trigone in micturition. J Endourol 1998;12: [29] Warren JW, Brown V, Jacobs S, et al. Urinary tract infection and inflammation at onset of interstitial cystitis/painful bladder syndrome. Urology 2008;71: [30] Del Poppolo G, Filocamo MT, Li Marzi V, et al. Neurogenic detrusor overactivity treated with English botulinum toxin A: 8-yr experience of one single centre. Eur Urol 2008;53: