BPS/IC: evolution of definition and prevalence

Transcription

1 BPS/IC: evolution of definition and prevalence ame in history Tic doloureux of the bladder 1836 Interstitial cystitis 1878 Cystitis parenchymatosa 197 unner s ulcer 1915 Panmural ulcerative cystitis 192 Urethral syndrome 1949 Painful bladder syndrome 1951 (Bourke), 22 ICS Bladder pain syndrome 26 (ESSIC, PUG) Why is there a problem? What Seems Simple and bvious May ot Really Be Bladder Pain / Frequency / Urgency Frequency dependent upon drinking habits and perspiration; absolute # may not be meaningful Urgency dependent upon definition: the complaint of a sudden compelling desire to pass urine which is difficult to defer (possibly) because of fear of incontinence (no); Consider term persistent urge Site of pain, source of pain can be difficult for patient or clinician to determine The world prior To IDDK A hole in the air Tage ald Endoscopic Definition unner s definition of Interstitial Cystitis a peculiar form of bladder ulceration whose diagnosis i depends d ultimately on its resistance to all ordinary forms of treatment in patients with frequency and bladder symptoms (spasms). unner, GL, Boston Medical and Surgical Journal, 172:66, 1917 BPS/IC: evolution of definition and prevalence P. anno 1

2 Clinical Definition: The Aunt Minnie (hard to describe but you know her when you see her) We have all met, at one time or another, patients who suffer chronically from their bladder; and we mean the ones who are distressed, not only periodically but constantly, having to urinate often, at all moments of the day and of the night, and suffering pains every time they void. Bourke, 1951 Symptoms & Endoscopic Appearance Definition Messing and Stamey: onspecific and highly subjective symptoms of around the clock frequency, urgency, and pain somewhat relieved by voiding when associated with glomerulations upon bladder distention under anesthesia Urology, 12:381, 1978 IDDK To define research parameters of IC so that clinical and basic research findings would have a common basis for comparison ot meant to be de facto definition for the clinician Revised IDDK Pain associated with the bladder or urinary urgency and glomerulations or unner s ulcer on cystoscopy under anesthesia Long list of exclusions of other disorders that might give rise to symptoms 9 month symptom duration 8 voids per day and nocturia X 1 minimum Less than 35 cc awake bladder capacity Interstitial Cystitis (anno, Wein, Staskin, Krane (eds); Springer Verlag 199) IDDK IC Database Definition for Entry Broaden criteria to attempt to validate IDDK criteria Include all IC-like patients Unexplained urgency or frequency (7 voids or more a day), or pelvic pain of at least 6 months duration o requirement for cystoscopy or endoscopic findings IDDK IC Database Findings Patients Agreed To ave IC By Expert Clinicians Missed Clinical IC Patients 424 patients with urgency or pain or frequency > 6 months not meeting meeting criteria criteria Fulfilled Mission anno, J. Urol Urology, 49:5A, 64-75, 1997 BPS/IC: evolution of definition and prevalence P. anno 2

3 Laboratory Definition: Antiproliferative Factor Unique protein found only in urine of IC patients Discovered by Sue Keay, U of MD In search for infectious etiology of IC, cell cultures showed differences between IC bladder and control cells Slow growth rate of IC cells led to discovery of antiproliferative factor APF is expressed solely in the bladder epithelium of IC patients with no expression evident in normal human bladder epithelial cells C 2 Ac Ac 2 ot ready for prime time Initial studies with 2 IC patients and 3 controls demonstrated specificity and sensitivity APF activity and altered levels of B-EGF and EGF previously identified in IC urine are related APF upregulates bladder epithelial cell production of EGF and down-regulates production of B-EGF in vitro C Pathologic Definition Provocative Testing Definition: Positive Potassium Test onulcerative IC unner s ulcer erve hypertrophy Detrusor mastocytosis Excludes tissue specific diagnoses only, no pathognomonic findings Intravesical potassium sensitivity testing (Parsons) uses pharmacologic.4, not physiologic concentrations + test may indicate increased permeability and/or increased neural acuity bstet Gynecol, 98:127, 21 Urology, 6:573, 22 J Urol, 168:154, 22 Urology, 59:329, 22 ICS Definitions AB: Urgency with or without urge incontinence, usually with frequency and nocturia Urgency: sudden compelling desire to pass urine for fear of leakage which is difficult to defer PBS: suprapubic pain related to bladder filling accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven uti or other obvious pathology The PBS problem (sensitivity) PBS definition has 64% sensitivity according to Warren The restriction to suprapubic pain in the ICS definition iti and the relationship of pain to filling were the criteria most responsible for the poor sensitivity. Warren; Urology, 67: , 26 Abrams et.al.: eurourology & Urodynamics, 21:167, 22 BPS/IC: evolution of definition and prevalence P. anno 3

4 ESSIC Proposed Definition Bladder Pain Syndrome/IC: Chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptom like persistent urge to void or urinary frequency. Confusable diseases as the cause of the symptoms must be excluded. Epidemiology Studies Left to Devise Their wn Definitions Results Vary Widely Depending Upon Definition and Methodology Initial Studies Were Based on Physician Assigned Diagnosis Prevalence per 1, Japan olland USA Finland ravisto Ann Chir Gynaecol Fenn 64:75, 1975 : BJU International 91:181, 23 : J. Urol 154:235, 1995 : BJU International 86:634, 2 Methodologies eld: IC Dx urologist survey and general population survey: 34.4/1, (USA) Curhan: urses ealth Study; self report and record review: 6/1, (USA) Clemens: Portland managed care: assigned Diagnosis without exclusion criteria: 158/1, (USA) Clemens: J.Urol 173:98, 25 eld, anno, Wein, et.al.: in anno: Interstitial Cystitis, Springer Verlag, London 199 Curhan: J. Urol,161:549, Prevalence per 1, Methodologies Japan olland USA Finland ravisto eld Curhan Clemens Jones and yberg: Self report, ational ousehold Interview Survey: 45/1, ong-jeng Yu: Leary Sant scores: 31/1, (Tapei) Leppilahti: Leary Sant Scores + exam: 3/1 (Finland) Temml: Leary Sant Scores: 36/1 (Austria) Leppilahti: J. Urol, 174:581, 25 ong-jeng Yu: Pan Asian Interstitial Cystitis Meeting, Tapei, April 26 TemmL: European Urol.(26) 8.28 Jones and yberg: Urology 49S:2, 1997 BPS/IC: evolution of definition and prevalence P. anno 4

5 Prevalence per 1, Japan olland USA Finland Taiwan Austria ravisto eld Curhan Clemens Jones Yu Leppilahati Temml BPS/IC: evolution of definition and prevalence P. anno 5