Interstitial Cystitis: The Paradigm Shifts

International Consultations on Interstitial Cystitis

MEETING REVIEW Interstitial Cystitis: The Paradigm Shifts International Consultations on Interstitial Cystitis [Rev Urol. 2004;6(4):200-202] © 2004 MedReviews, LLC Key words: Biomarkers • Chronic pelvic pain • Cystoscopy • Interstitial cystitis • Painful bladder syndrome • Symptom questionnaires his review highlights the 3 major international consultations on interstitial cystitis (IC) held in 2003 that will drive the diagnosis and management of IC for the next decade. T Reviewed by J. Curtis Nickel, MD, FRCSC, Department of Urology, Queen’s University, Kingston, Ontario, Canada International Consultation on Interstitial Cystitis, Japan (ICICJ), March 28-30, 2003, Kyoto, Japan The ICICJ held in Kyoto, Japan, sought to obtain a consensus on clinically applicable diagnostic criteria for IC. The meeting was attended by 25 international interstitial cystitis specialists from 14 countries and 5 continents as well as 26 participants from Japan. A consensus document was produced and published in an International Journal of Urology supplement, Volume 10, October 2003.1 The ICICJ workshop committees made the following recommendations: 1. The diagnosis of IC must have the elements of chronic pelvic pain and urinary frequency and/or urgency. 2. The term interstitial cystitis should be retained, followed by chronic pelvic pain syndrome, represented by the acronym IC/CPPS. 3. A majority agreed that a single diagnostic system is mandatory for both research and clinical diagnosis to promote clarity and communication. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) criteria may not be that single system. 4. No consensus was developed on the place of cystoscopy and hydrodistention in the diagnosis of IC (although a majority regarded cystoscopy and hydrodistention as important in the diagnosis of IC). 5. Bladder biopsy is not required for clinical work-up, and histology is not useful as a diagnostic criterion. Bladder biopsy is an optional test and relevant when other conditions are suspected. Bladder biopsy remains important in IC research. 200 VOL. 6 NO. 4 2004 REVIEWS IN UROLOGY 6. Urine cytology should be performed in the clinical work-up of the patient with IC. 7. Urodynamics are not necessary in the routine evaluation of patients suspected of having IC. 8. The potassium sensitivity test is not required in the routine evaluation of IC patients but should be considered in research studies to evaluate its usefulness in diagnosis. 9. Symptom questionnaires are useful for 2 purposes: 1) to identify patients and quantify their symptoms in a way that aids diagnosis and 2) to measure treatment outcome. The consensus was that further research of all questionnaires was indicated, and no definitive recommendations can be made as to which of the 3 published IC questionnaires are most appropriate (the University of Wisconsin IC Scale, the O’Leary-Sant IC Symptom Index and IC Problem Index, or the Pelvic Pain and Urgency/Frequency Scale). 10. Urinary biomarkers have the potential to revolutionize diagnosis of IC. Consultations on Interstitial Cystitis Copenhagen Workshop on Interstitial Cystitis, May 22-24, 2003, Copenhagen, Denmark The Copenhagen Workshop on Interstitial Cystitis, attended by European urologists, based its consensus on results from a European urology questionnaire, reports from European participants of the Kyoto ICICJ, and moderated discussion. The recommendations are discussed in the May 2004 issue of European Urology.2 The following consensus regarding the diagnostic investigation necessary for the work-up of IC was reported from the Copenhagen workshop: 1. The meeting participants believed that the term painful bladder syndrome was preferable to interstitial cystitis. This would correspond to the International Continence Society definition: suprapubic pain related to bladder filling, accompanied by other symptoms, such as increased daytime and nighttime frequency, in the absence of proven urinary infection or other obvious pathology. 2. History and physical examination are mandatory. 3. The O’Leary-Sant questionnaire for symptoms and bother supplemented by a sexual score (to be defined) should be given. Research Insights into Interstitial Cystitis, October 30–November 1, 2003, Alexandria, VA The Research Insights into Interstitial Cystitis meeting was jointly sponsored by the National Institutes of Health, the 4. The Visual Analogue Score should be used for grading of pain. 5. A voiding diary should be kept. 6. Filling cystometry should be performed in both men and women. 7. A pressure-flow study should be done in men. 8. The diagnosis of IC requires confirmation by cystoscopy. Standardized cystoscopy and bladder distention are described. 9. Bladder biopsies are recommended and must include muscle. 10. The modified potassium test is considered optional. NIDDK, and the Interstitial Cystitis Association and incorporated a format consisting of invited, “state-of-the-art” speakers; submitted research posters; and expert panels whose mandate was to revisit the diagnosis of IC. The expert panel subcommittees of the Research Insights into Interstitial Cystitis meeting made the following recommendations: 1. The terminology describing the syndrome should be addressed. It was suggested that the term interstitial cystitis/painful bladder syndrome (IC/PBS) be considered (see the definition in recommendation 1 from the Copenhagen meeting). 2. History and physical examination are key to the diagnosis of IC. 3. Questionnaires may be employed for the diagnosis of IC, monitoring of treatment responses, and as an outcome measure in therapeutic trials. There are advantages and disadvantages for each scale, and no single scale was recommended. 4. Hydrodistention under anesthesia for diagnosis and therapy of IC does not appear to be indicated. 5. Cystoscopy (under local or general anesthetic) may be performed to rule out other important conditions such as carcinoma in situ (CIS). 6. There are no definite histologic criteria for diagnosis of IC; 7. 8. 9. 10. therefore, utility of bladder biopsy is solely to rule out other causes of the symptoms. Urine cytology is an important study to rule out CIS of the bladder. Urodynamic studies have not been standardized for the diagnosis of IC. The potassium sensitivity test cannot be recommended for general use as a diagnostic tool for IC at this time; however, because the test is simple and inexpensive and clearly separates IC patients from normal controls, it is possible that further research will define a role for this test. Future studies should further evaluate the utility of the potassium sensitivity test. To date, no urinary or serum markers have been thoroughly characterized and established as practical in the diagnosis of IC. A number of these biomarkers, including antiproliferative factors, may have significant potential as tools for diagnosing IC. VOL. 6 NO. 4 2004 REVIEWS IN UROLOGY 201 Consultations on Interstitial Cystitis continued Summary It is clear that there is no international consensus for the diagnostic work-up for IC (research studies and clinical practice). European urologists continue to insist on the traditional invasive diagnostic algorithm; North American urologists tend to favor a more conservative, less invasive approach to diagnosis, whereas the international community of urologists (which includes Europeans and North Americans) suggest a compromise. The author’s interpretation of the North American approach to the clinical diagnosis of interstitial cystitis is described here: Mandatory investigations Investigations recommended only in specific patients 1. History and physical examination 2. Urinalysis 3. Culture 4. Cytology 1. Potassium sensitivity test 2. Hydrodistention 3. Biopsy 4. Urodynamics Optional investigations Investigations with future considerations 1. IC questionnaires 2. Cystoscopy 1. Biomarkers References 1. 2. 202 Proceedings of the International Consultation on Interstitial Cystitis. March 28-30, 2003. Kyoto, Japan. Int J Urol. 2003;10(suppl):i-S70. Nordling J, Anjum FH, Bade JJ, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol. 2004;45:662-669. VOL. 6 NO. 4 2004 REVIEWS IN UROLOGY