Aims Glycosaminoglycan (GAG) layer replenishment is a cornerstone in the therapy of interstitial cystitis (IC). During the last years intravesical GAG layer replenishment has proven to be an effective treatment for overactive bladder (OAB), radiation cystitis, and recurrent urinary tract infections (UTIs). Methods Examination of different substances available for intravesical GAG replenishment and evaluation of the evidence for the treatment of the above-mentioned conditions. Results We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database for studies on intravesical GAG replenishment. A total of 27 clinical studies remain relevant to this topic, many of them with mixed patient selection and suboptimal definition of symptom improvement/success. Two placebo controlled studies with hyaluronic acid failed to show superiority and have not been published. One active controlled randomized study has been published showing that chondroitin sulphate 0.2% has a clear benefit for OAB patients. Another study with chondroitin sulphate 2.0% failed to show statistically significant evidence, but was underpowered. Conclusions A short number of randomized controlled studies confirm efficacy of intravesical GAG layer replenishment therapy. Concluded from the study background (which comprises also uncontrolled studies), so far chondroitin sulphate 0.2% is in favor for intravesical GAG layer replenishment therapy. In general, large-scale trials are urgently needed to underline the benefit of this type of therapy. Neurourol. Urodynam. 32: 9-18, 2013. © 2012 Wiley Periodicals, Inc. Copyright © 2012 Wiley Periodicals, Inc.

RECORD STATUS:

This is a bibliographic record of a published health technology assessment from a member of INAHTA. No evaluation of the quality of this assessment has been made for the HTA database.

CITATION:

Pichon Riviere A, Augustovski F, Garcia Marti S, Glujovsky D, Alcaraz A, Lopez A, Bardach A, Ciapponi A, Spira C. Ácido hialurónico intravesical para el tratamiento del síndrome de vejiga dolorosa / cistitis intersticial. [Intravesical hyaluronic acid for painful bladder syndrome / interstitial cystitis] Buenos Aires: Institute for Clinical Effectiveness and Health Policy (IECS). Informe de Respuesta Rápida N° 258. 2012

A 60-year-old woman was treated for severe interstitial cystitis pain using sacral nerve stimulation. Pain and accompanying bladder dysfunction were improved by temporary and permanent sacral nerve stimulation. Six months after implantation of a sacral neuromodulator the patient is pain free and significantly improved on bladder dysfunction. Interstitial cystitis may be an indication for functional electrostimulation.

The efficacy of a single dose (four tablets) and of 10-day courses of trimethoprim-sulfamethoxazole (TMP-SMZ) was studied in 77 women with symptomatic cystitis and negative tests for antibody-coated bacteria. Cure rates after six weeks were 76% for single-dose therapy and 87% for 10 days of treatment. For Escherichia coli infections, cure rates after six weeks were 80% and 86%, respectively. However, 10-day treatment eliminated enteric bacilli from urethral and vaginal sites more often than did single-dose therapy. Two weeks after completion of treatment, perineal colonization was observed more often in the women who developed recurrent infections than in those who did not (P = 0.01). During these two weeks, recurrent infections were found somewhat more often in the women who had received single-dose therapy than in those who had undergone 10-day treatment (5 of 38 vs. 2 of 39; P = 0.07). With conventional courses of antibiotics, retreatment of all recurrent infections was less successful in women previously given single-dose therapy. Recurrent infections were also more frequent in women infected with bacteria other than E. coli. Both drug regimens were well tolerated. However, serious adverse reactions were fewer in patients treated with a single dose (8.5%) than in patients treated for 10 days (15%). Single-dose therapy with TMP-SMZ appears as effective as 10-day therapy in acute uncomplicated cystitis caused by E. coli.

We compared the safety and efficacies of ofloxacin and trimethoprim-sulfamethoxazole for the treatment of acute uncomplicated cystitis in women enrolled in a multicenter study. Data from three centers were combined for this report because the study design and study populations were identical, and patients were enrolled within an 18-month period. Cure rates for evaluable patients 4 weeks after treatment were high for all regimens: ofloxacin (200 mg) twice daily for 3 days, 22 of 25 (88%) cured; ofloxacin (200 mg) twice daily for 7 days, 42 of 49 (86%) cured; ofloxacin (300 mg) twice daily for 7 days, 25 of 25 (100%) cured; and trimethoprim-sulfamethoxazole (160/800 mg) twice daily for 7 days, 46 of 52 (88%) cured. Ofloxacin was more effective than trimethoprim-sulfamethoxazole in eradicating Escherichia coli from rectal cultures during and 1 week after treatment. Both ofloxacin and trimethoprim-sulfamethoxazole markedly reduced vaginal colonization with E. coli during and 4 weeks after therapy. Emergence of resistant coliforms in rectal flora was found in 5 (19%) of 27 patients treated with trimethoprim-sulfamethoxazole but none of 50 ofloxacin-treated patients who were studied (P = 0.004). Adverse effects were equally common among the four treatment groups. We conclude that 3 to 7 days of ofloxacin is as safe and effective as trimethoprim-sulfamethoxazole for treatment of uncomplicated cystitis in women and that ofloxacin effectively reduces the fecal and vaginal reservoirs of coliforms in such patients.

Introducción: La cistitis eosinofílica descrita por primera vez en 1960 por Brown, corresponde a una patología inflamatoria de la vejiga muy infrecuente, de etiología específica aún incierta. Puede variar desde inflamación moderada, hasta vejiga fibrótica con dilatación pielocalicilar y grados variables de insuficiencia renal. Si bien, tiene una presentación clínica variable, no se ha descrito previamente en la literatura la perforación vesical espontánea recurrente. Caso clínico: Presentamos el caso de una mujer de 35años con historia de hematuria, poliquiuria, tres perforaciones vesicales espontáneas y microvejiga fibrótica con hidroureteronefrosis bilateral que se maneja finalmente con ampliación vesical con segmento de íleon y además, exponemos una revisión actualizada de la literatura. Conclusión: La cistitis eosinofílica es una entidad de etiología incierta, con una historia natural impredecible. Su incidencia y prevalencia son desconocidas y si bien, no ha sido descrita previamente en un adulto en nuestro medio, es recomendable considerarla entre los diagnósticos diferenciales de una hematuria macroscópica o síndrome de irritación vesical persistente. La ruptura vesical espontánea recurrente es una presentación clínica no descrita previamente en la literatura. Se deben continuar periódicamente controles imagenológicos y de laboratorio y su tratamiento aún no está estandarizado.

PURPOSE:

In women symptoms of interstitial cystitis are difficult to distinguish from those of painful bladder syndrome and they appear to overlap with those of urinary tract infection, chronic urethral syndrome, overactive bladder, vulvodynia and endometriosis. This has led to difficulties in formulating a case definition for interstitial cystitis, and complications in the treatment and evaluation of its impact on the lives of women. We performed a systematic literature review to determine how best to distinguish interstitial cystitis from related conditions.

MATERIALS AND METHODS:

We performed comprehensive literature searches using the terms diagnosis, and each of interstitial cystitis, painful bladder syndrome, urinary tract infection, overactive bladder, chronic urethral syndrome, vulvodynia and endometriosis.

RESULTS:

Of 2,680 screened titles 604 articles were read in full. The most commonly reported interstitial cystitis symptoms were bladder/pelvic pain, urgency, frequency and nocturia. Interstitial cystitis and painful bladder syndrome share the same cluster of symptoms. Chronic urethral syndrome is an outdated term. Self-reports regarding symptoms and effective antibiotic use can distinguish recurrent urinary tract infections from interstitial cystitis in some but not all women. Urine cultures may also be necessary. Pain distinguishes interstitial cystitis from overactive bladder and vulvar pain may distinguish vulvodynia from interstitial cystitis. Dysmenorrhea distinguishes endometriosis from interstitial cystitis, although many women have endometriosis plus interstitial cystitis.

CONCLUSIONS:

In terms of symptoms interstitial cystitis and painful bladder syndrome may be the same entity. Recurrent urinary tract infections may be distinguished from interstitial cystitis and painful bladder syndrome via a combination of self-report and urine culture information. Interstitial cystitis and painful bladder syndrome may be distinguished from overactive bladder, vulvodynia and endometriosis, although identifying interstitial cystitis and painful bladder syndrome in women with more than 1 of these diseases may be difficult.

BACKGROUND:

Guidelines for the management of acute cystitis support empirical antibiotic treatment; however, up to half of symptomatic women have negative urine cultures.

OBJECTIVE:

To determine whether empirical treatment leads to unnecessary antibiotic prescriptions in women with symptoms of acute cystitis.

METHODS:

A cohort of 231 women (defined as females aged 16 years and older) presenting to family physicians' offices with symptoms of cystitis underwent a standardized clinical assessment, urine dip testing, and culture. Recommendations for urine testing and antibiotic treatment under 3 empirical strategies were compared with observed physician management and a logistic regression model for the outcomes of antibiotic prescriptions, urine culture testing, and unnecessary antibiotics, defined as a prescription where the subsequent urine culture was negative.

RESULTS:

There were 123 positive urine cultures (53.3%). Physicians prescribed antibiotics to 186 women (80.9%), of whom 74 (39.8%) were culture negative. Unnecessary antibiotic use was similar for 2 guidelines recommending empirical antibiotic treatment without testing for pyuria (41.4% and 40.6%). Treating women with classic cystitis symptoms and pyuria would have decreased unnecessary antibiotic use (26.2%; P =.02) but resulted in fewer women with confirmed urinary tract infection receiving immediate antibiotics (66.4% vs 91.8% usual care; P<.001). A derived prediction model incorporating testing for pyuria and nitrites would also have reduced unnecessary antibiotic use (27.5%; P =.03), but more women with confirmed urinary tract infection would have received immediate antibiotics (81.3%; P =.01).

CONCLUSIONS:

Empirical antibiotic treatment of acute cystitis in women without testing for pyuria promotes unnecessary antibiotic use. A simple decision rule provides for prompt treatment of infected women while reducing antibiotic overuse and unnecessary urine testing.

The efficacy of single-dose therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) and the cost-effectiveness of routine urinalyses and cultures were studied in a prospective randomized trial of 200 women who presented with symptoms of acute lower urinary tract infection. Without the physician's knowledge of the results of urinalysis or culture, the patients were randomly assigned to receive either a single dose or a 10-day multiple-dose course of TMP-SMZ and were followed up for 6 months. Of the 136 patients with positive urine cultures, 68 received single-dose therapy with TMP-SMZ--10 of whom had relapses--and 68 received multiple-dose therapy with TMP-SMZ--only 2 of whom had relapses (P less than 0.02). Fifteen patients in each treatment group experienced reinfection. Side effects of rash and vaginitis were more common in patients who received multiple-dose therapy, but they were mild and well tolerated. Of the 51 patients with urethral syndrome, 48 became asymptomatic after therapy. None of the following tests predicted treatment outcome: pretreatment urinalysis, urine culture or susceptibility testing, antibody-coated bacteria testing, or routine follow-up urinalyses or urine cultures. Empiric therapy with TMP-SMZ in selected women with symptoms of acute uncomplicated urinary tract infection seems practical, safe, and cost-efficient. Considerable savings can be achieved by reserving urinalyses and urine cultures for patients with persistent or recurrent symptoms. Higher cure rates can be expected in patients who receive a standard 10-day course of therapy with TMP-SMZ compared with those who receive single-dose therapy with TMP-SMZ.

OBJECTIVE:

compare the acceptability of 3-day regimen with that of 10-day regimen of fluoroquinolones for the treatment of recurrent uncomplicated lower urinary tract infection in women.

METHODS:

a multicentric, randomized open trial was conduced in 421 patients by gynecologic and general practitioners to determine acceptability, efficacy and safety of lomefloxacin 400 mg in a once a day dose given for three days compared with norfloxacin 800 mg in twice a day dose given for ten days for the treatment of recurrent uncomplicated lower urinary tract infection in women.

RESULTS:

acceptability, assessed at day 14, was significantly better for lomefloxacin group than norfloxacin group, respectively 57,1 p.100 and 38,0 p.100. Clinical success rate at day 14 was 97,2 p.100 for lomefloxacin and 97,5 p.100 for norfloxacin; at day 30 clinical success rate was respectively 97,6 p.100 and 98,1 p.100 relapse at one year was comparable between two groups. Adverse events were reported respectively in 15,6 p.100 and 16,6 p.100 of the patients, vaginal infections, dermatologic disorders and digestive disorders (abdominal pain, nausea) predominated. There were no serious adverse event.

CONCLUSION:

the acceptability is better for a 3-day regimen of lomefloxacin than a 10-day regimen of norfloxacin for treatment of recurrent uncomplicated lower urinary tract infection in women for comparable efficacy and safety.