[BLADDER PAIN SYNDROME - DOES DETRUSOR MASTOCYTOSIS PREDICT SYMPTOMATIC IMPROVEMENT FOLLOWING BLADDER HYDRODISTENTION UNDER ANESTHESIA?]

INTRODUCTION: Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic, debilitating syndrome involving bladder pain and lower urinary tract symptoms (LUTS), with a substantial effect on patients' quality of life. IC/BPS poses a diagnostic challenge, and its available treatment options remain only moderately effective. Bladder-wall biopsies from IC/BPS patients commonly uncover mastocytosis. While mast-cells are suspected as pivotal in disease pathogenesis, the clinical significance of their presence remains unclear. Clinical guidelines differ on whether or not bladder biopsies should be a part of routine IC/BPS workup. AIMS: To determine whether detrusor mastocytosis can serve as a prognostic marker for treatment response and improvement duration. METHODS: We retrospectively collected patient data for IC/BPS patients who underwent bladder hydrodistension under anesthesia. We used statistical modelling to determine the effect of mastocystosis and other possible predictive factors - age, comorbidity, Hunner lesions - on the presence and duration of symptom improvement. RESULTS: A total of 35 patients (89% female, median age 63.5 [IQR 48.8-73.6] years) underwent hydrodistension, of whom 28 (89% female, median age 63.0 [44.8-73.1] years) had bladder biopsies; 11 (39%) of them had mastocystosis. Within a median follow-up of 8.8 [1.7-24.2] months, 11 (100%) of the patients with mastocytosis and 9 (53%) of the patients without it, experienced symptomatic improvement (p=0.007). Improvement duration was 8 months longer (p=0.006) in those with mastocystosis. Univariate logistic regression models were used to estimate odds ratios (OR). Mastocytosis (p=0.004) and Charlson Comorbidity score were the only variables with a statistically significant OR. Univariate survival models were fitted, and improvement duration was estimated to be longer in patients with mastocystosis (p=0.01). A multivariate Cox regression model found no variable to be statistically significant, though mastocystosis was borderline significant (p=0.055). CONCLUSIONS: Mastocystosis defines a discernible phenotype of IC/BPS, which exhibits higher rates and longer duration of hydrodistention treatment response. DISCUSSION: Notwithstanding limitations of sample size and retrospective study design, we were able to demonstrate that mastocystosis can serve as a prognostic factor for symptom improvement after hydrodistension in IC/BPS patients. Prospective studies are required to validate this finding and to investigate the mechanisms involved.

[POSITION STATEMENT FOR INTERMITTENT CATHETERIZATION OF URINARY BLADDER].

INTRODUCTION: A position paper presents the standpoint of the Israeli Urological Association on clean intermittent catheterization (CIC) for all physicians and nurses. The position paper is based on international guidelines and professional literature and is adapted to medical activities in Israel. CIC is indicated for the treatment of temporary/permanent disability in the emptying of the bladder, which is expressed by large post-voided urine/urine retention and related complications. There are a few contra-indications for CIC (low bladder volume or compliance, pressure sores/external infection of the urethra, anatomical, functional or cognitive disorder that does not allow to perform CIC, recurrent macrohematuria or urethrorrhagia, urethral pain that does not allow frequent catheterization, patient unwillingness to perform CIC by himself or by another person). There are alternatives to performing CIC permanent urethral or suprapubic catheter, urinary tract diversion, sphincterotomy. Before starting to perform CIC, the patient should be verified as being able to perform CIC and adhere to a predetermined schedule. It is recommended to perform the CIC at regular intervals during the day. During training and early stages of the CIC, it is recommended to catheter every 4-6 hours to assess bladder volume at these time intervals (urinary volume per catheterization). It is recommended to record drinking volumes, voiding volumes, and catheterization volumes for adjusting and timing the CIC. In order to determine the right number of catheterizations, several factors should be taken into account, such as the patient's ability to void, bladder capacity, and various urodynamic variables. In some cases additional therapy might be administered to reduce bladder pressure. If a patient cannot perform CIC on his own, a caregiver or a family member may be instructed to perform the procedure. The Committee described the methods and techniques to perform CIC and described possible complications (although rare) such as urinary tract infections (UTI), urethral and/or bladder damage, and the difference between a condition of asymptomatic bacteriuria and UTI. The Committee recommends that preventive antibiotic treatment should not be given to CIC patients. Antibiotic treatment should be given only in the case of UTI. The Committee recommends active participation of medical, nursing, social workers, family members and direct caregivers to improve the quality of life of CIC patients. Long-term follow-up is needed to diagnose and prevent complications of CIC/underlying disease leading to CIC. Different follow-up tests should be performed based on underlying disease, complications or changes in patient symptoms. The Committee described different types of catheters and recommends that the use of single-use catheters is preferable. Pre-shielding should be used before using the catheters without external coating.