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Stellenwert von Hydrodistension und Blasentraining
Abstract
Zusammenfassung
Obwohl die Hydrodistension der Harnblase ein häufig angewendetes Konzept in der Behandlung der intestitiellen Zystitis (IC)
darstellt, ist die wissenschaftliche Datenlage zur therapeutischen Blasendehnung spärlich.
Bei ungeklärtem Wirkungsmechanismus, fehlenden prospektiven und kontrollierten Studien und bestenfalls kurzfristiger Effektivität
kann die Hydrodistension nicht als therapeutisches Standardkonzept mit wissenschaftlich nachgewiesenem Behandlungserfolg angesehen
werden und besitzt eher den Stellenwert eines Heilversuchs.
Die Wertigkeit von Blasentraining oder ähnlichen Miktonsverhaltensmodifikationen bei der IC bleibt ebenfalls unklar, ein gewisser
Effekt kann allenfalls für die vergleichsweise kleine Untergruppe von IC-Patienten ohne Schmerzkomponente erwartet werden.
To examine the specificity and sensitivity of the inflammatory markers histamine, methylhistamine, and interleukin-6 (IL-6) in the urine of patients with interstitial cystitis compared with that in healthy controls.
A total of 40 women with interstitial cystitis and 29 healthy controls collected 24-hour urine samples. During the 24 hours before urine collection, all participants refrained from consuming foods and medications that could contain bioactive amines. Methylhistamine and histamine were measured using radioimmunoassay kits and were normalized to urinary creatinine levels; IL-6 was measured using enzyme-linked immunosorbent assay. The data were analyzed by t tests, logistic regression analysis, and receiver operating characteristics.
IL-6 and histamine were significantly greater in the patients with interstitial cystitis than in the controls (P = 0.0003 and P = 0.038, respectively). The methylhistamine levels were also greater in the patients with interstitial cystitis than in the controls, but the results did not reach significance (P = 0.063). Using a combination of IL-6 and methylhistamine/creatinine, cutoff points were established. Using these cutoff points, the sensitivity was 70.0%, specificity 72.4%, positive predictive value 77.8%, and negative predictive value 63.6%.
All three markers--histamine, methylhistamine, and IL-6--were greater in the patients with interstitial cystitis than in the controls. A combination of methylhistamine and IL-6 could be used as a sensitive and specific marker for interstitial cystitis.
25 patients with interstitial cystitis were treated by prolonged bladder distension. 16 patients are symptom-free, but 5 of these have had 1 or more previous prolonged bladder distensions. 6 patients are improved, whilst 3 remain symptomatically unchanged. Prolonged bladder distension can be repeated successfully when symptoms return. These results suggest that prolonged bladder distension has a place in the treatment of interstitial cystitis.
The results from our first 43 treatments suggest the following:High malignant tumours are more sensitive to pressure treatment than low malignant types (Table VII).The situation of the tumour is of importance in so far as tumours situated close to the passage of larger vessels through the bladder wall responded poorly (Table VIII).The duration of increased intravesical pressure at values corresponding to or exceeding the diastolic (and below the systolic) blood pressure to a large extent determine the treatment result (Tables IX and X).Thus we found partial necrosis in 1 patient only who, considering the above-mentioned factors, was treated under optimal conditions, stressing the importance of taking these factors into account when deciding upon the duration of the procedure.Hydrostatic pressure treatment is a new method and the exact definition of its indications has not yet been finalised. Patients treated up till now fall into the following groups:Extensive papillomatosis responding poorly to other treatment regimens. Recurrences, mostly isolated tumours, may occur 8–13 months after pressure treatment. These tumours are easily controlled by electrocoagulation treatment.Large isolated tumours of malignancy grade II in patients not suited for more extensive surgical interventions.Highly malignant tumours are most sensitive and this type of tumour represents in our opinion the most important indication. This is in particular true for tumours not infrequently seen close to the trigone or bladder neck. Total extirpation of the bladder and urinary diversion are in such cases the only alternative surgical treatment.Highly malignant, far advanced tumours not accessible for irradiation or surgery. The palliative improvement obtained in such cases is not without importance, considering that some of the patients lived for a further year after treatment not forgetting the influence of the procedure on pain, voiding need, hæmorrhage and urinary incontinence. In addition improved general well-being of the patients is not infrequently seen.Hydrostatic pressure treatment may be combined with other therapeutic procedures such as irradiation. Irradiation after pressure treatment should however be delayed for 1–2 months in order not to disturb possible immunological processes.After technical failures of hydrostatic pressure treatment, the procedure may be repeated. Even following mucosal hernia, treatment may be repeated after approximately 1 week. The second treatment, however, should always be carried out by the balloon method.After muscle ruptures at least 2 months should elapse before re-treatment.If the primary result is unsatisfactory the interval before re-treatment may depend on the grade of malignancy of the tumour. If total necrosis of the tumour has not been achieved, low grade malignant tumours may be re-treated already after 1 month as necrosis normally then is completed. In highly malignant tumours at least 2–3 months should elapse.We have no experience regarding pressure treatment of recurrent bladder cancer in previously irradiated patients. If such patients are to be treated, however, it should be remembered that the immunological response of irradiated patients may be decreased. This may have an unfavourable influence upon the result of pressure treatment.Pressure treatment after previous electrocoagulation presented no difficulties. The same is true for patients having undergone bladder surgery, due to other diseases.Finally, the balloon-method is technically less difficult than the Foley catheter technique. It is therefore recommended that the balloon method should be used initially until experience in the application of the hydrostatic pressure treatment has been gained.
The short-term results of behavioral therapy in 42 women with refractory symptoms of interstitial cystitis were retrospectively analyzed. All patients had persistent symptoms at least 2 years in duration despite undergoing a number of empiric therapies. Symptoms included urinary frequency and urgency of at least once every 2 hours during waking hours and persistent pain or discomfort in the suprapubic, perineal or pelvic area. Treatment consisted of diary keeping, timed voiding, controlled fluid intake and pelvic floor muscle training techniques. After a mean of 12 weeks of treatment the inter-voiding interval increased in all patients by a mean of 93 minutes (p < 0.01) and 98% experienced a decrease in the number of micturitions per day by a mean of 9 (p < 0.01). Using a global assessment scale 50% of the patients reported that the symptoms were markedly improved and 38% were improved. These data confirm the short-term efficacy of behavioral therapy in selected patients with symptoms of interstitial cystitis.
Prolonged bladder distension continues to be recommended for the treatment of detrusor instability and other bladder conditions. We have reviewed our experience of the technique. A total of 45 patients have undergone 50 procedures. Only 1 of 29 patients with detrusor instability had sustained improvement. 6 of 7 patients with interstitial cystitis noted improvement, sustained in 3. All the other patients noted some improvement. There was a 20% complication rate. 33 (75%) of the living patients returned questionnaires with 27% feeling that the operation was worthwhile. We feel that prolonged distension of the bladder is unhelpful in the treatment of patients with detrusor instability. Its place in the management of patients with interstitial cystitis and irritative symptoms remains controversial. The place of simple bladder distension should be considered.
Six patients with long-standing interstitial cystitis (IC) were treated with intravesical electromotive drug-assisted (EMDA) therapy using lidocaine (1.5%) and 1:100,000 epinephrine in aqueous solution. A stainless-steel silver-coated anode placed through an 18F Foley catheter was positioned in the urinary bladder, and a 5 x 10-cm dispersion electrode (cathode) was placed on the suprapubic skin, which was well lubricated with conductive jelly. The two electrodes were connected to a pulsed DC generator, and electrical current was slowly ramped from 0 to 15 mA while the lidocaine and epinephrine were in the urinary bladder. After 40 minutes of current application, the bladder was hydraulically dilated to maximum tolerance. Significant bladder dilatation was achieved without systemic symptoms. Post-treatment, voiding symptoms decreased, as did suprapubic and perineal pain, and in four patients, the results have been durable.
Thirteen patients with interstitial cystitis diagnosed by the NIH criteria were treated with intravesical electromotive administration of lidocaine and dexamethasone followed by cystodistention. After a mean follow-up of 10 (range 3-22) months, 8/13 (62%) of the patients reported complete resolution of bladder symptoms lasting an average 4.5 (range 0.75-17) months. Partial or short-term improvement of bladder symptoms was observed in three patients, while two patients reported aggravation of pain for several days after therapy. A significant increase in bladder capacity, to an average 166% of the pretreatment capacity, was observed in all patients. Whenever symptoms recurred after initially effective therapy, retreatments were performed with equal efficacy in 11 patients. This promising new therapeutic approach, performed on an outpatient basis, may become first-line treatment for patients with interstitial cystitis.