This educational review outlines some of the key research to date into the potential impact of the microbiome on conditions such as interstitial cystitis/bladder pain syndrome (IC/BPS). The microbiome, which refers to the complex communities of microbes that inhabit and colonize the human body, is currently an areas of increasing interest among researchers. This is in part due to advances in microbe detection, which revealed a diverse community of bacteria throughout the urinary tract. The authors of this review highlight some of the most important investigations into the role of the microbiome in urinary tract diseases, including a recent, comprehensive analysis of biomarkers found in stool that one day could be targets for treatment of IC/BPS. They also point to specific findings from other studies, such as the finding that an increase in Lactobacillus in the urine is associated with IC/BPS. In another study, women with urgency urinary incontinence (UUI) were found to have a different microbiome in the urinary tract compared with control subjects; more recently, investigators have found that women with more severe UUI symptoms have a loss of microbiome diversity compared with women who have less severe symptoms. While these and other findings detailed in this article are compelling, further studies will be needed to understand the true significance of the microbiome in urinary tract diseases.

The year 2016 was exciting and productive for research into interstitial cystitis/bladder pain syndrome (IC/BPS), yielding a number of new insights and research breakthroughs that may have implications for patient care, according to authors of this end-of-year review. Of note, one key advance was the first-ever prospective, multicenter, randomized controlled trial showing that intravesical injections of botulinum toxin reduced bladder pain in patients with IC/BPS that was not responding to standard treatment. These results were significant enough to prompt the American Urological Association (AUA) to change their treatment guidelines to give a stronger recommendation for this treatment option. Another key development was the identification of a urinary biomarker that could help diagnose IC/BPS. The marker, known as urinary etio-S, effectively differentiates individuals who have IC/BPS from those who do not, with a sensitivity of 91.2% and specificity of 84.7%. While encouraging, the authors say further research is needed to confirm the utility of this biomarker. The authors also highlight a finding by Japanese researchers who used a novel approach to measuring inflammation of the bladder lining to distinguish between Hunner-type and non-Hunner-type IC/BPS, and review the new guide from the International Continence Society that helps establish standard terminology for chronic pelvic pain syndromes.

In this paper, a group of Dutch researchers propose a concept they call the “bladder-gut-brain axis” as a way to understand, and study, urological disorders such as interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, and chronic prostatitis/chronic pelvic pain syndrome. In particular, these researchers are concerned that sometimes, treatment of the urological disorder may yield poor results because of an underlying psychological/psychiatric disorder that contributes to the symptoms and remains untreated. Of note, anxiety and depression are both associated with more severe symptoms and increased burden of illness in certain urological or gastrointestinal disorders. In order to receive the best care, patients who have a combination of urologic and psychological/psychiatric conditions might receive the best care from a multidisciplinary team, rather than a single specialist. In integrated care, the researchers say, the “whole becomes larger than its parts” as specialists collaborate to ensure the patient has the best treatment, not only medically, but also with regard to psychological and social aspects of care. Thus, they recommend this type of multidisciplinary care as a standard for patients with visceral pain and other symptoms, particularly if the patient is resistant to previous treatments.

The Canadian Urological Association (CUA) has released comprehensive guideline for interstitial cystitis/bladder pain syndrome (IC/BPS) that includes citations from more than 200 scientific publications and covers aspects of diagnosis and treatment in detail. This guideline is based not only on current medical literature, but also on expert consensus conference proceedings. The guidelines include “grades” that correspond to the level of evidence supporting each recommendation: for example, patient education on IC/BPS gets a grade of “A” and is recommended for all patients; physiotherapy and massage gets a “B” grade and is recommended for patients with pelvic floor dysfunction; and trigger point injections only rate a “D” and are listed as an option for patients with trigger point pain. In all, the guidelines include a summary of treatment recommendations for 29 such treatment options. That summary itself could be a useful resource for physicians in Canada, where the only two officially approved treatments are pentosan polysulfate (Elmiron), which is given orally, and dimethysulfoxide (DMSO), which is administered intravesically. Most importantly, the guideline authors seek to identify the optimal therapy for different types of patients, when possible. The goal, according to the authors, is to individualize treatment plans to the specific patient, rather than follow a traditional approach where every patient gets the exact same therapy, one therapy at a time. They believe the individualized approach will yield the best patient outcomes.

In this educational article for physicians and patients, the authors describe a variety of urologic conditions that have negative associations with smoking and tobacco. In particular, interstitial cystitis (IC) is discussed. While no studies directly link cigarette smoking as a risk factor or cause of IC, some studies do suggest a correlation between smoking and IC, and there are many “help” articles urging women with IC to stop smoking because smoking might exacerbate IC symptoms. For example, a guide from the National Kidney Foundation cites smoking as a factor that might aggravate IC symptoms. The authors also cite ICA materials that recommend smoking cessation due to the chemicals in cigarette smoke that might be an irritant. Likewise, the International Urogynecological Association recommends smoking cessation. Among the evidence supporting these recommendations is an Austrian study, including nearly 1,000 subjects, in which smokers were more likely to have severe symptoms. Perhaps more concerning is the fact that smoking is a leading cause of cancer and cancer death–not only lung cancer, but also bladder cancer (smoking triples the risk of bladder cancer). Therefore, the authors say, urologists have a great opportunity to help patients adopt healthy lifestyles and end dependence on tobacco.

In this article, aimed at providing practical recommendations for family physicians to follow, the authors argue for a collaborative, patient centered approach to managing chronic pelvic pain in women with interstitial cystitis/bladder pain syndrome (IC/BPS) and other conditions. In particular, they recommend engaging the patient via a “biopsychosocial approach” that includes treatment of IC/BPS, depression, and any other diagnosed and related disease process. In terms of specific drugs, they say that there is limited evidence supporting the treatment of chronic pelvic pain with gabapentin (Neurontin), nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors (SSRIs). They recommend behavioral therapy and call it an “integral” part of treatment, as well as pelvic floor physical therapy, which may be helpful for many patients. They call hysterectomy a treatment of “last resort” and warn that only about a half of patients report significant improvement after the procedure.

This educational article helps explain the current American Urological Association (AUA) guidelines for interstitial cystitis (IC) and covers key research updates from even more up-to-date literature. The AUA guidelines are separated into six tiers of increasingly invasive treatments. The first step is to explore lifestyle modifications, while subsequent tiers involve physical therapy, drugs, and finally surgery for the most challenging cases that are not adequately treated by less invasive therapy. In practice, many patients will benefit from conservative measures, such as education, behavioral or dietary modification (for example, avoiding caffeine and spicy foods), and stress control. Physical therapy is also playing an increasingly important role, especially after studies that suggest it may provide some patients with a moderate or marked improvement in symptoms. If conservative therapy doesn’t work, the AUA guidelines say the next step could be oral therapy with agents such as amitriptyline, hydroxyzine/cimetidine, pentosan polysulfate, and cyclosporine A. If oral medications don’t work, the next step may be bladder instillation (delivery of a treatment into the bladder using a catheter); some of the most common of these therapies are DMSO, heparin, and lidocaine. Surgical procedures, such as cystoscopy with hydrodistention/fulguration of lesions, may be reserved for patients who don’t derive benefit from any of the above therapies. These surgical procedures are invasive but typically relatively benign. However, in the most extreme cases a more serious procedure, such as bladder removal or diversion, may be warranted. Since IC symptoms are quite variable from patient to patient, the authors recommend applying the AUA guidelines to tailor treatment to each specific situation.

This unique review article describes some of the most innovative research initiatives providing fresh insights into interstitial cystitis/bladder pain syndrome (IC/BPS). One of the better known initiatives is the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network, which was started in 2008 to address questions of how pelvic pain conditions develop, their underlying mechanisms, what patients typically experience them, and how the conditions relate to one another. Studies from MAPP have yielded numerous insights into IC/BPS and its pathophysiology, and in 2015, embarked on a new round of studies that will evaluate, among other things, how different groups of patients respond to certain treatments, potentially helping to pave the way for personalized medicine. Another initiative is the Interstitial Cystitis: Elucidation of Psychophysiologic and Autonomic Characteristics (ICEPAC) study, which was initiated in 2009 to assess how the nervous system and related factors contribute to IC/BPS symptoms. Some of the key findings of ICEPAC suggest that nervous system abnormalities are more than just a result of pain and may actually help sub-group patients that would potentially benefit from different types of treatments. A third initiative is the development of the Urinary, Psychosocial, Organ-specific, Infection, Neurologic/Systemic and Tenderness of Skeletal Muscle (UPOINT) classification system. The UPOINT system uses six different clinical characteristics (such as urinary symptoms, neurologic issues, and muscle tenderness) to classify patients into distinct subgroups. Taken together, the findings of these different initiatives are reshaping the views of the scientific and medical communities on the diagnosis, prognosis and clinical management of patients with IC/BPS.

What exactly causes interstitial cystitis/bladder pain syndrome (IC/BPS) is a matter of continued debate and discussion. One of the most recent theories is that the condition could be caused by a disruption of the mucosal bladder surface layer, leading to a loss or alteration of glycosaminoglycans (GAGs), a class of molecules that repel water. When GAGs are not present, the bladder wall may be penetrated by substances that trigger an inflammatory response. One treatment that could help is replenishment of the GAG layer. This treatment is commonly used for patients with IC/BPS who don’t respond (or have poor response) following more conventional treatments. The key treatments that help achieve GAG replenishment include heparin, chondroitin sulfate, pentosan polysulphate, and hyaluronic acid. One of the most recent promising developments is a combination of chondroitin sulphate and hyaluronic acid that has had promising results. However, encouraging results from all of these therapies need more study in randomized, controlled studies with a larger number of patients so the treatments can be optimized to deliver more long-term therapeutic effects.