Treatment of bladder pain syndrome/interstitial cystitis 2008: can we make evidence-based decisions?

CONTEXT: Opinions on how to best treat bladder pain/interstitial cystitis are ambiguous.

OBJECTIVE: To review previous and recent literature on this subject to assess the current state of evidence.

EVIDENCE ACQUISITION: With important previous papers reviewed for the 2003 European Association of Urology guidelines as background, the PubMed database was searched and articles published in 2003-2007 were reviewed and relevant ones were selected for detailed study.

EVIDENCE SYNTHESIS: A large number of studies describing a variety of quite dissimilar therapeutic principles were retrieved. The various methods and level of evidence are summarised in tables. Only pentosan polysulfate sodium (oral and intravesical), amitriptyline, hydroxyzine, cyclosporin A, intravesical dimethyl sulfoxide, transurethral resection of visible Hunner lesions, and major reconstructive surgery reached a high degree of recommendation. However, a number of pitfalls hamper evaluation of the available information; a crucial one is that our understanding of basic mechanisms causing bladder pain is fragmentary. So far, we are faced with a large variety of hypotheses although it is difficult to identify the most relevant ones. In this respect, we are not much helped by the recent literature because many studies have poor descriptions of patients or are of a pilot character, with no follow-up by larger trials. Controlled studies are rather scarce. On the other hand, some good-quality studies following up positive pilot trials end up with negative results.

CONCLUSION: Perhaps the most significant problem concerns inclusion and exclusion criteria in bladder pain syndrome/interstitial cystitis studies. At this stage, it is not too easy to communicate the wide available expert knowledge to the general audience. More sophisticated standards, capable of being generally used, have to come.