The article in this issue of CUAJ on endoscopic ablation of Hunner’s ulcers1 raises several issues related to interstitial cystitis/painful bladder syndrome (IC/PBS) that are noteworthy: IC/PBS is common, Hunner’s ulcers are rare, but their presence should prompt biopsy and fulguration.
Interstitial cystitis is common.2 Payne and colleagues1 cite 10-year-old data showing that the prevalence of IC/PBS approaches 1 million people in the United States.3,4 Even this number underestimates its true prevalence.5,6,7 A recent, exhaustive study with over 100 000 American households with follow-up interviews for possible IC/PBS subjects shows a prevalence estimate of 3% to 6% of American women over the age of 18 meet symptom criteria for IC/PBS.8 Urologists undoubtedly encounter IC/PBS patients frequently in their practices.6
Hunner’s ulcers represent the minority of IC/PBS cases, typically less than 7% of patients. Moreover, this study mirrors others in that Hunner’s ulcers generally occur in older patients, with median ages of 53 to 65.9–11 Historically, Hunner’s ulcers were considered the hallmark of IC/PBS. Yet, they are rare and seen primarily in advanced phases of IC/PBS. Hunner’s ulcer patients tend to be more symptomatic (more pain, more nocturia, smaller voided volumes) and may have increased mast cell counts below the denuded epithelium.12,13 Importantly, the absence of Hunner’s ulcers on cystoscopy does not exclude IC/PBS as a diagnosis. In the younger patient whose symptoms suggest IC/PBS, cystoscopy may show a normal-appearing bladder.2,14 A normal cystoscopy does not exclude IC/PBS.
In the current study, the authors describe a non-validated test, whereby “touching” the patch of denuded epithelium with the cystoscope tip produced pain, and their control was to “touch” similarly non-affected areas. In my experience of outpatient flexible cystoscopy with IC/PBS patients with Hunner’s ulcers, small volumes of bladder filling reproduce their pain. I am not convinced that “touching” the lesion to reproduce pain is a valid test. More importantly, the image of the Hunner’s ulcer is difficult to distinguish from carcinoma in situ. Any patient with these cystoscopy findings should undergo bladder biopsy, at which time the lesion can be fulgurated or ablated.
The excellent results reported in this study1 mirror my own experience, in that I find older IC/PBS patients frequently have Hunner’s ulcers, and they obtain symptom relief from fulguration of the ulcer.11 In my follow-up of these patients, if they have flare-ups, I am quick to repeat the cystoscopy. If I find a recurrent ulcer, and it is re-fulgurated, these patients tend to obtain symptom relief.
Footnotes
Competing interests: None declared.
This paper has been peer-reviewed.
References
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