Necrotizing Fasciitis Mimicking Interstitial Cystitis: An Atypical Clinical Presentation.

Necrotizing fasciitis is a severe, life-threatening disease with a nonspecific clinical presentation, making it a challenging diagnosis. Early treatment with broad-spectrum antibiotics and surgical debridement is crucial to prevent rapid disease progression and poor outcomes. Given its high mortality rate and ambiguous presentation, maintaining a high index of suspicion for necrotizing fasciitis is essential. In this case, a 60-year-old woman presented to her gynecologist with urinary tract infection symptoms of frequency, hematuria, and suprapubic pain, with a year-long history of night sweats, hematuria, dysuria, and incomplete voiding. Although initially treated with outpatient antibiotics, she returned to the emergency department one day later with severe lower abdominal pain, overlying erythema, and a high fever. Abdominal imaging revealed extensive cellulitis. Upon the development of rapidly expanding erythema and crepitus, there was concern for necrotizing fasciitis. The patient received immediate treatment with broad-spectrum antibiotics and underwent urgent surgical debridement. While she showed clinical improvement in the following days, laboratory studies revealed profound hypercalcemia, anemia, and persistent leukocytosis. Additional testing ultimately led to the diagnosis of advanced bladder cancer. This case underscores the importance of prompt recognition and treatment of necrotizing fasciitis. It also highlights the influence of confirmation and availability biases, which can lead to overlooking symptoms that may indicate more serious underlying conditions. As medical professionals, it is crucial to remain vigilant and not disregard seemingly insignificant symptoms, as they could be indicative of life-threatening diagnoses.

Efficacy of a pharmacist care protocol to manage uncomplicated female cystitis in community pharmacies: an open-label, multicenter, randomized, controlled, cluster study: the PharmaCyst' protocol.

BACKGROUND: Urinary tract infections are common affections, especially for women. Difficult access to a general practitioner to obtain a prescription has led France to offer dispensing under protocol by community pharmacists. The primary objective of this study is to evaluate the effectiveness of a pharmacist care protocol provided to manage women with urinary tract infection symptoms. This objective will be assessed using the Acute Cystitis Symptom Score. METHODS: PharmaCyst' is an open-label, multicenter, controlled, cluster-randomized study conducted in the Loire region, France. Women aged between 18 and 65 years presenting to a pharmacy complaining of at least one symptom of an uncomplicated urinary tract infection present over the last 3 days (including burning pain during micturition, dysuria, pollakiuria, urgent urination) will be considered for inclusion. All patients will be contacted on day 3, 10, and month 3. A total of 480 patients need to be recruited for the 24 clusters participating in the research. The quantitative data will be described using means and standard deviations and compared using Student's t-test. The qualitative data will be described using numbers and percentages and compared using chi2 test (or Fisher's exact test if necessary). The primary and secondary outcomes analyses will consider the intention-to-treat population. DISCUSSION: PharmaCyst' is the first clinical trial conducted in France only by community pharmacists. Its results could lead to an extension of the protocol. TRIAL REGISTRATION: The protocol has been approved by the French ethics committee on 2022/12/02 and is registered under the number 49RC22_0240 on ClinicalTrials.gov.

Management of ketamine cystitis: National Guidelines from the French Association of Urology (CUROPF/CTMH).

OBJECTIVE: The objective of the CUROPF and CTMH was to establish recommendations about ketamine induced uropathy management. METHODS: A systematic review of the literature was conducted on Pubmed/Medline by the members of the French committees of female urology and male lower urinary tract symptoms focusing on the epidemiology, pathophysiology, diagnosis and treatment of ketamine induced uropathy, evaluating references and level of evidence. RESULTS: Recommendations include epidemiology, pathophysiology, diagnosis and treatment of ketamine induced uropathy. It represents a rising healthcare issue, with major augmentation of ketamine consumers and new patients across the world. Several pathophysiology pathways are suspected and need clinical validation. The diagnosis is clinical, with hyperactive bladder symptoms mostly including pollakiuria, but also lower urinary tract symptoms, and histological, requiring bladder biopsies to rule out carcinoma and show specific features and inflammation. Therapeutics are currently limited and non-specific, combining abstinence, hydrodistension, pentosane polysulfate and Botox injections. Complex reconstructive surgeries should be avoided and be considered as a last resort. CONCLUSION: These guidelines should provide tools to help every physician confronted to ketamine induced uropathy patients, which represents a growing issue. Hopefully, this work will allow the improvement of the screening, management and care of ketamine induced uropathy in the future.

APRIL/BAFF upregulation is associated with clonal B-cell expansion in Hunner-type interstitial cystitis.

Hunner-type interstitial cystitis (HIC) is a chronic inflammatory disease of the urinary bladder with an unknown etiology. We conducted comprehensive immunogenomic profiling of bladder specimens obtained by biopsy and cystectomy from 37 patients with HIC. Next-generation RNA sequencing demonstrated abundant plasma cell infiltration with frequent light chain restriction in HIC-affected bladder tissue. Subsequent analysis of the B-cell receptor repertoire revealed spatial and temporal expansion of B-cell clones. The extent of B-cell clonal expansion was significantly correlated with the gene expression levels of TNFSF13 and TNFSF13B, which encode APRIL and BAFF, respectively. These findings indicate that APRIL and BAFF are the key regulators of clonal B-cell expansion in HIC and might serve as therapeutic targets in this debilitating disease. © 2024 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Coping With Interstitial Cystitis/Bladder Pain Syndrome.

AIMS: Compensatory coping, or maladaptive alterations in behavior with the intention of preventing or managing symptoms, is increasingly being explored as a key factor in how people respond to bladder conditions. Preliminary investigations have identified relations between coping behaviors and psychological distress in urologic conditions, including interstitial cystitis/bladder pain syndrome (IC/BPS). However, previous explorations of coping have not accounted for heterogeneity in coping behaviors or addressed the likelihood that some coping behaviors may be more adaptive than others. This study sought to examine how two specific types of coping behaviors, primary control coping and disengaged coping, are related to distress and symptoms in IC/BPS, and to explore the potential role of pain phenotype in this relationship. MATERIALS AND METHODS: A secondary data analysis was conducted with a large community data set (N = 677 women with IC/BPS) and employed descriptive and inferential statistics to characterize coping patterns and explore novel predictors of distress. RESULTS: Results indicated that almost all participants engaged in at least one compensatory coping behavior within the last week. Both types of coping behaviors correlated with psychological symptoms, and when controlling for relevant clinical variables (i.e., age and severity of urinary symptoms), disengaged coping behaviors were significantly associated with psychological distress. Further, the addition of pain phenotype to multiple regression models resulted in a more effective predictive model when considering the relation between coping behaviors and depression. CONCLUSIONS: By investigating more deeply the relationship between coping and distress, understanding of potential risk factors and mechanisms is increased, offering valuable insights for intervention strategies for IC/BPS patients.

Antibiotic prescribing for acute uncomplicated cystitis among community pharmacists in Thailand.

OBJECTIVES: This study aimed to evaluate the knowledge of community pharmacists toward acute uncomplicated cystitis regarding diagnosis, referral, and conformity to guidelines of the chosen antibiotic and to identify the associated factors with the pharmacist's knowledge. METHODS: This was a descriptive cross-sectional survey using a questionnaire. Data was collected from 349 community pharmacies in upper southern Thailand between December 2021 and February 2022. Univariate logistic regression analysis was used to assess factors associated with an inappropriate diagnosis of acute uncomplicated cystitis. The variables with P-value < 0.2 were included in the multivariate model. The statistically significant level was set as P-value < 0.05. KEY FINDINGS: Three hundred and forty-nine pharmacists from 349 community pharmacies were included. Approximately 65% and 69% of the participants had the knowledge to identify which patients should be considered for cystitis and which patients should be considered for acute uncomplicated cystitis. Ninety eight percentage of pharmacists could select the appropriate antibiotic for uncomplicated cystitis patients. The most prescribed antibiotics were ciprofloxacin (44.7%), norfloxacin (40.7%), and ofloxacin (10.3%). Inappropriate diagnosis was significantly related to age (P = 0.016) and role in the community pharmacy (P = 0.033). CONCLUSION: The majority of participants had misconceptions about the differential diagnosis between complicated and uncomplicated cystitis. These were related to the community pharmacists' advanced age. Continuous pharmacy education should be established to advocate rational antibiotic use, especially in a country where community pharmacists are legally allowed to dispense antimicrobials without a prescription.

Unusual coexistence: A case of mixed small and large cell neuroendocrine tumor in a bladder previously affected by bilharzial cystitis.

Neuroendocrine tumors of the bladder are rare, accounting for less than 1% of all bladder tumors. Among these, large cell neuroendocrine carcinoma is an extremely uncommon subtype. We report on a histologically confirmed case of mixed both large and small cells neuroendocrine tumor of the bladder in a 64-year-old male with a history of bilharzial cystitis. The diagnosis was made after radical cystectomy with Immunohistochemical staining revealing positivity for synaptophysin, CD56, and AE1/3. While bilharzia is commonly linked to squamous cell carcinoma in the bladder, the potential relationship with neuroendocrine tumors is still relatively unexplored in this context. This case marks the first reported instance of the atypical coexistence of bilharzial cystitis and mixed large and small cell neuroendocrine carcinoma of the bladder. This unique case of coexisting highlights a rare phenomenon warranting further study. Similar associations have been documented in other organs, emphasizing the importance of exploring underlying mechanisms and clinical implications for improved patient care and outcomes.

Genetic requirements for uropathogenic E. coli proliferation in the bladder cell infection cycle.

Uropathogenic Escherichia coli (UPEC) requires an adaptable physiology to survive the wide range of environments experienced in the host, including gut and urinary tract surfaces. To identify UPEC genes required during intracellular infection, we developed a transposon-directed insertion-site sequencing approach for cellular infection models and searched for genes in a library of ~20,000 UTI89 transposon-insertion mutants that are specifically required at the distinct stages of infection of cultured bladder epithelial cells. Some of the bacterial functional requirements apparent in host bladder cell growth overlapped with those for M9-glycerol, notably nutrient utilization, polysaccharide and macromolecule precursor biosynthesis, and cell envelope stress tolerance. Two genes implicated in the intracellular bladder cell infection stage were confirmed through independent gene deletion studies: neuC (sialic acid capsule biosynthesis) and hisF (histidine biosynthesis). Distinct sets of UPEC genes were also implicated in bacterial dispersal, where UPEC erupts from bladder cells in highly filamentous or motile forms upon exposure to human urine, and during recovery from infection in a rich medium. We confirm that the dedD gene linked to septal peptidoglycan remodeling is required during UPEC dispersal from human bladder cells and may help stabilize cell division or the cell wall during envelope stress created by host cells. Our findings support a view that the host intracellular environment and infection cycle are multi-nutrient limited and create stress that demands an array of biosynthetic, cell envelope integrity, and biofilm-related functions of UPEC. IMPORTANCE: Urinary tract infections (UTIs) are one of the most frequent infections worldwide. Uropathogenic Escherichia coli (UPEC), which accounts for ~80% of UTIs, must rapidly adapt to highly variable host environments, such as the gut, bladder sub-surface, and urine. In this study, we searched for UPEC genes required for bacterial growth and survival throughout the cellular infection cycle. Genes required for de novo synthesis of biomolecules and cell envelope integrity appeared to be important, and other genes were also implicated in bacterial dispersal and recovery from infection of cultured bladder cells. With further studies of individual gene function, their potential as therapeutic targets may be realized. This study expands knowledge of the UTI cycle and establishes an approach to genome-wide functional analyses of stage-resolved microbial infections.

Advancements in Understanding and Managing Radiation Cystitis: A Comprehensive Review.

PURPOSE OF REVIEW: This manuscript aims to provide a comprehensive overview of the pathophysiology, risk factors, prevention strategies, and management options for radiation cystitis. RECENT FINDINGS: Recent studies have shed light on the pathophysiology of radiation cystitis, highlighting the role of inflammation, fibrosis, and vascular damage. Emerging preventive measures like stem cell therapy offer promise, alongside novel treatments such as amniotic bladder therapy and hyperbaric oxygen therapy. This review outlines the latest research on radiation cystitis, covering its pathophysiology, risk factors, prevention, and management. Major findings include insights into the mechanisms of RC development, promising preventive and therapeutic approaches, and the importance of standardized treatment pathways. Future research should focus on identifying genetic risk factors, improving treatment efficacy, and enhancing patient outcomes. This review offers valuable insights for clinicians and researchers, guiding future investigations into radiation cystitis management.

Association between non-neoplastic bladder diseases and bladder cancer risk: insights from Mendelian randomization studies.

PURPOSE: Our aim is to explore the relation between non-neoplastic bladder diseases and bladder cancer (BC) from a genetic level utilizing Mendelian randomization (MR). METHODS: Single nucleotide polymorphisms (SNPs) related to cystitis, bladder stones, and neuropathic bladder were gathered from the IEU genome-wide association studies database. Quality control on SNPs was performed via stringent screening criteria. The relation between non-neoplastic bladder diseases and BC risk was evaluated using inverse-variance weighted, MR-Egger, weighted median, simple mode, and weighted mode methods. Cochran's Q test was conducted to assess the heterogeneity of SNPs; in addition, the MR-Egger intercept test was employed to examine the horizontal pleiotropy of SNPs. Exposure and outcomes were validated using a validation database. Finally, BC was used as the exposure and non-neoplastic bladder diseases as the outcome to evaluate reverse causality. RESULTS: The outcomes showcased that genetically predicted cystitis is significantly correlated to a raised risk of BC (inverse-variance weighted: odds ratio [95%] = 1.1737 [1.0317, 1.3352], P = .0149), consistent with the BC validation cohort in the MR analysis. Nevertheless, no causal relation was found between bladder stone and neuropathic bladder with BC risk (P > .05). In this study, sensitivity analysis indicated no heterogeneity or horizontal pleiotropy. CONCLUSION: The study presents proof of a genetic-level causal relation between cystitis and increased BC risk, while bladder stones and neuropathic bladder do not show similar associations.

Successful treatment of Candida albicans-induced fungal cystitis in a dog using caspofungin: a case report.

A 7-year-old castrated male poodle was brought to the referral Animal Medical Center and diagnosed with diabetes and pancreatitis. One month later, the patient presented with cloudy urine, and ultrasonography revealed a large number of spherical substances. The patient was subsequently diagnosed with fungal cystitis with Candida albicans. Initially, 10.00 mg kg-1 itraconazole was prescribed twice daily for six weeks, and the symptoms of prolonged urination improved; however, the fungal balls persisted in the bladder. The six months later, the patient showed recurrent symptoms, such as dysuria and stranguria; therefore, 5.00 mg kg-1 fluconazole was prescribed twice daily; however, it was not effective. Subsequently, 1.00 mg kg-1 caspofungin once daily was administered for three consecutive days. Finally, the fungal balls in the bladder disappeared. The patient was regularly monitored after completion of treatment and, 17 months later, doing well without recurrence. Few reports exist on the use of caspofungin in veterinary medicine. The recommended dose of caspofungin in dogs remains unknown. In the case of azole-resistant Candida, treatment using caspofungin should be considered; although, additional studies on the established dosing and side effects are needed.

Adult zymosan re-exposure exacerbates the molecular alterations in the brainstem rostral ventromedial medulla of rats with early life zymosan-induced cystitis.

Recent evidence suggests that the descending modulatory pathways from the brainstem rostral ventromedial medulla (RVM) are important for bladder inflammatory pain. This study aimed to identify the long-term molecular changes in RVM neurons due to early life cystitis during neuronal development and the effect of reexposure later in adulthood. RVM tissues from two treatment protocols were used: (1) neonatal zymosan exposures with acute adult rechallenge (RC) and (2) only neonatal zymosan exposures (NRC). RNAseq analysis showed upregulation of several genes associated with synaptic plasticity (Grin1, Grip2, Notch1, Arc, and Scn2b) in the cystitis groups compared to controls in both protocols. The RC protocol exhibited a stronger treatment effect with significantly higher fold differences between the groups compared to the NRC protocol (p < 0.001, fold differences RC vs NRC). In microarrays, miR-34a-5p showed cystitis-induced downregulation in both protocols. Bioinformatics analysis identified multiple 3'UTRs complementary binding sites for miR-34a-5p on Grin2b, Notch1, Grip2, Scn2b, and Arc genes. The enhanced response in the RC protocol indicates a possible priming effect of early life cystitis on rechallenge in adulthood. These long-term molecular alterations may play a critical role in the development of chronic bladder pain conditions as seen in patients with Interstitial Cystitis/Bladder pain syndrome.

Case reports of immune-related cystitis and the antibody combination hypothesis.

Immune-related cystitis is a rare condition, and its diagnostic criteria and pathogenesis are not yet fully understood. Here, we report two cases of immune-related cystitis. Both patients were previously diagnosed with lung squamous cell carcinoma and received combined treatment with immune checkpoint inhibitors and chemotherapy, leading to hemorrhagic cystitis. We reviewed the cystoscopic images and pathological features of previous cases and found that autoantibodies against hemidesmosomes may be the cause of immune-related cystitis, proposing the "antibody combination" hypothesis to explain the tissue specificity of the condition.

Lung squamous cell carcinoma can produce certain proteins called autoantigens. Some patients treated with immune checkpoint inhibitors might develop antibodies against these autoantigens. A specific combination of these antibodies may cause the bladder lining to slough, leading to immune-related cystitis. Symptoms of this condition include frequent urination, urgent need to urinate, painful urination and blood in the urine. These patients typically require treatment with steroids.

Definition Change and Update of Clinical Guidelines for Interstitial Cystitis and Bladder Pain Syndrome.

The clinical guidelines for interstitial cystitis (IC) and bladder pain syndrome (BPS) have been revised by updating our previous guidelines. The symptoms of IC and BPS, collectively called as hypersensitive bladder (HSB) symptoms, are virtually indistinguishable between IC and BPS; however, IC and BPS should be considered as a separate entity of disorders. We define IC as a bladder disease with Hunner lesions, usually associated with HSB symptoms and bladder inflammation, and BPS as a condition with HSB symptoms in the absence of Hunner lesions and any confusable diseases. Pathophysiology totally differs between IC and BPS. IC involves immunological inflammation probably resulting from autoimmunity, while BPS is associated with the interaction of multiple factors such as neurogenic inflammation, exogenous substances, urothelial defects, psychological stress, and neural hyperactivity. Histopathology also differs between IC and BPS. IC is associated with severe inflammation of the whole bladder accompanied by plasma cell infiltration and urothelial denudation, while BPS shows little pathological changes. Management should begin with a differential diagnosis of IC or BPS, which would require cystoscopy to determine the presence or absence of Hunner lesions. The patients should be treated differently based on the diagnosis following the algorithm, although pain management would be common to IC and BPS. Clinical studies are also to be designed and analyzed separately for IC and BPS.

A cynomolgus monkey E. coli urinary tract infection model confirms efficacy of new FimH vaccine candidates.

The increase in urinary tract infections (UTI) caused by antibiotic-resistant Escherichia coli requires the development of new therapeutic agents and prophylactic vaccines. To evaluate the efficacy of new lead candidates, we implemented a cynomolgus macaque UTI challenge model that mimics human uncomplicated cystitis in response to transurethral challenge with a multidrug-resistant (MDR) E. coli serotype O25b ST131 isolate. E. coli fimbrial adhesin FimH and O-antigens are separately under clinical evaluation by others as vaccine candidates to prevent UTI and invasive urosepsis disease, respectively. Accordingly, we assessed the protective efficacy of three 50-µg intramuscular doses of a novel recombinant FimH antigen adjuvanted with liposomal QS21/MPLA compared with saline placebo in groups of nine animals. A third group was vaccinated with this FimH formulation in combination with 1 µg each of a four-valent mixture of serotype O1a, O2, O6, and O25b O-antigen CRM197 lattice glycoconjugates. Both vaccines elicited high levels of serum FimH IgG and adhesin blocking antibodies at the time of bacterial challenge and, for the combination group, O-antigen-specific antibodies. Following bacterial challenge, both vaccinated groups showed >200- and >700-fold reduction in bacteriuria at day 2 and day 7 post-infection compared with placebo, respectively. In parallel, both vaccines significantly reduced levels of inflammatory biomarkers IL-8 and myeloperoxidase in the urine at day 2 post-infection relative to placebo. Results provide preclinical proof-of-concept for the prevention of an MDR UTI infection by these new vaccine formulations.

Using Urine Biomarkers to Differentiate Bladder Dysfunctions in Women with Sensory Bladder Disorders.

Sensory bladder disorders encompass several distinct conditions with overlapping symptoms, which pose diagnostic challenges. This study aimed to evaluate urine biomarkers for differentiating between various sensory bladder disorders, including non-Hunner's interstitial cystitis (NHIC), detrusor overactivity (DO), hypersensitive bladder (HSB), and urodynamically normal women. A retrospective analysis of 191 women who underwent a videourodynamic study (VUDS) was conducted, with some also receiving cystoscopic hydrodistention to confirm the presence of NHIC. Participants were categorized into four groups: DO (n = 51), HSB (n = 29), NHIC (n = 81), and normal controls (n = 30). The urine levels of inflammatory and oxidative stress biomarkers were measured. The DO patients exhibited elevated IP-10 levels, while the HSB patients had decreased TAC and 8-OHdG levels. The NHIC patients showed lower IL-2 and higher TNF-α levels. A TNF-α ≥ 1.05 effectively identified NHIC, with an AUROC of 0.889, a sensitivity of 98.8%, and a specificity of 81.3%. An IP-10 ≥ 6.31 differentiated DO with an AUROC of 0.695, a sensitivity of 56.8%, and a specificity of 72.3%. An 8-OHdG ≤ 14.705 and a TAC ≤ 528.7 identified HSB with AUROCs of 0.754 and 0.844, respectively. The combination of 8-OHdG and TAC provided an AUROC of 0.853 for HSB. These findings suggest that TNF-α, IP-10, TAC, 8-OHdG, and IL-2 are promising non-invasive biomarkers for distinguishing between these conditions, which may improve diagnosis and management.

Ketamine-induced cystitis: A case report and literature review.

Ketamine, a dissociative anesthetic drug, has gained popularity as a recreational substance, particularly among young adults. However, chronic ketamine abuse can lead to various complications including ketamine-induced cystitis. We present the case of a 46-year-old Caucasian male with a history of HIV infection and daily recreational ketamine use for 7 months, who was admitted to the emergency room with hypogastric pain and hematuria. Laboratory examinations and contrast-enhanced abdominal CT tomography revealed significant irregular circumferential thickening of both ureters, substantial bilateral pyeloureteral ectasia, and a bladder with markedly thickened walls. Bilateral flexible ureteropyeloscopy, bladder transurethral resection, and bladder fulguration were performed, and pathology confirmed the diagnosis of ketamine-induced cystitis. Treatment consisted of ketamine withdrawal, pain relief, and support from psychiatrists and urologists. The patient's symptoms improved and he was discharged without complications. This case highlights the importance of recognizing the potential adverse effects of recreational ketamine use and the need for a multidisciplinary approach to managing ketamine-induced cystitis. Further research is necessary to elucidate the precise mechanisms underlying this condition and develop effective prevention and treatment strategies.

Mathematical Approach to Synergistic Management of Bladder Pain Syndrome/Interstitial Cystitis and Vulvodynia: A Case Series Utilizing Principal Component Analysis, Cluster Analysis, and Combination Laser Therapy.

This case series presents three patients with bladder pain syndrome/interstitial cystitis (BPS/IC) and vulvodynia, demonstrating the efficacy of an individualized treatment approach using cluster analysis and combination laser therapy. Principal component analysis (PCA) was used to visualize the dynamic nature of symptom clusters and guide treatment decisions. Case 1 was a 41-year-old woman initially classified as Cluster 1 (PCA coordinates: 1.65, 0.03) transitioned to Cluster 2 (-16.93, -21.75) after bladder hydrodistension. Subsequent Fotona laser (Ljubljana, Slovenia) treatment resulted in the complete resolution of symptoms. Case 2 was a 55-year-old woman, contraindicated for hormone therapy due to breast cancer history, presented as Cluster 2 (PCA coordinates: -24.16, 8.74). Fotona laser treatment shifted her to Cluster 1 (11.22, -20.22), followed by bladder hydrodistension for complete cure. Case 3 was a 49-year-old woman, initially in Cluster 0 (PCA coordinates: 1.892, 30.11), who underwent fulguration for Hunner's lesions. Posttreatment, she moved to Cluster 2 (-24.31, 1.767) and achieved full recovery after Fotona laser therapy. The dynamic nature of symptom clusters, visualized through PCA, guided treatment decisions. The PCA transformation, represented as y =WTz, where z is the standardized symptom vector and W is the principal component matrix, allows for the objective tracking of symptom changes. Combination Fotona laser therapy, including vaginal erbium YAG and neodymium YAG, has proven effective in managing vulvar pain, particularly when hormone therapy is contraindicated. This approach, addressing both urological and gynecological aspects, resulted in sustained symptom improvement for over 12 months in all cases. This case series highlights the synergistic relationship between BPS/IC and vulvodynia, demonstrating the efficacy of comprehensive, adaptive treatment strategies guided by mathematical analysis for complex pelvic pain syndromes.

Towards a Reference Standard Definition of Urinary Tract Infection for Research.

Urinary tract infection (UTI) is among the most common human bacterial infections. In the context of increasing antibiotic resistance, there are many research efforts to improve the pathophysiological understanding, diagnosis, and treatment of UTI. Despite the high clinical relevance of UTI, there is high variability in definitions in the literature, making interpretation and comparison of research studies difficult, and even impossible in some cases. A recent Delphi consensus study generated a new reference standard definition for UTI that incorporates symptoms, pyuria, and urine culture results. This definition allows for designation of systemic involvement, and no longer categorizes UTIs as complicated or uncomplicated. The definition aligns with guidance from regulatory bodies for approval of UTI drugs. Implementation of a reference standard definition in the design and reporting of future investigations will allow better research design and interpretability within and outside the urology field. The new reference standard resolves some issues and offers a suitable way to unify methodology, and hence increase the potential strength of research in this area. There are some limitations and challenges for implementation, such as difficulties in establishing sensitivity and specificity values for the various settings in which the definition will be used. The inclusion of "probable" and "possible" UTI categories could be a problem in studies that require dichotomous outcomes. Nonetheless, the reference standard should be recommended until new developments become available, notably a more specific UTI biomarker than pyuria. Approaches to standardized diagnosis of catheter-associated UTIs remain unresolved. PATIENT SUMMARY: A new research definition for urinary tract infection (UTI) has been developed. Use of a single standardized definition in research will help in better design of research studies and comparison of results. Although the new definition will help in reducing the variability in UTI research reports, it has some limitations and there may be challenges to overcome before it is widely used.

Evaluation of outcomes of clinical phenotyping-based treatment for bladder pain syndrome/interstitial cystitis.

Introduction: Bladder pain syndrome/Interstitial cystitis (BPS/IC) is clinically of diverse types because different causes contribute to the development of their symptoms. It is important to classify patients into various groups based on the possible etiopathogenesis of their condition. Treatment may be tailored to each specific group according to the possible cause. Methodology: Twenty-five patients diagnosed with BPS/IC were categorized into four different clinical phenotypes (CP) based on their history of symptoms, allergy, dysfunctional voiding, neuropathic pain, and the presence of Hunner's ulcer. Some patients could be classified into multiple groups. The patients were given oral pentosan polysulfate, and treatment specific to their CP. Patients in CP1, CP2, and CP3 groups received, respectively hydroxyzine, clonazepam, and amitriptyline. Patients with Hunner's lesions (HL) (CP4) underwent hydro distension and ablation of the lesion, followed by intravesical instillation of heparin and hydrocortisone. The patients were evaluated using the Apollo clinical scoring (ACS) system and their clinical scores were recorded at 1, 3, and 6 month(s). Results: Among the 25 patients, 5, 7, 4, and 9 patients were classified into CP 1 - CP4 groups respectively, and were all subjected to ACS assessment. In CP1 group (allergy group), 80% (4/5) of patients responded well to the treatment and 20% (1/5) had unsatisfactory responses. In CP2 group (dysfunctional voiding group), 71.42% (5/7) patients had good, and 28.57% (2/7) had excellent responses. In CP3 group (neuropathic pain group), 28.57% (3/4) patients had excellent, and 75% (1/4) patients had good responses. In CP4 group (HL group), 33.33% (3/9) patients had unsatisfactory, 44.44% (4/9) achieved good, and 22.22% (2/9) had excellent responses. Overall, 16% (4/25) patients had unsatisfactory, 56% (14/25) attained good, and 28% (7/25) had an excellent response at the completion of the study. Conclusion: Using clinical phenotyping-based features indicative of etiology could potentially improve treatment outcomes by targeting the specific pathological processes contributing to the patients' symptoms.