UroToday - BPS may be a heterogeneous spectrum of diseases rather than a single, easily identifiable disorder. It is still poorly defined, and different experts have varying perceptions as to what it is about. Magnus Fall, Frank Oberpenning, and Ralph Peeker from Goteborg, Sweden and Bocholt, Germany have done a very useful literature review trying to answer the question, "Is evidence-based treatment possible?" The answer is not clear, but they outline the issues and point the way. BPS, as it is comprehended by a majority of clinicians today, is not a disorder dominated by the feature of bladder inflammation, which occurs in only a subset of patients.

The extensive review of the authors comes to the following conclusions regarding evidence-based therapy. Only oral pentosan polysulfate sodium, amitriptyline, hydroxyzine, and cyclosporine A reach a high level of recommendation based on clinical trial evidence. Intravesical pentosan polysulfate and dimethyl sulfoxide also have an acceptable level of evidence to justify their use. Transurethral resection of visible Hunner's lesions and major reconstructive surgery can be recommended in selected situations. These recommendations differ slightly from those to come from the 2008 International Consultation on Incontinence (currently in press for 2009) which found only a D recommendation for pentosanpolysulphate based on conflicting study results and marginal efficacy. In addition, the Consultation found little data from which to recommend hydroxyzine.

Fall and colleagues point out that the most significant problem concerns inclusion and exclusion criteria in BPS studies. The overwhelming majority of studies have a poor patient description, simply stating that subjects were fulfilling the NIDDK criteria. Better phenotyping of these patients is the new goal of clinical researchers around the world, and this effort is being spearheaded by the National Institutes of Health MAPP research program (Multidisciplinary Approach to the study of Pelvic Pain) Link here.

At this time, the authors conclude, it is not very easy to communicate the spectrum of available expert knowledge to a general audience. More sophisticated standards, capable of being generally used, have to come.

Fall M, Oberpenning F, Peeker R.
Eur Urol. 2008 Jul;54(1):65-75.
doi:10.1016/j.eururo.2008.03.086

UroToday Contributing Editor Philip M. Hanno, MD, MPH

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