0022-5347/99/1622-0330/0 zyxwvutsrqpo "HE zyxwvutsrqpo JOURNAL zyxwvutsrqponml OF URolacY Copyright zyxwvutsrqpo 8 1999 by zyxwvutsrqponmlk -CAN URO~ICAL A~~~~IATION, INC. Vol. 162,930454, August 1999 z Printed in U.S.A. COMPARISON OF BLADDER BLOOD FLOW IN PATIENTS WITH AND WITHOUT INTERSTITIAL CYSTITIS MICHEL A. PONTARI, PHILIP M. HA"0 AND MICHAEL R. RUGGIERI From the Department of Urology, Temple University School of Medicine, Philadelphia, Pennsylvania ABSTRACT Purpose: We compared bladder blood flow during filling and emptying in patients with and without interstitial cystitis, and correlated blood flow with symptoms in those with interstitial cystitis. Materials and Methods: Bladder perfusion was measured using a dual channel endoscopic laser Doppler flow probe. Measurements were obtained in superficial and deeper vascular beds from the bladder mucosa at the trigone and back wall at baseline, at the volume of awake capacity, during 80 cm. water hydrodistention and after bladder drainage. American Urological Association symptom score was obtained preoperatively in interstitial cystitis patients. Results: In all areas bladder perfusion decreased with filling in interstitial cystitis patients and increased in those without interstitial cystitis. There were no significant differences in response to emptying the bladder, as perfusion tended to increase in both groups. There was no correlation between bladder perfusion at baseline, or in response to filling or emptying with overall symptom score. Conclusions: Bladder perfusion decreases with bladder filling in patients with but increases in those without interstitial cystitis. The inability of the interstitial cystitis bladder to increase bladder blood flow with filling may be a reflection of other pathological processes in the bladder mucosa. The lack of correlation between blood flow and symptoms suggests that bladder ischemia alone cannot account for the symptoms in interstitial cystitis. KEY WORDS: cystitis, interstitial; bladder; perfusion; laser Doppler flowmetry Interstitial cystitis is a symptom complex characterized by pelvic pain and voiding dysfunction, such as frequency, ur- gency and nocturia. A proposed etiology for the symptoms of interstitial cystitis is bladder ischemia. Decreased perfusion is known to produce pain in conditions such as cardiac isch- emia due to vascular blockade and reflex sympathetic dys- trophy from an overactive sympathetic nervous system. Many years ago Herbst et a1 produced bladder lesions that resembled Hunner's ulcers in a dog by ligating the blood vessels to the posterior bladder wall and infecting the area with Streptococcus viridans.1 More recently Irwin and Galloway reported that the bladder is relatively ischemic during bladder filling in patients with compared to those without interstitial cystitis.2 This study demonstrated that bladder perfusion increased with bladder filling. This finding is at odds with almost all other studies which have demon- strated that bladder perfusion usually decreases with blad- der filling.3-7 We compared bladder blood flow in patients with and without interstitial cystitis at baseline, with blad- der filling and emptying, and correlated the response of bladder blood flow with symptoms in those with interstitial cystitis. MATERIALS AND METHODS Bladder perfusion was measured using a custom designed dual channel laser Doppler flow probe. The center-to-center separation between the incident laser light fibers and record- ing fibers was 0.14 and 0.6 mm. in channels 1 and 2, respec- tively, which results in readings from a superficial and a deeper vascular bed (fig. 1). Perfusion was measured at the trigone just in front of the right ureteral orifice and the back Accepted for publication March 19, 1999. Supported by National Institutes of Health Grant ROlDK49501. Presented at annual meeting of American Urological Association, San Diego, California, May 3OJune 4, 1998. wall by lightly touching the endoscopic flow probe to the bladder mucosa. Readings were taken when a stable baseline was established free from movement artifact. No predeter- mined time span was used for taking measurements and the usual time to establish a stable baseline ranged from 30 to 60 seconds. The laser Doppler signal was sampled and recorded at 8 Hz. Perfusion measurements were input directly to a computer using custom software. Bladder perfusion was measured in 39 women and 4 men with interstitial cystitis with a mean age of 39.8 years (range 22 to 80). Patients met all National Institute for Diabetes and Digestive and Kidney Diseases diagnostic criteria, and were studied between 1995 and 1997 while undergoing cystoscopy and bladder hydrodistention with general anesthesia. Perfu- sion was monitored with the bladder at minimal volume to allow probe placement (baseline), at the volume of awake capacity as measured by preoperative urodynamics and after bladder emptying. After filling to the volume of awake capac- ity measurements were also made at hydrodistention to 80 cm. water, with recordings during hydrodistention minutes 1 and 8 (the final minute), and after bladder drainage in 21 in- terstitial cystitis patients. Hydrodistention was performed by instilling sterile saline from a height of 80 cm. water through a cystoscope port. Once intravesical pressure reaches 80 cm. water (generally 45 to 90 seconds) the saline stops flowing. American Urological Association symptom scores were ob- tained before hydrodistention. Mean awake capacity was 179 ? 13 ml. in the patients and average intraoperative capacity at 80 cm. water was 708 +- 35 ml. Bladder perfusion was measured in 15 women and 15 men without interstitial cystitis (controls) with a mean age of 57.5 years (range 21 to 82). Measurement was done in 15 controls under general and in 15 under local anesthesia. Indications for cystoscopy in controls included hematuria in 8, inconti- nencelfrequency in 5, evaluation of lower urinary tract symp- 330