IC/BPS: One-fourth of patients have Hunner lesions

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About one-fourth of patients with interstitial cystitis/bladder pain syndrome have Hunner lesions in the bladder visible on cystoscopy.

Boston-About one-fourth of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) have Hunner lesions in the bladder visible on cystoscopy.

Their urologic symptoms are indistinguishable from those of patients without Hunner lesions, according to H. Henry Lai, MD, and colleagues.

In addition, “IC patients with Hunner lesions may be less likely to have certain systemic manifestations, such as irritable bowel syndrome and anxiety,” said Dr. Lai, associate professor of surgery and anesthesiology, Washington University, St Louis. He presented his data at the AUA annual meeting in Boston.

The rate of Hunner lesions found is substantially higher than that reported in the literature.

“We probably have a selected group of patient for which Hunner lesions may be enriched,” Dr. Lai told Urology Times. “I think generally the experience is that about 10% of patients may have Hunner lesions, based on some of the published studies from the U.S. and Canada.”

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Since patients with Hunner lesions respond to specific treatments (such as triamcinolone injection, fulguration, or cyclosporine) and because Hunner lesions may represent a distinct phenotype among patients with IC/BPS patients, “one should consider cystoscopy to look for Hunner lesions, particularly for patients over the age of 50 or in men,” he said.

The authors hypothesized that IC/BPS patients with Hunner lesions may represent a different phenotype from patients without Hunner lesions. For their study, they compared urologic symptoms (urgency, frequency, nocturia, urologic pain, bladder hypersensitivity, and sexual dysfunction) and nonurologic features (severity and distribution of systemic pain, comorbid functional pain syndromes, anxiety, and depression) between patients with and those without Hunner lesions visible on office cystoscopy without hydrodistention.

All patients completed a battery of questionnaires in which urologic features were assessed, such as the Interstitial Cystitis Symptom and Problem Indexes (ICSI, ICPI), Pelvic Pain and Urgency/Frequency Questionnaire, numeric ratings (0 to 10) of pain, urgency, and frequency, RICE Questionnaire, and the AUA Symptom Index. Nonurologic measures included the Hospital Anxiety and Depression Scale (HADS), psychologic stress, the Body Pain Map, Brief Pain Inventory, Poly-Symptomatic Poly-Syndromic Questionnaire, and comorbid pain conditions (irritable bowel syndrome [IBS], fibromyalgia, and chronic fatigue syndrome).

A Hunner lesion was defined as “a circumspect, reddened mucosal area that can have vessels radiating toward a central scar and/or a fibrin deposit of coagulum attached to this area.” It often bleeds (like a waterfall) with bladder distention.

Next: Hunner lesions found in 27%

Hunner lesions found in 27%

Forty-one of 150 patients (27%) were found to have Hunner lesions. Those with Hunner lesions were about 15 years older on average than those without (57.3 vs. 42.3 years; p<.001). Those with Hunner lesions also reported less intense urologic pain scores (5.3 vs. 6.5; p=.021) as well as less bladder pain on the ICSI (3.0 vs. 3.5; p=.034) and increased nighttime frequency on the ICSI (3.5 vs. 2.6; p=.034).

A lower percentage of patients with Hunner lesions had anxiety on the HADS (22.0% vs. 43.1%; p=.017), and a lower percentage had IBS (15.0% vs. 36.1%; p=.013).

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There was no difference between the groups in daytime frequency, urgency, depression, fibromyalgia, and chronic fatigue syndrome.

“I personally don’t find that patients have a lot of discomfort during cystoscopy. You may not want to do it in every single patient,” said Dr. Lai. “The older ones are probably more likely to be the ones in whom you’ll find Hunner lesions. I would suggest cystoscopy to look for Hunner lesions or other conditions in the differential diagnosis in patients over the age of 50, in men, or in those with hematuria or at risk for bladder cancer.”