Interstitial Cystitis : Legitimacy of the herpetic hypothesis
The following clinical case has been observed during three periods : 1986-1993, 1993-1999 and 1999-2004, corresponding to three different urology departments, three different diagnosis and three different treatments, in spite of an always identical histopathology.
My best acknowledgements go to my colleagues who conveyed orally their data although they did not take part in the present publication.
There is no paper publication nor video. That is why this clinical case is published in extenso and in french ( 8 pages HTM ) on the International network.
You will find here below the abstract and the conclusions in english.
The reader is supposed to be well aware of medical terms and meanings.
The patient is a 54 years old women, farmer in Normandy. She complains of extremely sharp bladder pain with irradiation to bone pelvis, coccyx, upper thighs down to the legs. Cystoscopy shows numerous mucosal ulcers which induce the hypothesis of interstitial cystitis. Both superficial and whole bladder wall biopsies show granulomatous aspects which could evoke tuberculosis but no bacteriological support was found.
Failure of antituberculous and classical intertitial cystitis treatments led to evoke the implication of herpes or even zona virus, because the patient was suffering of recurrent cutaneous herpes and her mother presented a necrotic zona of the breast.
( Years later vulvar ulcers were found to be herpetic ). Treatment by aciclovir brought total relief of symptoms for two years.
Then many urinary infections turned into acute pyelonephritis and the forecast vesico-renal reflux became obvious by Technetium radioisotopes cystopyelography. (See : Technique)
Antireflux operation by lower ureter bilateral advancement ( See : Technique ) was performed and antiherpetic treatment continued. The patient remained free of symptoms for four more years.
Eventually the patient had to consult another urological service because of recurrent bladder pain.
The whole range of usual drugs and vesical instillations for intertitial cystitis remained unsuccessful.
In the following university service of urology, diagnosis of hyperactive bladder was tentatively assumed. Implantation of a neuromodulating electrode was performed but without any success while it led to severe complications when the electrode had to be removed.
Finally cystectomy with preservation of the trigone , ureteral reimplantation and detrusor replacement by detubularized intestinal graft obtained a satisfying result which seems stable in the final four years of this observation.
Report of out-patients clinic, endoscopic procedures, histology, isotopic diagnosis and operations can be found in the french full text.
Comments and conclusions
Many facts back the herpetic implicatrion up :
- facial and vulvar ulcers
- bladder ulcers aspect and evolution
- antibodies against Herpes 1 virus
- uninterrupted effectiveness of aciclovir
- dead cert recurrence of bladder pain when aciclovir was removed
- lack of evidence of any genuine nervous disorder and failure of neurostimulation
- histological aspects made of oedema, vascular dilatation and neogenesis, erosive and desquamative bladder ulcers, plasmocytic and giant cells infiltrates of the chorion.
It must be said that no laboratory immunohistochemical reaction was available which could bring more scientific evidence. Nevertheless intrusion of bacteriological changes in the viral scene, specially common in female bladder, could blur the pathologist.
This unique observation of interstitial cystitis along eighteen years cannot lead to the assertion that herpes is the origin of the disease.
My opinion is that including the herpes virus hypothesis into the differential diagnosis panel and tentative treatment are quite legitimate .
Moreover inquiries towards all the members of the herpes family, the chickenpox and zona virus or even other potentially neurotropic virus could be well-founded.