Several studies that failed to find a relationship between symptom reports and cystoscopic findings were performed with patients undergoing intravesical thearpy for BPS/IC.  In this study, we investigated the relationship between cystoscopic findings and intravesical therapy response in patients with BPS/IC

We retrospectively queried our institutional records for all patients undergoing cystoscopy and our institutional experience with hydrodistention and early started intravesical combined therapy (ICT) (chondroitin sulphate and Hyaluronic acide). After hydrodistention all patients have received ICT in two hours. Additionally ICT was continued weekly in 8 weeks, 2 times in followed month and then monthly throughout 7 months (17 times in total). Cystoscopic findings were noted as glomerulations, focal or diffuse vascularization with or without glomerulation and Hunner’s Lesion (HL). The therapy responses were evaluated with VAS (Visual analoque scale), O´Leary/Sant ICSI (Interstitial cystitis symptom index) and ICPI (Interstitial cystitis problem index) scores. The relationship between cystoscopic findings and intravesical therapy response were evaluated in 1,3,6,12. months, respectively.

There were fiftyfive patients identified as bladder pain syndrome/interstitial cystitis and followed. In this group there were thirtyfour patients  who underwent hydrodistention and early started ICT. Hunner’s lesions were seen during cystoscopy in four (11.8%) of those patients. Glomerulations were seen during cystoscopy in fifteen (44.1%) of those patients. Vascularization was seen during cystoscopy in thirteen (38.2%) of those patients.In two patients (5.8%) there were no pathological findings. Twentsix patients’ in 3.month , sixteen patients in 6. Month and twelve patients’ follow up was fulfilled in 12. Month. Mean VAS, ICSI, ICPI scores  were decreased in glomerulations group at total follow up. (Table-1) However nine of thirteen patients (70%) with only vascularization had poor response to intravesical therapy. Four of the thirteen patients had vascularization and additionally glomerulation, those patients had good treatment response.

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease characterized by pelvic pain, frequency and urgency; which effects quality of life terribly. Several treatment strategies are defined, restoration of the urothelial barrier with exogenous GAG administration is one of the choices(1). According to some studies HA/CS combination therapy appears to be effective with a potentially more favorable safety profile (2,3). But there are no studies defining the factors that effect  the success of intravesical therapy. With this study we showed that cystoscopic findings might play important role choosing treatment strategy.
It can be seen that in glomerulation group benefit of the intravesical HA/CS therapy continues till 12. Month. Patients with vascularization  and Hunner lesion had poor treatment response and those patients might be directed to other treatment strategies. Nine of thirteen patients (70%) with only vascularization had poor response to intravesical therapy on the other side four of the thirteen patients had vascularization and additionally glomerulation, those patients had good treatment response. Glomerulation might be a criteria for  choosing intravesical therapy as treatment strategy.
In our study, cystoscopic findings were defined according to ESSIC criteria. Focal and diffuse vascularization is not a finding that has been defined yet. In follow up of those patients it has been seen that some group of patients did not respond to intravesical treatment. Those patients had only vascularization as cystoscopy finding , other than ESSIC criteria. Vascularization is a new cystoscopic identification has some own characteristics, especially in treatment response.  
When groups were splitted in 12. Month responses , in some groups,  mean-median scores could not be computed because of little number of patients. Our first limitation is small sample size . With multiinstutional studies these findings can be more precise.

Focal or diffuse vascularization are overlooked cystoscopic findings in BPS/IC. The presence of vascularization has been associated with more severe symptoms and decreased ICT response. Patients with glomerulations as cystoscopy findings, might be good candidates for intravesical early started therapy.

Madersbacher, H., et al. GAG layer replenishment therapy for chronic forms of cystitis with intravesical glycosaminoglycans--a review. Neurourol Urodyn, 2013. 32: 9.
Cervigni M et al. A randomized, open-label, multicenter study of the efficacy and safety of intravesical hyaluronic acid and chondroitin sulfate versus dimethyl sulfoxide in women with bladder pain syndrome/interstitial cystitis. Neurourol Urodyn. 2017 Apr;36(4):1178-1186
Porru D et al. Impact of intravesical hyaluronic acid and chondroitin sulfate on bladder pain syndrome/interstitial cystitis. Int Urogynecol J. 2012 Sep;23(9):1193-9