Die Komplexität chronischer Beckenschmerzen am Beispiel der Interstitiellen Zystitis

Zusammenfassung

Die Interstitielle Zystitis ist ein chronisches Schmerzsyndrom und weniger eine reine Endorganerkrankung der Harnblase. Neue Definitions- und Nomenklaturvorschläge tragen dieser Kenntnis Rechnung. In Unkenntnis der Ätiologie und Pathogenese ist eine kausale Behandlung zurzeit nach wie vor nicht möglich. Es existiert weder ein evidenz-basierter Therapiealgorithmus noch eine sog. Standardtherapie. Die bislang unternommenen Therapieansätze sind sehr vielfältig. Die therapeutischen Ansätze können in orale, intravesikale, operative und physikalische Verfahren unterteilt werden. Auch gibt es sinnvolle ergänzende Therapieverfahren jenseits der klassischen Schulmedizin. Grundlage jeder Schmerztherapie stellt das WHO-Stufenschema dar. Unter den oralen Therapieverfahren werden z. Zt. folgende Medikamente mit unterschiedlichen Evidenzleveln empfohlen: Amitriptylin, Hydroxyzin, Pentosanpolysulfat. Viele weitere orale Medikamente werden eingesetzt, wobei der Nachweis ihrer Wirksamkeit z. T. lückenhaft ist, darunter Antikonvulsiva, L-Arginin und verschiedene Immunmodulatoren und -suppressiva. Bei den intravesikalen Therapieverfahren finden Botulinumtoxin A, Dimethylsulfoxid, Heparin und Glykosaminoglykan-Ersatzstoffe Anwendung. Unter den physikalischen Therapieverfahren gilt neben der Blasendistension die hyperbare Sauerstofftherapie als wirksame Therapieform. Bei Versagen der konventionellen Therapieverfahren stellen die operative (Teil-) Entfernung der Harnblase oder Harnumleitungsoperationen die therapeutische Ultima Ratio dar. Kontrollierte Studien zu alternativen Heilverfahren existieren kaum; recht gute Resultate bei chronischen Beckenschmerzsyndromen konnten aber mit Akupunktur als additives Therapieverfahren erreicht werden.

Abstract

The so-called interstitial cystitis is a chronic pain syndrome rather than a purely end organ disease of the urinary bladder. New suggestions for definition and nomenclature take this into consideration. Since aetiology and pathogenesis are still unknown a causal treatment is still not at hand. There are neither evidence-based treatment algorithms nor a so-called standard therapy. Numerous therapeutic approaches have been tried up to now. These attempts can be divided into oral, intravesical, surgical and physical procedures. There are also meaningful supplementary therapy procedures beyond the boundaries of classical school medicine. The WHO guidelines provide the basis for every pain therapy. For the oral therapeutic procedures in current use the following medications with differing levels of evidence have been recommended: amitriptylin, hydroxyzin, pentosan polysulfate. Many other orally administered drugs have also been used although in many cases evidence of efficacy is lacking, these included anticonvulsants, L-arginine and various immunomodulators and immunosuppressants. Among the intravesical therapeutic procedures botulinum toxin A, dimethyl sulfoxide, heparin and glycosaminoglycan substitutes have been used. For the physical procedures, besides bladder distension, hyperbaric oxygen therapy shows efficacy. When conventional therapeutic methods fail, surgical (partial) removal of the urinary bladder or urinary diversion procedures represent the therapeutic ultimo ratio. There are hardly any controlled studies on alternative curative procedures although rather good results have been obtained in chronic pelvic pain syndrome with acupuncture as an additional therapeutic modality.

Schlüsselwörter

Definition - Nomenklatur - Pathogenese - Diagnostik - klinische Studien

Key words

definition - nomenclature - aetiology - diagnosis - clinical trials

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