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Introduction
Hunner's lesion or ulcer is a distinctive inflammatory lesion presenting a characteristic deep rupture through the mucosa and submucosa provoked by bladder distension. Despite the name that has been commonly used, it is not an ulcer. ESSIC therefore opted to use the term Hunner’s lesion instead of Hunner's ulcer and this is gradually being adopted worldwide.
The detection of Hunner's lesions is in general only possible at cystoscopy with hydrodistension under general or epidural anaesthesia by an experienced urologist trained to detect them.
Definition of Hunner's lesion
The following definition by Magnus Fall was
accepted by ESSIC:
Hunner’s lesion typically presents
as a circumscript, reddened mucosal area with small
vessels radiating towards a central scar, with a fibrin
deposit or coagulum attached to this area. This site
ruptures with increasing bladder distension, with
petechial oozing of blood from the lesion and the
mucosal margins in a waterfall manner. A rather
typical, slightly bullous edema develops post-distension
with varying peripheral extension.
Types
Interstitial cystitis (IC) with Hunner's lesions is called classic IC as opposed to non-ulcer IC in which Hunner's lesions are not found. Classic IC is the same as ESSIC’s BPS/IC type 3A, 3B or 3C (see http://www.essic.eu/pdf/ESSICconsensus2007.pdf) depending on whether or not biopsies were done and, if performed, the biopsy findings. It is not clear to date whether the non-ulcer and classic types represent different stages of a single disease, or whether they are different disease entities. The lack of data indicating that BPS patients without Hunner's lesions progress to BPS/IC with Hunner's lesions is in line with the hypothesis that they represent different diseases. Future studies, in which patients are classified according to the BPS/IC types as proposed by ESSIC, are needed to clarify this issue.
Patients with Hunner's lesions are on average 10 years older than those without, but this difference is compatible with both theories. There is no relationship between symptoms, including pain scores and the presence of Hunner's lesions. The bladder capacity under general anaesthesia has been found to be significantly smaller in patients with Hunner's lesions. |
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Prevalence
In urology centres with the expert skills to detect Hunner's lesions, Hunner's lesions are detected in about 50% of the patients with BPS. The majority of BPS/IC patients with Hunner's lesions, however, are probably not recognized in centres with less experience. This under-diagnosis is probably due to a combination of factors such as:
1. the confusion caused by the name Hunner's ulcer while it is not an ulcer: the term Hunner's ulcer suggests that it can be seen at cystoscopy without hydrodistension
2. it is often impossible to detect Hunner's lesions if cystoscopy is performed without hydrodistension
3. many urologists suppose that Hunner's lesions are rare; the fact that they rarely detect them is considered to be in line with this false impression
4. even when cystoscopy with hydrodistension is performed, Hunner's lesions are likely to be detected only by experienced urologists. Biopsy may be necessary to prove that it is a Hunner's lesion and/or to exclude a carcinoma in situ.
Treatment
Bladder pain and other symptoms may improve dramatically when Hunner's lesions are treated by electrocoagulation, lasercoagulation or resection. A promising new treatment with good results from a single centre is the cystoscopic injection of steroids (triamcinolone) into the submucosal space in the centre and periphery of lesions. (Cox M, Klutke JJ, Klutke CG. Can J Urol 2009;16:4536-40).
While Hunner's lesions unfortunately tend to recur, the interval may vary between several months and in some patients more than 5 years.
See also: Diagnostic Criteria, Classification, and Nomenclature for Painful Bladder Syndrome/Interstitial Cystitis: An ESSIC Proposal.
Eur Urol 2008;53:60-7
Joop P van de Merwe |
