Could Ginger
Protect Urothelium From Cyclophosphamide Toxicity? Histopathological and
Ultrastructural Study

Yasser M. Elbastwisy1&2

1
Anatomy and Embryology Department, Faculty of Medicine, Mansoura University,
Mansoura, Egypt.

2.Department
of Anatomy and Embryology, Faculty of Medicine, Taibah University, Madinah,
KSA.

[email-masked]

Abstract: Background:
Cyclophosphamide (CP) is a chemotherapeutic agent used in managing various
neoplastic and non-neoplastic diseases. However, its clinical application is
often restricted due to its baleful side effects particularly interstitial
cystitis (IC). Several studies recommended the administration of a sulfhydryl
compound MESNA or forced saline diuresis to reduce the CP-induced bladder
toxicities, but it was not sufficient in all patients. Ginger is a flavoring spice that was proofed to have
antioxidant, and anti-inflammatory properties. These properties favor its use
as a possible agent to prevent CP-induced bladder toxicity. Aim of
work: The goal of the current investigation was to
clarify the CP-induced histopathological and ultrastructural effects on the
urothelium of the adult male albino rats and to evaluate the possible
protecting role of Ginger on such alterations. Materials and Methods:
Forty-five adult male albino rats (200–250 g) were utilized in the
existing study. They were randomly allocated into three equal groups. Group I
rats served as control and were given sterile normal saline. The rats of group
II were given a single intraperitoneal dose of CP dissolved in sterile normal
saline. Group III animals received CP as in group II but in combination with
Ginger (by gastric gavage) 7 days before and 7 days after CP injection. Urinary
bladders were excised and prepared for histological and transmission electron
microscope examination. Results: Administration of CP induced decreased
thickness and desquamation of urothelial cells with hemorrhage. Inflammatory
cell infiltrate was also noticed in the lamina propria. Ultrastructural
examination revealed shrinkage of the nucleolar membrane, decreased nuclear
volume and disturbed chromatin together with intracellular vacuolation and less
prominent cytoplasmic organelles. There was also blebbing of the cell membrane
with wide spaces between the cells. Administration of Ginger to the rats, the
overall scene of the urothelium structure documented that there was an evident
improvement so that it, more or less, resembled that of the control animals.
Conclusion: Based on the previous data, it may be concluded that Ginger has
a protecting effect on the CP-induced IC.

[Yasser M.
Elbastwisy. Could Ginger Protect Urothelium From
Cyclophosphamide Toxicity? Histopathological Study. Nat Sci 2021;19(9):43-48]. ISSN 1545-0740
(print); ISSN 2375-7167 (online). http://www.sciencepub.net/nature  6. doi:10.7537/marsnsj190921.06.

Keywords:  Ginger; Cyclophosphamide; Urothelium.

1. Introduction

Interstitial
cystitis (IC) is a major pathological and clinical condition characterized by
chronic pelvic pain, frequency, urgency, and nocturia [1]. The etiology
and pathophysiology of IC are poorly understood, and several factors have been
suggested, including inflammation, autoimmune mechanisms, mast cell activation,
neurogenic causes, and genetic predisposition [2]. Therapeutic
strategies against IC are still limited and unsatisfactory [3].

Animal
models of IC used several chemicals to induce IC with typical histopathological
changes. Well-established models used potassium chloride (KCl [4],
cyclophosphamide (CP) [5], and
lipopolysaccharide (LPS) [6].

Cyclophosphamide
is a chemotherapeutic agent that has been widely used in managing various
neoplastic and non-neoplastic diseases. The commonest neoplastic diseases
treated by CP are lymphoma, breast cancer, and leukemia [7]. The known
non-neoplastic and autoimmune diseases treated with this drug are antineutrophil cytoplasmic antibody-associated vasculitis
[8] and systemic
inflammatory diseases [9-12]. Although the
mechanism by which CP treats autoimmune diseases is not well known, many
researchers suggested possible mechanisms as the decreased production of
cytokines and adhesion molecules, B cell suppression, and subsequent decreased
IgG production and induction of apoptosis [13,
14]. However, the
clinical application of CP is often restricted due to its baleful side effects [15]; particularly
hepatotoxicity[16], IC, and bladder
cancer [17]. Interstitial
cystitis occurs in 10 - 40% of patients receiving high-dose CP [15]. CP-induced IC
has a wide range of severity (ranges from mild to severe) and may require a
variety of treatment procedures such as hydration, clot extraction via
cystoscopy, continuous bladder irrigation, or cystectomy [18].
Unfortunately, these treatment options may fail, and the condition becomes
fatal [19]. Therefore, IC
prevention is a great challenge. Most CP side effects are dose-dependent.
Although the doses prescribed in non-neoplastic diseases are much lower than
those prescribed for cancer chemotherapy, it is often used for a longer duration
due to a high rate of relapses with the subsequent increased adverse effects [20].

Several
methods were tried to reduce the CP-induced bladder toxicities; concomitant
administration of a sulfhydryl compound MESNA [21], reduction of
the total CP dose given to a patient [22] while other
studies investigated a strategy encouraging large volumes of fluids drinking by
the patients [23]. Unluckily,
these procedures are not always effective and cannot be applied to all patients
[24]. Hence, there
is a need for novel agents that could be useful in preventing adverse urologic
effects during CP therapy.

Ginger
(Zingiber officinale) is a known flavoring spice and medicinal herb in
Southeast Asia [25]. It was
proofed to be effective against nausea of different causes including that
induced by chemotherapy [26]. The active
constituents of Ginger were proofed to have antioxidant, anti-inflammatory [27], and
antimutagenic properties [28]. It was also
found to be able to lower lipid peroxidation, attenuate free radical-mediated
toxic effects, and provoke the activities of antioxidants [29-32]. These
properties favor the use of Ginger as a possible agent to prevent CP-induced
bladder toxicity.

In
this investigation, a rat model of CP-induced IC will be established to
describe the histological and ultrastructural changes in urothelium and to
assess the possible protective effect of Ginger.

2. Materials and methods

Chemicals

Cyclophosphamide
was purchased from Baxter Oncology GmbH, Frankfurt, Germany. The Zingiber
Officinale powder was obtained from the Pharmacognosy department in the Faculty
of Pharmacy, Taibah University, Almadinah Almonawarah, KSA.

Animals

Forty-five
adult male albino rats (200–250 g) were obtained from the Animal House of
Taibah University (KSA). The animals were acclimated to the environment for 7
days by housing in well-ventilated hygienic cages under the standard conditions
(12:12 light/dark cycle, room temperature of 24 - 28 C° and the humidity at
50%–60%.). They were fed a standard balanced diet and allowed water ad
libitum. All animal procedures were conducted according to the principles of
laboratory animal care (National Institutes of Health Guide for the Care and
Use of Laboratory Animals [NIH Publication 85–23 Rev. 1985]).

Experimental
design

Rats
were assigned randomly into three equal groups (15 rats in each group). Group,
I rats were controls injected intraperitoneally with a single dose (0.5 CC) of
normal saline. Rats in group II were treated with a single intraperitoneal dose
of CP (CP is dissolved in saline and given by a dose of 150 mg/kg) to induce
cystitis [33]. While rats in
group III received the same dose of CP (150 mg/kg intraperitoneally) together
with Ginger powder dissolved in water at a measurement level of 24 mg/ml given
orally by intragastric gavage (1 ml/day) starting 7 days before CP and
continuing throughout the experiment [34].

Tissue
sampling and preparation

Seven
days after CP injection, all animals were subjected to light intraperitoneal
pentobarbital anesthesia (50 mg/kg) and sacrificed. Urinary bladders were
carefully dissected, removed, and fixed in a relaxed state after emptying by
aspiration of urine with a 27-gauge needle [35]. The fixed
bladders were divided into 2 samples; the first one is fixed in 10% neutral
buffered formalin for 24 hours and processed for the usual tissue handling for
paraffin blocks preparation. Sections of 3-4 µm thickness were stained
with Hematoxylin and Eosin (H&E). The other tissue sample was cut into
small pieces, fixed in glutaraldehyde and osmium tetroxide and processed for
transmission electron microscopic examination. JEOL JEM 1200 EXII Electron
Microscope (Joel CX 100 transmission electron microscope operated at an
accelerating voltage of 60 kV Ltd.) was used to examine the specimens at
Mansoura University, EM Unit (Egypt).

3. Results

Histological
examination of hematoxylin and eosin-stained sections of the control group
revealed a highly folded mucosa of the urinary bladder consisting of the
transitional epithelium (urothelium) with underlying lamina propria. The
urothelium is formed of multiple layers. The superficial cells are large,
puffy, and dome-shaped (umbrella-like) with abundant eosinophilic cytoplasm and
some binucleated cells. The intermediate cells are smaller with ample cytoplasm
and oval nuclei. The basal cells are cuboidal and resting on a thin basement
membrane, which separates the cells from the lamina propria. The lamina propria
was formed of connective tissue and rich in blood capillaries (Fig. 1A).

A
single dose of CP (group II) caused a decrease in thickness and desquamation of
urothelial cells together with variable grades of hemorrhage. There is also
disruption of the basement membrane and inflammatory cell infiltrate in the
lamina propria (Fig. 1B).

In
group III urothelial cells appeared more or less similar to the control group
but, the lamina propria still showing inflammatory infiltrate (Fig. 1C).

Ultrastructurally,
the cytoplasm of the apical cells of the control group (group I) showed
prominent cytoplasmic discoid vesicles. Well-formed junctional complexes
(Zonula occludence, zonula adherence, and desmosome) are observed between and
along the sides of the umbrella cells (Fig. 2A). The superficial layer of the
transitional epithelium showed characteristic ridging. The cytoplasm contained an
indented euchromatic nucleus with prominent nucleoli. Mitochondria and few
lysosomes were also noticed (Fig. 2A).

CP-treated
rats showed apoptotic changes in the form of shrinkage of the nucleolar
membrane with a decrease in the nuclear volume and disturbed chromatin together
with intracellular vacuolation and less prominent cytoplasmic organelles. There
was also blebbing of the cell membrane with wide spaces between the cells. The
basement membrane appeared disturbed (Fig. 2B).

Group
III appeared more or less close to the control group apart from few apoptotic
cells (Fig. 2C).

Fig.
(1): A photomicrograph of the urothelium. (A) Group I: shows intact
urothelium and basement membrane. The lamina propria contains blood capillaries
and scattered connective tissue cells. The mucosa is folded and the urothelium
has a superficial layer of large bulbous or elliptical umbrella cells,
sometimes binucleated (arrow). (B) Group II: shows decreased thickness, loss of
integrity, ulceration and hemorrhage (arrowhead) of the urothelium with
disruption of the basement membrane (broad arrow). The lamina propria shows
infiltration by inflammatory cells (curved arrow). (C) Group III: The
epithelium restored its integrity but the lamina propria still contain many
inflammatory cells.

Fig.
(2): An electron
micrograph of the urothelium. (A) Group I: shows intact umbrella cell
membrane with many discoid vesicles (arrowhead). Well-formed junctional complex
between the umbrella cells (Zonula occludence [tailed arrow], zonula adherence
[small thin arrow], and desmosome [tailed thin arrow]). Intact basement membrane
(BM) with many hemidesmosomes (thin long arrow). Intended euchromatic nucleus
(N) with prominent nucleoli. Prominent cytoplasmic organelles especially
lysosomes (L) and mitochondria (M). (B) Group II: shows shrinkage of the
nuclear membrane with a decrease in the nuclear volume (N) with disturbance of
their chromatin. Blebbing of the cell membrane (arrowhead) with wide spaces
between the cells (S). Intracellular vacuolations (V) with less prominent
cytoplasmic organelles. (C) Group III: shows normal urothelial cells (N) and a
small shrunken cell (thick arrow) with dark irregular nucleolus and numerous
lysosomes (arrow heads).capillaries (Cap) appear in the lamina propria.

4. Discussion

CP
is a widely used drug, but its side effects are still a major problem
particularly with high doses. Injection of a single intraperitoneal dose of CP
in rats could produce most features of IC in humans such as increasing voiding
frequency, decreasing urine volume per void, and increasing permeability of the
bladder wall [36]. CP-induced
hemorrhagic cystitis is used as an experimental model of human diseases like
urinary bladder inflammation, inflammatory infiltration, and disruption of
urothelium [37].

In
the present study, intraperitoneal injection of a single dose of CP caused
interstitial cystitis which was demonstrated by decreased thickness and
degeneration of urothelial cells together with disruption of the basement
membrane. Some urothelial cells showed large vacuoles within the cytoplasm,
while others showed areas of exfoliation together with variable grades of
hemorrhage. Inflammatory cell infiltrate was also noticed in the lamina
propria. Several studies have demonstrated histological changes like our
results. Prashant et al. [36] reported
urothelial ulceration, hemorrhage, and inflammatory cell infiltration. They
alleged that; these findings are due to the CP pro-oxidant nature that induces
oxidative stress through decreasing the activities of the antioxidant enzymes.
Choi et al. [37] claimed that
these findings represent the adverse effects of the toxic metabolites of CP
which exert cytotoxic effects on the rapidly dividing cells.  However, Sridhar et al. [38] attributed
these changes to early nonapoptotic death of superficial cells, followed by
apoptotic death of deeper layers. Anna et al. [39] reported
similar changes in the rat genitourinary tract. They claimed that urinary
bladder injury is multifactorial and involves first of all the reaction of CP
metabolite (acrolein) with the urothelium with subsequent inflammatory cascade.

TEM
examination of CP-treated rats demonstrated apoptotic changes in the urothelium
in the form of shrinkage of the nuclei and disturbed chromatin together with
intracellular vacuolation and decreased cytoplasmic organelles. Also, there
were wide spaces between the cells and blebbing of the cell membrane. The
basement membrane appeared disturbed. Similar findings were described by
Lavelle et al, [40] who reported
detachment of umbrella cells from each other, with disruption of tight junctions
in rats with Feline interstitial cystitis. In addition, Jia-Fong et al, [41] ascribed
umbrella cell pleomorphism and loss of tight junctions in IC patients. Jock et
al, [42] described
prominent widening in intercellular spaces between urothelial cells after
partial bladder outlet obstruction in the rats.

These
results highlight that, IC is a potentially life-threatening complication of CP
therapy that necessitated searching for methods to protect against this
toxicity. Previous studies recommended the administration of MESNA or forced
saline diuresis, but it was not sufficient in all patients (Moy, B. et al.
2018). Therefore, there is a great need to search for new substances to prevent
CP-induced toxicity.

Natural
compounds, such as Ginger, or its chemically modified derivatives are in the
interest of many researchers [32&43] due to their
potential anti-inflammatory and antioxidant activities.

To
our knowledge, no previous studies described the protective effect of Ginger on
CP-induced urothelial toxicity. In the present work, Ginger administration to
rats 7 days before and after CP therapy revealed evident light and electron
microscopic urothelial improvement so that it resembled that of the control
animals. In parallel with this, Kandemir et al. [44] reported
significantly decreased apoptosis, inflammation, and histopathological
alterations in CP-induced nephrotoxicity in female rats after Ginger
administration. In addition, Elshiekh et al. [43] emphasized on
the alleviating role of Ginger against cisplatin-induced reproductive toxicity
in rats. They alleged that these protective effects are due to decreased
oxidative stress. Moreover, Dina et al, [32] proposed that
Ginger exerted a potential anti-proliferative activity against Diethyl
nitrosamine in liver, stomach, and colon via nuclear factor-erythroid 2-related
factor2 activation, whilst suppression of oxidation and inflammation. Sridhar
et al, [45] postulated
that Keratinocyte growth factor pretreatment blocks CP-induced urothelial
apoptosis in mice, likely via protein kinase B signaling, and drives
phosphorylated extracellular signal-regulated kinase-mediated keratin 5/keratin
14 cell proliferation, leading to early urothelial regeneration.

In
conclusion, in light of the demonstrated protective imprints of
Ginger against CP-induced urothelial injury, in the current investigation, it
is advisable to widen the scale of its intake for the patients receiving CP
therapy to minimize, as possible, its undesirable side effects. Eventually,
further studies with different techniques are recommended to understand the
underlying mechanisms of its protective effect.

Funding

This
research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.

Conflict of interest

The
author declares no conflict of interest.

Acknowledgments

I am
grateful to all behavior laboratory technicians who helped me in this research.

References

1.   de Oliveira, M.G., et al.,
Activation of soluble guanylyl cyclase by BAY 58-2667 improves bladder function
in cyclophosphamide-induced cystitis in mice. Am J Physiol Renal Physiol, 2016.
311(1): p. F85-93.

2.   Bae, W.J., et al., Reduction of
oxidative stress may play a role in the anti-inflammatory effect of the novel
herbal formulation in a rat model of hydrochloric acid-induced cystitis.
Neurourol Urodyn, 2015. 34(1): p.
86-91.

3.   Neuhaus, J. and T. Schwalenberg,
Intravesical treatments of bladder pain syndrome/interstitial cystitis. Nat Rev
Urol, 2012. 9(12): p. 707-20.

4.   Tyagi, P., et al., Instillation of
liposomes vs dimethyl sulphoxide or pentosan polysulphate for reducing bladder
hyperactivity. BJU Int, 2009. 104(11):
p. 1689-92.

5.   Lee, G., R. Romih, and D. Zupancic,
Cystitis: from urothelial cell biology to clinical applications. Biomed Res
Int, 2014. 2014: p. 473536.

6.   Charrua, A., et al.,
Co-administration of transient receptor potential vanilloid 4 (TRPV4) and TRPV1
antagonists potentiate the effect of each drug in a rat model of cystitis. BJU
Int, 2015. 115(3): p. 452-60.

7.   Moignet, A., et al.,
Cyclophosphamide as a first-line therapy in LGL leukemia. Leukemia, 2014. 28(5): p. 1134-6.

8.   Haubitz, M., et al., Intravenous
pulse administration of cyclophosphamide versus daily oral treatment in
patients with antineutrophil cytoplasmic antibody-associated vasculitis and
renal involvement: a prospective, randomized study. Arthritis Rheum, 1998. 41(10): p. 1835-44.

9.   Tashkin, D.P., et al., Cyclophosphamide
versus placebo in scleroderma lung disease. N Engl J Med, 2006. 354(25): p. 2655-66.

10. Ginzler, E.M., et al., Mycophenolate mofetil or
intravenous cyclophosphamide for lupus nephritis. N Engl J Med, 2005. 353(21): p. 2219-28.

11. Hoyles, R.K., et al., A multicenter,
prospective, randomized, double-blind, placebo-controlled trial of
corticosteroids and intravenous cyclophosphamide followed by oral azathioprine
for the treatment of pulmonary fibrosis in scleroderma. Arthritis Rheum, 2006. 54(12): p. 3962-70.

12. Jayne, D.R., et al., Randomized trial of plasma
exchange or high-dosage methylprednisolone as adjunctive therapy for severe
renal vasculitis. J Am Soc Nephrol, 2007. 18(7):
p. 2180-8.

13. Richmond, R., T.W. McMillan, and R.A. Luqmani,
Optimisation of cyclophosphamide therapy in systemic vasculitis. Clin
Pharmacokinet, 1998. 34(1): p.
79-90.

14. Wrobel, A., et al., Intravesical administration
of blebbistatin prevents cyclophosphamide-induced toxicity of the urinary
bladder in female Wistar rats. Neurourol Urodyn, 2019. 38(4): p. 1044-1052.

15. Tsai-Turton, M., et al.,
Cyclophosphamide-induced apoptosis in COV434 human granulosa cells involves
oxidative stress and glutathione depletion. Toxicol Sci, 2007. 98(1): p. 216-30.

16. Emadi, A., R.J. Jones, and R.A. Brodsky,
Cyclophosphamide and cancer: golden anniversary. Nat Rev Clin Oncol, 2009. 6(11): p. 638-47.

17. Travis, L.B., et al., Bladder and kidney cancer
following cyclophosphamide therapy for non-Hodgkin's lymphoma. J Natl Cancer
Inst, 1995. 87(7): p. 524-30.

18. Matz, E.L. and M.H. Hsieh, Review of Advances
in Uroprotective Agents for Cyclophosphamide- and Ifosfamide-induced
Hemorrhagic Cystitis. Urology, 2017. 100:
p. 16-19.

19. Ebiloglu, T., et al., Treatment of Resistant
Cyclophosphamide Induced Haemorrhagic Cystitis: Review of Literature and Three
Case Reports. J Clin Diagn Res, 2016. 10(4):
p. PD15-6.

20. Sudharsan, P.T., et al., Cardioprotective
effect of pentacyclic triterpene, lupeol and its ester on
cyclophosphamide-induced oxidative stress. Hum Exp Toxicol, 2005. 24(6): p. 313-8.

21. Monach, P.A., L.M. Arnold, and P.A. Merkel,
Incidence and prevention of bladder toxicity from cyclophosphamide in the
treatment of rheumatic diseases: a data-driven review. Arthritis Rheum, 2010. 62(1): p. 9-21.

22. De Groot, K., et al., Randomized trial of
cyclophosphamide versus methotrexate for induction of remission in early
systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis
Rheum, 2005. 52(8): p. 2461-9.

23. Reinhold-Keller, E., et al., An
interdisciplinary approach to the care of patients with Wegener's
granulomatosis: long-term outcome in 155 patients. Arthritis Rheum, 2000. 43(5): p. 1021-32.

24. Payne, H., et al., Chemical- and
radiation-induced haemorrhagic cystitis: current treatments and challenges. BJU
Int, 2013. 112(7): p. 885-97.

25. Afzal, M., et al., Ginger: an ethnomedical,
chemical and pharmacological review. Drug Metabol Drug Interact, 2001. 18(3-4): p. 159-90.

26. Ryan, J.L., et al., Ginger (Zingiber
officinale) reduces acute chemotherapy-induced nausea: a URCC CCOP study of 576
patients. Support Care Cancer, 2012. 20(7):
p. 1479-89.

27. Rani, M.P., et al., Inhibitory potential of
Ginger extracts against enzymes linked to type 2 diabetes, inflammation and
induced oxidative stress. Int J Food Sci Nutr, 2011. 62(2): p. 106-10.

28. Prasad, S. and A.K. Tyagi, Ginger and its
constituents: role in prevention and treatment of gastrointestinal cancer.
Gastroenterol Res Pract, 2015. 2015:
p. 142979.

29. Ahmed, R.S., et al., Protective effects of
dietary Ginger (Zingiber officinales Rosc.) on lindane-induced oxidative stress
in rats. Phytother Res, 2008. 22(7):
p. 902-6.

30. Reddy, Y.A., et al., Ameliorating activity of
Ginger (Zingiber officinale) extract against lead induced renal toxicity in
male rats. J Food Sci Technol, 2014. 51(5):
p. 908-14.

31. Gumusay, O.A., et al., Drying effects on the
antioxidant properties of tomatoes and Ginger. Food Chem, 2015. 173: p. 156-62.

32. Mansour, D.F., et al., The Carcinogenic Agent
Diethylnitrosamine Induces Early Oxidative Stress, Inflammation and
Proliferation in Rat Liver, Stomach and Colon: Protective Effect of Ginger
Extract. Asian Pac J Cancer Prev, 2019. 20(8):
p. 2551-2561.

33. Zhang, Q.H., et al., Melatonin improves bladder
symptoms and may ameliorate bladder damage via increasing HO-1 in rats.
Inflammation, 2013. 36(3): p. 651-7.

34. Al-Amoudi, W.M., Toxic effects of
Lambda-cyhalothrin, on the rat thyroid: Involvement of oxidative stress and
ameliorative effect of Ginger extract. Toxicol Rep, 2018. 5: p. 728-736.

35. Mothana, R.A., Anti-inflammatory,
antinociceptive and antioxidant activities of the endemic Soqotraen Boswellia
elongata Balf. f. and Jatropha unicostata Balf. f. in different experimental
models. Food Chem Toxicol, 2011. 49(10):
p. 2594-9.

36. Gore, P.R., et al., Protective Effect of
Thymoquinone against Cyclophosphamide-Induced Hemorrhagic Cystitis through
Inhibiting DNA Damage and Upregulation of Nrf2 Expression. Int J Biol Sci,
2016. 12(8): p. 944-53.

37. Choi, S.H., Y. Byun, and G. Lee, Expressions of
uroplakins in the mouse urinary bladder with cyclophosphamide-induced cystitis.
J Korean Med Sci, 2009. 24(4): p.
684-9.

38. Narla, S.T., et al., Keratinocyte Growth Factor
Reduces Injury and Leads to Early Recovery from Cyclophosphamide Bladder
Injury. Am J Pathol, 2020. 190(1):
p. 108-124.

39. Merwid-Lad, A., et al., Morin-5'-Sulfonic Acid
Sodium Salt (NaMSA) Attenuates Cyclophosphamide-Induced Histological Changes in
Genitourinary Tract in Rats-Short Report. Pharmaceuticals (Basel), 2021. 14(3).

40. Lavelle, J.P., et al., Urothelial
pathophysiological changes in feline interstitial cystitis: a human model. Am J
Physiol Renal Physiol, 2000. 278(4):
p. F540-53.

41. Jhang, J.F., et al., Electron microscopic
characteristics of interstitial cystitis/bladder pain syndrome and their
association with clinical condition. PLoS One, 2018. 13(6): p. e0198816.

42. Jock, M., et al., Effect of partial bladder
outlet obstruction and reversal on rabbit bladder physiology and biochemistry:
duration of recovery period and severity of function. BJU Int, 2014. 114(6): p. 946-54.

43. Elshiekh, A.A., et al., Possible Protective
Effect of Ginger Extract and Beetroot Juice Against Cisplatin Induced
Testicular and Cytogenetic Toxicity in Adult Male Albino Rats. 2019. 76(5): p. 4046-4054.

44. Kandemir, F.M., et al., Protective effects of
zingerone on cisplatin-induced nephrotoxicity in female rats. 2019. 26(22): p. 22562-22574.

45. Narla, S.T., et al., Keratinocyte growth factor
reduces injury and leads to early recovery from cyclophosphamide bladder
injury. 2020. 190(1): p. 108-124.

9/12/2021