Advances in Painful bladder syndrome

Stephen MarkChristchurch

Overview

Diagnosis: Interstitial Cystitis [IC] vs Painful bladder syndrome [PBS]

Syndrome associationMedical managementSurgical management

Symptoms: Urgency, Frequency,Nocturia, Pelvic pain { bladder, urethral,vaginal, rectal,perineum}

IC: Cystoscopic findings: pain on filling, inflammation and histologic abnormality

Diagnosis: Exclusion all other pathology : UTI, OAB, Cancer, Endometriosis

IC vs PBS

ICS 2002: “supra-pubic pain,related to bladder filling,frequency,nocturia,urgency,”without other pathology”

Cystoscopy•General vs local

•Capacity [ 300 ml ]

•Pain on filling

•Biopsy [ inflammation, granulation tissue, mast cells, fibrosis ]

•Ulcers [ not true ulcer bit fissure in mucosa due to filling ]

Associated complaints

Mental Health: Depression and Panic disorders are more common : J Urol 2008, 180 1378

Depression more difficult to treat in these patients

Mental health, pain and urinary symptoms are correlated.

Medical management

AnalgesiaUrinary alkaliniser, dilute urineCranberryWith-hold irritantsDMSO instillationAnticholinergics

Medical management

Sub optimalLack of efficacyProlonged time for effectPoor durability of effectRequire: safe, effective, prompt relief

of symptoms with durability

Medical management:Intravesical Resiniferatoxin

Previously effective in pilot studies Presumed action on pain C fibers Recent RCT 163 patients : No improvement in

overall symptoms, pain, urgency…etc . J Urol 2005,173.1590

Natural Hx PBS is characterised by remissions and exacerbations thus require placebo controlled RCT for effect.

Surgical managementBotox A

Single arm pilot studies only.Small numbersSome evidence to suggest Botox

may affect pain pathwaysClinical effect mainly for paralysis of

smooth and striated muscleTemporary effect

Surgical management Botox studies

Urology 2004 64, 871: 13 patients. 69% improvement. [ 1 - 8 months]

Eur Urol 2006 49. 704 14 patients. 85% improvement . 10 recurred within 5 months

Little else…..

Surgical managementHydrodistension

Diagnostic and theraputicCapacity { 300 ml}May lead to prolonged symptom

reliefRare complication of “total bladder

necrosis” J Urol 2007 177 , 149

Surgical managementReconstruction

Total vs Partial cystectomyUrethral vs stomal emptyingIndications: Pain location and relation to

bladder, capability of CIC, bladder capacity reduced…..no other confounding issues

Durable success in VERY select patients. 80% success approx. J Urol 2002 167, 603

PBS Local management algorithm

Presentation: History, exam, MSU, GA cysto and biopsy.

High volume vs Low volume. High vol: medical management, instillations,

symptomatic management… occ hydrodilatation Low vol: all of the above , if resistant consider

surgery

PBSLocal results of surgery

6 patients: age 35 - 68Total cystectomy and bladder

reconstruction1 reoperation for leakagePain resolution complete 3/4… 1 pouch

painAll resumed “ normal” lifestyle

PBSSummary

Debilitating common remitting disease

Unknown aetiologyImpairs quality of lifePoor treatment optionsSignificant economic burden to

patient and health system