Advances in Painful bladder syndrome

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Advances in Painful bladder syndrome

• Stephen Mark
• Christchurch

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Overview

• Diagnosis Interstitial Cystitis IC vs Painful
  bladder syndrome PBS
• Syndrome association
• Medical management
• Surgical management

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IC vs PBS
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
ICS 2002 supra-pubic pain,related to bladder
filling,frequency,nocturia,urgency,without other
pathology
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• 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

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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.
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Medical management

• Analgesia
• Urinary alkaliniser, dilute urine
• Cranberry
• With-hold irritants
• DMSO instillation
• Anticholinergics

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Medical management

• Sub optimal
• Lack of efficacy
• Prolonged time for effect
• Poor durability of effect
• Require safe, effective, prompt relief of
  symptoms with durability

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Medical managementIntravesical Resiniferatoxin

• Previously effective in pilot studies
• Presumed action on pain C fibers
• Recent RCT 163 patients No improvement in
  overall symptoms, pain, urgencyetc . J Urol
  2005,173.1590
• Natural Hx PBS is characterised by remissions and
  exacerbations thus require placebo controlled RCT
  for effect.

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Surgical managementBotox A

• Single arm pilot studies only.
• Small numbers
• Some evidence to suggest Botox may affect pain
  pathways
• Clinical effect mainly for paralysis of smooth
  and striated muscle
• Temporary effect

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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..

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Surgical managementHydrodistension

• Diagnostic and theraputic
• Capacity 300 ml
• May lead to prolonged symptom relief
• Rare complication of total bladder necrosis J
  Urol 2007 177 , 149

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Surgical managementReconstruction

• Total vs Partial cystectomy
• Urethral vs stomal emptying
• Indications 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

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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

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PBSLocal results of surgery

• 6 patients age 35 - 68
• Total cystectomy and bladder reconstruction
• 1 reoperation for leakage
• Pain resolution complete 3/4 1 pouch pain
• All resumed normal lifestyle

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PBSSummary

• Debilitating common remitting disease
• Unknown aetiology
• Impairs quality of life
• Poor treatment options
• Significant economic burden to patient and health
  system