MIAMI, FL USA (UroToday.com) - Dr. Debbie Erickson moderated a panel of clinicians who have expertise in treating IC/BPS.
The variations in the approaches, by these experts, to this population were evident. Dr. Erickson began by presenting the IC/Bladder Pain Syndrome (BPS) SUFU definition which was used in the AUA guidelines: “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6-weeks duration, in the absence of infection or other identifiable causes.” The presence of Hunner’s lesion is not part of the IC/BPS diagnosis, but if present, endoscopy treatment is recommended.
The panel was asked to describe their initial endoscopic treatment of choice (fulguration (laser, cautery), transurethral resection, triamcinolone injection). Drs. Kenneth Peters and Robert Evans are very aggressive with multimodal therapy. They perform initial endoscopy procedures for patients with Hunner’s lesion. Both do fulguration (to cauterize the lesions) as well as bladder hydrodistension, and they stated that their patients do well. Dr. Robert Moldwin noted that his approach has shifted and he will do a cystoscopy to determine the presence of a Hunner’s lesion, followed by an injection of anesthetic and a steroid. He only does small injections as bleeding will occur. None of the panelists use lasers because of concerns about adverse events (bowel complications).
Dr. Erickson asked the panel members about their use of bladder hydrodistension. She noted that it is no longer recommended for diagnosis of IC/BPS, however, it is used as a treatment. She asked the panel to discuss where hydrodistension falls in their treatment algorithm, in what patient is it indicated or not indicated, and any specifics on technique. While Dr. Evans continues to do a fair number of hydrodistension treatments, he does not use it for initial diagnosis. He performs this treatment in patients who:
- failed all other therapies (drug, instillations) ,
- has seen several physicians and does not believe the diagnosis,
- had it previously and found it helpful (and will not do it if a previous poor response occurred).
In contrast to Dr. Evans, Dr. Moldwin has moved away from hydrodistension and feels this treatment will be phased out, like urethral dilation has. Dr. Peters performs hydrodistension rarely and only in bladder-centric patients who have no pelvic floor complaints.
The use of Botox injection in patients with IC/BPS was discussed. Dr. Erickson noted that the use of Botox injections in IC/BPS patients is an off-label use as it is not FDA approved. She asked the panel about specifics on their use of Botox.
Dr Moldwin occasionally will do Botox injections in patients who have urgency and/or frequency, but not as a treatment for pain. He feels that these patients are poor candidates for Botox injections because of the possibility of incomplete bladder emptying post-injection. If performed, he follows the technique described by Mike Chancellor who advocates injections in the bladder trigone, not the bladder dome. Dr. Moldwin will not do Botox injections in patients with a Hunner’s lesion. Dr. Peters injects for several different pelvic pain conditions. In women with levator ani spasm, he does 6 trigger-point Botox injections, transvaginally, on each side of the muscle. He will add Marcaine to lessen the pain from these injections. Dr. Evans routinely does Botox injections in patients with voiding dysfunction, urgency, frequency, urge UI, but not for IC/BPS symptoms. He is doing injections for tight pelvic floor muscles, as trigger injections, as part of a Botox injection study for Allergan. Dr. Evans does not worry if urinary retention occurs after Botox injections as many of these women are already performing self-catheterizations to instill intravesical treatments.
Next there was discussion involving the use of neuromodulation (another off-label use). Dr. Peters is using neuromodulation, specifically sacral neuromodulation (SNS), in patients with IC/BPS, and he sees good results. Dr. Evans also reported that he does office-based PNE and staging in patients with IC/BPS who had high tone pelvic floor. Dr. Moldwin does not use neuromodulation as often. Both Drs. Peters and Evans prefer SNS over Botox injections as the long-term outcome is better. Dr. Peters felt that SNS is more of a restorative treatment.
Final discussion was the use of urinary reconstruction and augmentation cystoplasty. Dr. Evans will perform reconstructive surgery (cystectomy, ileoconduit or Indiana pouch) on patients who have intractable pain, with very small bladders, or those who are intractable, or are on narcotics, or are experiencing renal deterioration. Dr. Moldwin felt the ideal candidates for reconstruction are those with Hunner’s lesions or who have scarring of the bladder. The most important thing is to make sure that the bladder is the origin of the pain. Dr. Peters feels cystectomy is indicated in the ulcerative patient, bladder-centric patient, and those with small bladder capacity. He will perform similar procedures.
Moderated by Debbie Erickson, MD at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) Winter Meeting - February 25 - March 1, 2014 - Doral Golf Resort and Spa - Miami, Florida USA
Panelists:
Endoscopic Management Including OnobotulinumtoxinA: Robert M. Moldwin, MD
Neuromodulation: Kenneth M. Peters, MD
Urinary Reconstruction/Diversion: Robert J. Evans, MD
Reported for UroToday.com by Diane K. Newman, DNP, FAAN, BCB-PMD