Robert Moldwin: Thanks very much, Alan. What I'd like to talk about today is an article that my wife and I wrote regarding interstitial cystitis and how by phenotyping patients, clinically characterizing these patients more effectively, that will guide better therapies for patients and hopefully better outcomes. The major points of the article starts off talking about how this is a condition that, of course, has been very difficult on both the clinicians and patients in terms of getting satisfactory results.
Research, unfortunately in the field, particularly these RCTs trying to investigate for new medications, more devices have also had poor outcomes, and I think much of this is due to just having such a heterogeneous population. The idea behind the article is really to take a step back and to re-categorize the patient population to actually phenotype them in terms of their clinical characteristics and hopefully develop therapies that align best with those specific pathologies, clinical characteristics, and get better clinical results, not only in the office setting, but hopefully in research settings to come.
Really, the genesis of this heterogeneous population I think really rests with the definition of interstitial cystitis that we've created over the years, which is very, very general, very broad-based. Because of that, we're seeing lots of different related pathologies from bladder wall structural changes to centralized dysfunction to even changes in normal processes such as viscero-viscero convergence or viscero-somatic convergence, the last on being that communication, at least in urology circles, between bladder and pelvic floor behavior.
The question is, as they say, what's a urologist to do? We have a really good American Urological Association guidelines. But unfortunately, as I'm sure many of you know in clinical practice, not everything works for every patient and how to figure out where to start, where to go, what's going to work best for any given patient is often a dilemma for most clinicians, just where do we go? At least the gist of this article is to look at the patients in terms of their phenotypic presentations. Basically, what are their pain generators? We have those patients with bladder-centric pain, those patients with and without inflammatory disease, so that's two groups. Patients with a great deal of pelvic floor pain, related pain, is often termed high-tone pelvic floor dysfunction, and those patients with widespread pain, meaning they have more centralized processes at hand. So it's not necessarily their bladder, but perhaps how they interpret pain.
And again, really, I hope to read the article because it's a lot of more specific suggestions as far as various therapies. But the idea now is when we break them down into these groups, as you can see here, they may have therapies that correspond. As a perfect example, someone we find has a very tender pelvic floor. They have all the signs and symptoms of some type of muscular dysfunction of the pelvic floor at hand, muscle relaxants, pelvic floor physical therapy, even injections of anesthetics into the muscles to the nearby neuros and so forth, all of these things are possibilities for this population. Whereas, those patients with widespread issues, those patients maybe who just perceive they just have constant burning in their pelvis that they perceive to be in their bladder and no other pathologies are fine, those are patients who might best respond to more centrally acting patients. For example, the tricyclic anti-depressants, the gabapentinoids, et cetera.
And finally, of course, the classic patients that we think of as really being IC are those patients where you can define the pain really does seem to be coming from that bladder either through inflammatory processes that are visible, i.e. those patients with Hunner lesions or patients who just have, we'll say, a sensitive bladder wall. And of course, those patients would be hopefully responsive perhaps to intravesical therapies, to, let's say, a botulinum toxin injection into the trigone, not FDA-approved, but certainly something that's been discussed. Hydrodistensions of the bladder. Again, local therapies might be most helpful for that population. Those are the basic essentials of the paper, and we'll have more of a discussion hopefully in the next few minutes. Thanks.
Alan Wein: That was a remarkably intellectual approach that seems very logical. I want to know how the master evaluates these. In other words, person comes to you, a woman, 60 years old falls into the category of, okay, possible interstitial cystitis, bladder pain syndrome. What's the exact evaluation including the particulars of a physical exam that you go through initially with these people?
Robert Moldwin: Well, I think the first thing is to do a very detailed history and physical exam. I think most people in the field would agree that probably 90%, if not more, of the diagnosis rests with this. I think that, again, something very, very important. When a patient comes to me, I'm looking for the basics. I'm looking for the degree of pain. I want a pain severity score. I want to see, is that pain occurring with bladder filling? Does it reduce, at some point, with bladder emptying? I want to look at the characteristics of the pain. Is it a burning pain? Is it a constant burning pain?
Let's say I have a patient who's coming in and they tell me that the pain is getting worse with bladder filling, it gets better with emptying. I'm starting to think that that's more of a bladder-centric patient as compared to, for example, someone that perceives that it's their bladder, they have constant pelvic burning, burning, burning, burning. It doesn't change whether the bladder's full, whether the bladder's empty. That's a patient where I'd be more concerned about some centralized process at hand.
I'll be asking questions about voiding frequency. How are you voiding very frequently during the day, and what's your motivating factor that makes you void so frequently? Usually, in the IC patient, it's going to be pain that's going to be the driver there. I also want to find out if these are large or low-volume voids during the day and during the evening. I also want to look at nocturia. Nocturia is also very important. Many patients with just voiding dysfunctions, I'm sure you've encountered this innumerable times during your own practices, they void innumerable times during the day, but at night, they sleep right through. Those are patients I start to think about more, again, voiding dysfunction, not so much related necessarily to bladder, but often pelvic floor related issues.
I'll ask them questions about sexual activity, dyspareunia, entry versus deep dyspareunia. Deep dyspareunia, of course, could be musculoskeletal, deep dyspareunia can also be related to bladder pain. Entry dyspareunia could be related to vulvar pain related issues, vulvodynia that may need to be separately addressed. I'm asking all these different questions. I'll also ask the patients often to fill out a voiding diary, just simply to quantify or to get a baseline. Not necessarily, these aren't usually patients. I'll exclude anybody who has urinary incontinence issues or real clear-cut OAB. But if they do have sudden urgency, that would make me think outside the spectrum of interstitial cystitis, might think that there's some concomitant other issues to deal with.
Alan Wein: What kind of physical do you-?
Robert Moldwin: Physical exam? Yeah, physical.
Alan Wein: We try to detect muscle tenderness, like some people say with the diagram and trying to assess, I guess, what you'd call hypertonia or localized muscle discomfort with a vaginal exam. What exactly do you do?
Robert Moldwin: Basically, it's an abdominal exam. You want to make sure that they are emptying their bladder. Certainly, a bladder scan is reasonable to do a post-void check. I'll do a Q-tip test of the introital area. Assuming, again, keep in mind that there are men with interstitial cystitis as well, which is by a whole nother topic to address. But essentially, I'll do a Q-tip test just to see if there's sensitivity or tenderness there. We'll look for atrophic changes and so forth. Again, looking for other pain generators. With reference to what you were mentioning, we're talking about doing literally just a one finger pelvic exam. That's all that's necessary. I literally am just feeling the levators and the obturator internis bilaterally just to get a sense of muscle banding, the tone of the muscle, and also if I can reproduce the patient's pain with these maneuvers. And if they're really jumping off the table, those aren't normal things. They should not really detect any terrible discomfort during those examinations.
The other thing, of course, I'm going to be testing for is, since many of these patients, obviously, we're looking for bladder pain, we're going to want to try to palpate along the bladder fundus, the bladder neck region, and of course, along the course of the urethra to look at for any other abnormalities that one might find that might be associated with pain.
Alan Wein: Now, do all these people get cystoscope initially or not?
Robert Moldwin: I tend to ... if I think a patient ... So let's take a scenario. If I have a patient I feel has a lot of, let's say pelvic floor tenderness, and yes, they may have bladder tenderness and they may ... I think that they probably do have a diagnosis of IC, but I'm really detecting pelvic floor abnormalities. What I'll usually do is I'll send them out the office the first visit with a whole schedule of what to do. I'll send them to physical therapy. We'll get them on some muscle relaxants. We'll get them into the tub. We'll change some of their behaviors because a lot of these patients tend to be pushers. I call them pushers and clinchers. They tend to always clinch like one might see in a TMJ situation, and we have to work on those behaviors. They'll come back to the office, perhaps six to eight weeks later and then I will do a cystoscopy.
And at that time, what I'll do is I'll introduce an anesthetic into their bladders, what's been termed an anesthetic challenge. That's not only to identify to see if I can reproduce some of their discomfort with filling. We can use the tip of the scope as a way to actually test different areas of the bladder, even to see if there's some hyperemic response on the bladder wall. And then finally, I'll empty the bladder and introduce a combination of usually bupivacaine and lidocaine, 0.5% bupivacaine and 2% lidocaine, and see what their response is. Even a short-lived response would suggest bladder centricity. I don't think it's a perfect test, but there's no question if the patients really feel better. And when they feel better, it's just an incredible experience for the clinician and the patient.
Alan Wein: All that is such terrific information. I would encourage everybody to read what you write, because it is a nice stepwise approach and I think it's a lot better than what many people are doing in the community and even at the academic centers as far as taking care of these people that are in actual fact so miserable. And I think having somebody, you might want to comment about the value of having somebody, like your wife who's an experienced advanced practice provider to look after these people in between visits with you.
Robert Moldwin: Yeah. I think you have to use the talents of people in your offices if you're working. And again, this, I think, may vary from state to state or country to country, of course. For example, in New York where I am, nurse practitioners can actually practice independently. My wife has her own practice, and she's not a surgical person, nor for the most part is interstitial cystitis or pelvic pain exclusively, 90% of it is in office work. To use their talents or to have somebody within any given practice, whether it be academic or just in regular private practice to become an expert in this area is incredibly useful and the patients love this. They really do.
Alan Wein: So listen, thank you so much, because I think that anyone who listens will be encouraged to read a little more and to really take much better care of these patients. You do it, obviously, extremely well, so thanks so much. See you at the AUA meeting.
Robert Moldwin: Well, thank you so much for having me. It was really wonderful, wonderful. And it's a great service of these videos really. Thanks again.
Alan Wein: Thanks. Take care, Rob.