Advances in Painful bladder syndrome Stephen Mark Christchurch

Overview Diagnosis: Interstitial Cystitis [IC] vs Painful bladder syndrome [PBS] Syndrome association Medical management Surgical management

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”

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

Medical management Sub optimal Lack of efficacy Prolonged time for effect Poor durability of effect Require: 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 management Botox 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

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 management Hydrodistension Diagnostic and theraputic Capacity { 300 ml} May lead to prolonged symptom relief Rare complication of “total bladder necrosis” J Urol 2007 177 , 149

Surgical management Reconstruction 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

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

PBS Local 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

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