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Advances in Painful bladder syndrome

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.

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Advances in Painful bladder syndrome

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  1. Advances in Painful bladder syndrome Stephen Mark Christchurch

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

  3. 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”

  4. 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 ]

  5. 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.

  6. Medical management • Analgesia • Urinary alkaliniser, dilute urine • Cranberry • With-hold irritants • DMSO instillation • Anticholinergics

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

  8. 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.

  9. 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

  10. 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…..

  11. 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

  12. 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

  13. 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

  14. 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

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

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