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,
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,
Natural Hx PBS is characterised by remissions and exacerbations thus require placebo controlled RCT for effect.

9. 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

10. Surgical management Botox studies
Urology , 871: 13 patients. 69% improvement. [ months]
Eur Urol patients. 85% improvement . 10 recurred within 5 months
Little else…..

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

12. 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 , 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. PBS Local results of surgery
6 patients: age
Total cystectomy and bladder reconstruction
1 reoperation for leakage
Pain resolution complete 3/4… 1 pouch pain
All resumed “ normal” lifestyle

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