Painful bladder syndrom

Pr Xavier Deffieux (MD, PhD)University of Paris, France

Complying with regulations concerning the transparency of event funding and to guarantee accuracy of scientific

contents, this disclosure certifies that in the past 5 years:

I have collaborated with the following companies, which have commercial interests in the healthcare area

q Speaker/consultant (UrgoTech, Allergan, Astellas, Hologic, Laborie, Mylan, B-Braun, Pfizer)

q Travel and accommodation expense (LeoPharma, Allergan, Aspide, AMI)

q Ownership or other investments, including shares (Sanofi, Nanobiotics)

Painful bladder syndrome (PBS)

Definitions (ICS terminology ≠ NIDDK / ICDB criteria)

Lack of universally accepted definition ++

ICS terminology = good for clinical use !

« Complaint of suprapubic pain related to bladder fililng»

Unpleasant sensation (pain, pressure, discomfort) perceived to be related to the bladder

Associated with LUTS (nocturia, daytime frequency)

Lasting > 6 month

+/- prementrual worsening/exacerbation

Absence of infection.01-4/1,000 women

(Japan, Europe, US)

Sex ratio (female/male) 5:1

PBS is not …

PBS

≠

OAB (urgency, urge incontinence, frequency, nocturia)

≠

Dysuria (pain that occur at the start of / or after urination)

Bladder painful + frequency/nocturiaAND> 6 moisANDPain resolution after voidingANDPhysical exam excludes urethritis / vaginitis / PID / vulvar infection / HSV…ANDUrine culture during symptoms is negative (no infection)ANDNo neurological disease / malignancy

When Suspect PBS ?

Urodynamics

OABPBS

Pain OD OD

PBS pathophysiology ?

Damage to bladder epithelium …activation of C fibers

Autoimmune disorder

Urothelial dysfunction : glycoaminoglycane (GAG)

Urinary microbiote abnormality

Hypersensibility

Neurogenic inflammation

Bladder biopsy ? …No pathognomonic findings

PBS treatment = pain management

Avoid surgery…except fulguration of Hunner’s lesionsMultiple simultaneous treatments often best

Behavioural modificationAvoid alcohol-coffee-tea / acidic or spicy food / beverageControl fluid intake

PFMTSoft tissue massageBiofeedbackMyofascial release

PBS treatment

Oral therapy

- H2 histamine receptor antagonist (cemetedine, loratadine)

- Inhibitors recapture of serotonin (amytriptiline) 10-50mg/day

- ELMIRON (sodim pentosan polysulfate (correct GAG défect)

- Others : hydroxyzine, misoprostol

Antibiotics : no role for now

PBS treatmentSacral nerve stimulation (S3-S4)

Invasive procedure

Implanation of a permanent electrode

50% of patients with PBS may derive benefit from S3n stimulation

Sacral nerve stimulation

PTNS

At home ! Once a day

Good efficacy for OAB

But very data in PBS women…

Non invasive procedure

… after

before …

Posterior tibial nerve stimulationUROSTIM2 TM Schwa Medico

PTNS

Program selection

Program Symptom Frequency (Hz) Pulse (µs) Session (min)

UUI (PTNS)UUI (PTNS)UUI (PTNS)UUI (PTNS)

PainUUI (probe)SUI (probe)MUI (probe)

AI

ON

Program

PTNS

Electrodes placement

Set intensity of the stimulation

From pulse…to pinching

…to pain

Between pinchingand pain…

+/- OH (oily skin)

PBS treatmentHydrodistension using cystoscopyInflate bladder with saline 80cmH2O or 800-1000 mlMaintain presure for a few minutes, then drain bladder

Intravesical therapyDMSO (dimethyl sulfoxide) RIMSO-50 (anti-inflammatory)Heparin : good sucessLidocain (time duration-limited effect)

Hyaluronic acid : no effect

BOTOX ? (still needs study)

Intra-detrusor botulinum toxin (BOTOX) injection

Uretro-cystoscopy

Flexible or rigid

Sterile saline solution

PBS treatmentSurgery

Bowel bladder reconstruction

Bladder-augmentation cystoplasty

Following sustrigonal cystectomy

Total cystectomye and urethrectomy…

Only considered for very few advanced cases

Conclusion

Lack of universally accepted definition ++

Complaint of suprapubic pain related to bladder filling

Pain resolution after voiding

Associated with frequency and nocturia

After eliminating other diagnosis

Multiple simultaneous treatments