UROLOGICAL SURVEY
Neurourology & Female Urology
Dyspareunia response in patients with interstitial cystitis treated with intravesical lidocaine, bicarbonate, and heparin
Welk BK, Teichman JM
Division of Urology, Providence Healthcare, Vancouver, British Columbia, Canada
Urology. 2008; 71: 67-70
OBJECTIVES: To test the dyspareunia response of patients with interstitial cystitis/painful bladder syndrome treated with an intravesical therapeutic solution of lidocaine, heparin, and sodium bicarbonate.
METHODS: We studied consecutive patients with interstitial cystitis/painful bladder syndrome who were sexually active and were treated with an intravesical therapeutic solution. All patients provided their medical history, underwent a physical examination, and completed the Pelvic Pain Urgency Frequency symptom scale, voiding diary, and the pain domain (questions 17 to 19) of the Female Sexual Function Index before and after therapy. The patients were treated with intravesical instillations three times weekly for 3 weeks. The patients returned for follow-up 3 weeks later. The patients rated their response using a Patient Objective Rating of Improvement of Symptom scale.
RESULTS: A total of 23 patients (mean age 38 years) were included in this study. Of the 23 patients, 15 (65%) reported improvements of greater than 50% on the Patient Objective Rating of Improvement of Symptom scale. Before and after instillation, nocturia was 4 +/- 2 versus 2 +/- 1 (P < 0.001), the voided volume was 98 +/- 59 mL versus 169 +/- 80 mL (P < 0.001), the Pelvic Pain Urgency Frequency score was 21 +/- 6 versus 15 +/- 6 (P < 0.001), and the Female Sexual Function Index pain domain score was 1.9 +/- 0.9 versus 3.7 +/- 1.6 (P < 0.001), respectively. Of the 23 patients, 13 (57%) reported resolution of dyspareunia. Of the 13 patients with bladder tenderness only versus the 7 with multiple tender locations on the vaginal examination, 11 (85%) versus 2 (29%) had resolution of dyspareunia (P < 0.01) and 12 (92%) versus 2 (29%) had successful overall outcomes (P < 0.01).
CONCLUSIONS: The results of this study have demonstrated that an intravesical therapeutic solution provides relief of voiding symptoms, pain, and dyspareunia in patients with interstitial cystitis/painful bladder syndrome. A randomized, prospective trial is warranted.
Editorial Comment
The authors analyzed the rate of dyspareunia in a female patient population diagnosed with interstitial cystitis and subsequently treated with intravesical instillations of a lidocaine/sodium bicarbonate/heparin solution three times a week for three weeks in a row. The therapy seemed to have a certain level of durability in that a definite percentage of patients were asymptomatic for three weeks. The authors noted that patients had a much higher response rate if prior to treatment they were plagued with bladder tenderness only on physical examination as opposed to a diffusely painful vagina on digital palpation.
This interesting paper highlights the association of sexual problems in patients with interstitial cystitis. It is heartening that those patients who had basically only bladder tenderness on vaginal palpation experienced an 85% resolution of their dyspareunia with this instillation therapy. The authors note that alkalinizing the lidocaine will allow it to have a greater penetration of bladder epithelium. Alkalinization of lidocaine has also been reported to diminish pain during interdermal injections with local infiltrated anesthesia. I found it noteworthy that the total solution instilled in the bladder was only 14 cc while the lidocaine gel instilled in the urethra to anesthetize prior to catheterization was 10 cc in itself. The logistical efficacy of intravesical therapies for patients in the office cannot be understated. Those with an interest in this specific population and therapy should definitely review the article upon which this report is based (1).
Steven P. Petrou, M.D
Associate Professor of Urology
Chief of Surgery, St. Luke's Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu
The expectations of patients who undergo surgery for stress incontinence
Mallett VT, Brubaker L, Stoddard AM, Borello-France D, Tennstedt S, Hall L, Hammontree L; Urinary Incontinence Treatment Network
Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38138, USA
Am J Obstet Gynecol. 2008; 198: 308.e1-6
OBJECTIVE: The purpose of this study was to assess patient expectations of surgical outcome after preoperative counseling of surgical procedures in a randomized trial of 655 women in a comparison of the rectus fascial sling and Burch colposuspension.
STUDY DESIGN: Women who selected surgery for treating stress incontinence and who consented to this randomized, surgical trial completed a preoperative questionnaire to assess expectations for the postsurgical effects of surgery on urinary incontinence-related symptoms, limitations, and emotions. Associations of expectations with a range of preoperative urinary incontinence measures were explored.
RESULTS: The most frequent preoperative symptoms were urine leakage (98%), embarrassment (88%), frequency (74%), physical activity (72%), and urgency (70%). Sexual and social limitations were less frequent (< or = 44%). Treatment expectations were higher for women who reported more symptom bother. As expected, most women (98%) had an expectation that urine leakage would be completely or almost completely eliminated. However, most women (92%) who reported urgency or frequency (83%) expected significant improvement of these symptoms after surgery.
CONCLUSION: Patients who undergo stress incontinence surgery have high expectations regarding the outcome of incontinence surgery, which include the resolution of urgency and frequency.
Editorial Comment
The authors reviewed the expectations of patients with regards to the anticipated results of their upcoming anti-incontinence operation (be it a Burch urethropexy or a autologous fascial suburethral sling). The patients had a consultation with their surgeon as well as viewing a standardized video presentation on the future surgery. The discussion of expectations and explanation of risks and benefits of surgery was standardized among the 22 surgeons at all the participating study sites. Even after both a video presentation and verbal discussion, 92% of the patients still expected that their urgency symptoms would resolve and 74% that their urinary frequency would improve with an anti-incontinence operation. Expectations were not related to preoperative health, age, physical examination or history of previous surgery.
An interesting article that formalizes the anecdotal experience of urologic surgeons: no matter how intensive the preoperative counseling and explanation of risks and benefits, patients expect an anti-incontinence operation will address all aspects of their voiding dysfunction. It has been noted in the past that a certain percent of patients will have their urgency addressed with an anti-stress incontinence operation (1). The segment in whom the urgency persists will definitely report a lower satisfaction with their surgery even with a technically perfect procedure (2).
References
Steven P. Petrou, M.D
Associate Professor of Urology
Chief of Surgery, St. Luke's Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu
- 1. Parsons CL: Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis. Urology. 2005; 65: 45-8.
- 1. McGuire EJ, Savastano JA: Stress incontinence and detrusor instability/urge incontinence. Neurourol Urodyn 1985; 4: 313-6.
- 2. Haab F, Trockman BA, Zimmern PE, Leach GE: Results of pubovaginal sling for the treatment of intrinsic sphincteric deficiency determined by questionnaire analysis. J Urol. 1997; 158: 1738-41.
Publication Dates
-
Publication in this collection
06 Oct 2008 -
Date of issue
Mar 2008
