UPDATES ON UROLOGIC CAUSES OF PELVIC PAIN

TANYA NAZEMI, MD GOALS

• COMMON CLINICAL PRESENTATIONS • DDX • EVALUATION • TESTING • TREATMENT OPTIONS COMMON PROBLEMS ENCOUNTERED IN PRACTICE

• “IT HURTS WHEN I PEE” • “I FEEL LIKE I HAVE A UTI” • “I DON’T FEEL LIKE I AM EMPTYING MY BLADDER ALL THE WAY” • “I FEEL PRESSURE OR URGE TO PEE EVEN THOUGH I JUST WENT” • “I FEEL LIKE I HAVE TO GO ALL THE TIME” • “I HAVE PAIN IN MY ” • “IT FEELS LIKE I AM HAVING A PERIOD EVEN THOUGH I DON’T HAVE A UTERUS” DIFFERENTIAL DIAGNOSES FOR UROLOGIC SOURCE OF PELVIC PAIN

• URINARY TRACT • • • CANCER • UROLITHIASIS • RETENTION • PROLAPSE • VOIDING DYSFUNCTION • URETHRAL DIVERTICULUM • • • /BLADDER PAIN SYNDROME (IC/BPS) • FOREIGN BODY

• IS IT OR IS IT NOT A UTI???? • UA – MICROSCOPY, CULTURE • ALWAYS GET A CULTURE IF INFECTION IS SUSPECTED • IMPORTANT TO GET A MID STREAM CLEAN CATCH SPECIMEN, INSTRUCT THE PATIENT • RETRACT THE FORESKIN • CATH CULTURE IF UNSURE URINARY TRACT INFECTION

• ANTIBIOTICS MAY HELP SYMPTOMS BUT NOT IDEAL IF CULTURE IS NEGATIVE • DON’T FORGET THE ATYPICAL BACTERIAS – UREAPLASMA AND MYCOPLASMA • TREAT THE PARTNER • MASSAGE UROLITHIASIS

• DISTAL URETERAL STONE UROLITHIASIS

• PROLAPSE

• CYSTOCELE • RECTOCELE PROLAPSE

• UTERINE PROLAPSE • PROCIDENCIA URETHRA

• URETHRAL PROLAPSE • URETHRAL STRICTURE

• URETHRAL DIVERTICULUM FOREIGN BODY FISTULA RETENTION VOIDING DYSFUNCTION CAUSES OF VOIDING DYSFUNCTION

BLADDER OUTLET OBSTRUCTION STRUCTURAL LESIONS NEUROLOGICAL FUNCTIONAL DISORDERS (MECHANICAL OBSTRUCTION) DETRUSOR SPHINCTER DYSSYNERGIA URETHRAL STRICTURE/DIVERTICULUM NON-RELAXING SPHINCTER URETHRAL STENOSIS SPINA BIFIDA UROTHELIAL MALIGNANCY FOWLER'S SYNDROME POORLY-RELAXING PELVIC FLOOR BLADDER STONE DETRUSOR UNDERACTIVITY NEUROLOGICAL EXTRINSIC COMPRESSION FROM BENIGN OR LESIONS OF THE CONUS MEDULLARIS OR CAUDA MALIGNANT GYNECOLOGICAL CONDITIONS EQUINE EXTRINSIC IATROGENIC COMPRESSION (EG, MULTIPLE SCLEROSIS SYNTHETIC TAPE OR OTHER ANTI-INCONTINENCE MEDICATIONS SURGERY)

Panicker, Jalesh & Anding, Ralf & Arlandis, Salvador & Blok, Bertil & Dorrepaal, Caroline & Harding, Chris & Marcelissen, Tom & Rademakers, Kevin & Abrams, Paul & Apostolidis, Apostolos. (2018). Do we understand voiding dysfunction in women? Current understanding and future perspectives: ICI-RS 2017. Neurourology and Urodynamics. 37. S75-S85. 10.1002/nau.23709. BLADDER PAIN

• INTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROME (IC/BPS) - "AN UNPLEASANT SENSATION (PAIN, PRESSURE, DISCOMFORT) PERCEIVED TO BE RELATED TO THE , ASSOCIATED WITH LOWER URINARY TRACT SYMPTOMS OF MORE THAN SIX WEEKS DURATION, IN THE ABSENCE OF INFECTION OR OTHER IDENTIFIABLE CAUSES.“ • APPROXIMATELY 83,000 MEN AND 1.2 MILLION WOMEN ACROSS THE US • ETIOLOGY OFTEN UNKNOWN • ABSENCE OF DEMONSTRABLE PATHOLOGY OF THE VISCERA OR ASSOCIATED NERVES • FREQUENTLY OVERLAP WITH OTHER CONDITIONS INCLUDING IRRITABLE BOWEL SYNDROME, FIBROMYALGIA, CHRONIC FATIGUE SYNDROME, ANXIETY DISORDERS, AND A NUMBER OF OTHER SYNDROMES NOT DIRECTLY RELATED TO THE URINARY BLADDER

Birder LA. Pathophysiology of interstitial cystitis. Int J Urol 2019;26: (Suppl 1): 12–5. Clemens JQ, Joyce GF, Wise M et al: Interstitial cystitis and painful bladder syndrome. In: Urologic Diseases in America. Edited by M. S. Litwin and C. S. Saigal. Washington, DC: US Department of Healt and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, 2007 PATHOPHYSIOLOGY OF IC/BPS

Birder L, Andersson KE. Urothelial signaling. Physiol. Rev. 2013; 93: 653–80. Lovick TA. Central control of visceral pain and urinary tract function. Auton. Neurosci. 2016; 200: 35– 42. Kanter G, Komesu YM, Qaedan F et al. Mindfulness‐based stress reduction as a novel treatment for interstitial cystitis/bladder pain syndrome: a randomized controlled trial. Int. Urogynecol. J. 2016; 27: 1705– 11. EVALUATION

• HISTORY • MIDSTREAM CLEAN CATCH UA OR CATH SPECIMEN • ALWAYS CULTURE IF CONCERNED FOR UTI (NOT “CULTURE IF INDICATED”) • POST VOID RESIDUAL • SUPRAPUBIC TENDERNESS, CVA TENDERNESS • SPECULUM EXAM • BLADDER DIARY TESTING

• IF THERE IS GROSS OR ≥3 RED BLOOD CELLS PER HIGH-POWER FIELD ON MICROSCOPIC EVALUATION IN THE ABSENCE OF INFECTION, SHOULD BE REFERRED TO • CTIVP, RENAL , MR UROGRAPHY • CULTURE • • URODYNAMICS CYSTOSCOPIC FINDINGS

• BLADDER GLOMERULATIONS DURING HYDRODISTENTION

• HUNNER'S LESION

Vignoli G. (2018) UDS in Pain Bladder Syndrome (PBS) and Overactive Pelvic Floor Dysfunction. In: Urodynamics for Urogynecologists. Springer, Cham. https://doi.org/10.1007/978-3-319-74005- 8_11 TREATMENT

• SELF-CARE PRACTICES AND BEHAVIORAL MODIFICATIONS • STRESS REDUCTION, COUNSELING, ACUPUNCTURE • DIETARY MODIFICATIONS • AVOIDANCE OF BLADDER IRRITANTS • PELVIC FLOOR PT • WEIGHT LOSS MEDICATIONS

• ANTIBIOTICS • PENTOSAN POLYSULFATE SODIUM (PPS) • ANTICHOLINERGICS • AMITRIPTYLINE • BETA-3 AGONISTS • CIMETIDINE • PHENAZOPYRIDINE • HYDROXYZINE • URIBEL • ALOE VERA CAPSULES • VAGINAL ESTROGEN BLADDER INSTILLATION

• DIMETHYL SULFOXIDE (DMSO) • HEPARIN • LIDOCAINE • BLADDER COCKTAILS TREATMENT HUNNER’S ULCERS

Malloy TR, Shanberg AM: Laser therapy for interstitial cystitis. Urol Clin North Am 1994; 21: 141. Therapeutic effects of endoscopic ablation in patients with Hunner type interstitial cystitis Kwang Jin Ko, Hyunwoo Chung, +3 authors Kyu-Sung LeeMedicineBJU international 2018 Derisavifard S., Moldwin R. (2020) Surgical Management of Interstitial Cystitis/Bladder Pain Syndrome. In: Firoozi F. (eds) Female Pelvic Surgery. Springer, Cham. https://doi.org/10.1007/978-3- 030-28319-3_19 HYDRODISTENSION

• CYSTOSCOPY UNDER WITH LOW-

PRESSURE (60 TO 80 CM H20), SHORT DURATION (LESS THAN 10 MINUTES) BOTULINUM TOXIN INJECTION

• IN OFFICE PROCEDURE • PAIN • UTI • HEMATURIA • RETENTION • REPEAT INJECTION • COMBINATION WITH HYDRODISTENSION NEUROMODULATION

• MODULATE URINARY TRACT REFLEXES • PERCUTANEOUS TIBIAL NERVE STIMULATION NEUROMODULATION

• SACRAL NEUROMODULATION MAJOR SURGERY

• END STAGE FIBROTIC BLADDER • AUGMENTATION CYSTOPLASTY • URINARY DIVERSION WITH OR WITHOUT CYSTECTOMY TAKE HOME POINTS

• CAREFUL HISTORY • CULTURE CULTURE CULTURE • SET EXPECTATIONS – NO QUICK FIX, MULTIDISCIPLINARY APPROACH • MAKE SURE TO ADDRESS POTENTIAL CONTRIBUTING FACTORS • MEDICATIONS, CONSTIPATION, PELVIC FLOOR DYSFUNCTION, STRESS, DEPRESSION, IBS, MENOPAUSE, CHRONIC PAIN SYNDROMES