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Genitourinary Syndrome of Menopause: Procedural & Surgical Management
Ishaan Sangwan • Sep 6, 2021 • 65 hits
Most cases of genitourinary syndrome of menopause improve with estrogen and pelvic floor therapy within a year. However, sometimes patients continue to have genitourinary symptoms refractory to treatment, such as incontinence, cystitis, and voiding problems. In these cases, several procedural interventions may be useful, such as interstitial cystitis (IC) cocktails, Botox, and neuromodulation therapies. In extreme cases, certain surgical interventions, such as a urinary diversion with cystectomy, may also be indicated.
Dr. Santiago-Lastra discusses her approach to the management of these cases. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Interstitial cystitis cocktail installations are a second line therapy for interstitial cystitis, and work best for patients with specific bladder pain.
• Botox and neuromodulation therapies, such as InterStim and percutaneous tibial nerve stimulation, are effective at treating urgency incontinence symptoms, and are usually equally effective.
• In patients with voiding dysfunction and bowel symptoms in addition to urgency incontinence, neuromodulation therapy is preferred over Botox.
• Urinary diversion with cystectomy is a surgical option to treat an extremely inflamed and ulcerated bladder, and should be considered when other conservative therapies have failed.
Table of Contents
(1) Interstitial Cystitis Cocktails for Genitourinary Syndrome of Menopause
(2) Botox, InterStim, and PTNS for Genitourinary Syndrome of Menopause
(3) Urinary Diversion for Genitourinary Syndrome of Menopause
Interstitial Cystitis Cocktails for Genitourinary Syndrome of Menopause
If interstitial cystitis develops as a complication of genitourinary syndrome of menopause and is unresponsive to estrogen supplementation, interstitial cystitis cocktail installations can be performed as second line therapy. IC cocktail installations are most useful for patients that have pain that is specific to the bladder, and do not report pain elsewhere. Motivated patients can even administer the installations at home if they respond well to them. While the AUA also recommends IC cocktails for patients who have failed other therapy, Dr. Santiago-Lastra finds that they are unlikely to help if the pain is not bladder specific.
[Dr. Yahir Santiago-Lastra]
The ideal patient for an installation is a patient that describes pain that is very specific to the bladder. So pain that is absolutely at its worst when the bladder is full. A patient that brings in a bladder diary, and you can see that the patient has a very low bladder capacity. A patient who doesn't describe pain in other areas as well. So the pain that's really specific to the urinary bladder. They may also be patients that upon cystoscopy, the bladder tissue looks friable, you see glomerulations. And also, is a patient that you give a test installation to who states that that first installation provided some relief. So those patients I'll talk about putting on a several weeks course, six or 12 weeks course of installations once a week. And we have highly motivated patients that do well with installations that actually learn how to administer those installations at home.
So those are the ideal candidates. Sometimes we also have patients, unfortunately, for whom none of the other treatments have worked, and we're going down that American Urological Association List of Guidelines, and we'll try them on installations. But I've found that if the pain is not very specific to the bladder, it's unlikely that installations are going to help. And I try some multimodal therapy to help them, again, including some of the other treatment options that we've discussed today.
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Botox, InterStim, and PTNS for Genitourinary Syndrome of Menopause
Botox, InterStim, and PTNS are potential treatment options for patients suffering from urgency incontinence symptoms related to genitourinary syndrome of menopause. These are comparable therapies, and the choice of one over the other comes down to patient preference. Patients who do not want a catheter inserted may prefer PTNS or sacral neuromodulation, whereas patients averse to using an electrical stimulation device may prefer Botox. Two exceptions to this rule are patients who have both urgency incontinence and voiding dysfunction, and patients with severe bowel symptoms. These patients would benefit more from neuromodulation therapies, as Botox only affects the bladder.
[Dr. Jose Silva]
And in terms of Botox, InterStim, Axonics, how do you go about deciding who to try first Botox? Or just going straight into a Stage 1 or a PNE?
[Dr. Yahir Santiago-Lastra]
So for patients that have a lot of urgency incontinence symptoms, in addition to the pain, I will talk to them about Botox and InterStim as equivalent options. And I'll explain the risks and benefits of each. For some patients, the idea that they could potentially have to catheterize is completely prohibitive. So those patients will typically choose to do either PTNS or sacral neuromodulation. For patients that don't love the idea of a device, they may choose to do Botox injections, which can be quick and easy and done in the clinic. For women who don't have clear-cut overactive bladder symptoms, or who have had those really in true UTIs, even febrile UTIs, I will recommend that we do a urodynamic study beforehand. But because the data suggests that Botox and InterStim or a sacral neuromodulation, because we also have Axonics now, sacral neuromodulation and Botox are considered to be equivalent treatments, and I'll offer them both to my patients, explaining the pros and cons.
I don't think that I have yet identified a patient that would be better served by one or the other, except for two circumstances. So one would be the patient who has urgency incontinence, but also has what looks like voiding dysfunction on their urodynamics. That is not going to be a good Botox patient, that's going to be a patient that's going to do better with neuromodulation. And then the other part is the patient who also has severe bowel symptoms, fecal urgency, accidental bowel leakage, in addition to all of this pain, and that is actually pretty common. Those patients are better candidates also for sacral neuromodulation, because both of those things can be addressed by the neurostimulator, whereas Botox only directs its efficacy towards the bladder.
Urinary Diversion for Genitourinary Syndrome of Menopause
Urinary diversion is a surgical procedure that can be performed to remove the bladder and redirect urine flow if the bladder has become severely inflamed and ulcerated, and does not respond to other therapies. The surgery can be done open or robotically, depending on the comfort level of the surgeon. If a patient is highly motivated, and there is a possibility that the cystitis is caused by urine, a nephrostomy tube may be tried before the cystectomy. In this case, symptoms may also be relieved by trying an elimination diet to identify if a specific food or toxin is causing the inflammation. However, more often, inflammation is intrinsic to the bladder, and has a vascular or neurogenic cause, in which case a cystectomy with urinary diversion is the best option.
[Dr. Yahir Santiago-Lastra]
I have had patients with ulcerative interstitial cystitis and a very low bladder capacity who have had excruciating pain, who come to the turning point of whether or not to try cyclosporine. And where the conversation also turns to urinary diversion with removal of the bladder. And I think that that ulcerative interstitial cystitis, there can be a subclassification of it that may be a vascular insult to the bladder where the bladder loses some of its blood supply because these bladders can be really low capacity, a lot of pain, they look really inflamed and ulcerated. And I have had a handful of patients over the course of my career who are so terribly bothered by their bladder that they elect to undergo urinary diversion.
And when I do a urinary diversion, I typically will do it open because I wasn't trained to do robotic cystectomy. So I'll usually partner with one of my oncology colleagues who's now doing robotic cystectomies so they can offer my patients the robotic cystectomy. Because I think for patients with pain, that's a really nice way to go. And we're so selective with those patients that the ones that we have chosen for this route have actually done really well and have been really excited to get rid of their bladder.
[Dr. Jose Silva]
Do you give a trial ... I don't know if it's worth it to do a trial of nephrostomy tubes to see if it's a urine, for example, that is causing the pain. Because some patients will just continue with the same pain afterwards.
[Dr. Yahir Santiago-Lastra]
So usually the patients that have been selected for diversion are patients, again, that have pain that's really specific to the bladder. But you're absolutely right. I think if I had the option or had a motivated patient who was willing to do that trial of the nephrostomy tubes to see whether diverting the urinary stream alone helps the patients or whether they continue with the same pain. The only doubt that I have with that approach is that I don't think it's the urine specifically that causes the pain. I think it's an intrinsic inflammatory issue to the bladder. That's why I was mentioning that I think for some patients there can be something vascular involved. And if it's neurogenic, if it's a neurogenic cause, diverting the urine stream away is not going to make a difference either. What's going to make a difference is actually removing the organ itself. And so trying with nephrostomy tubes may not help that, and you may still be caught in a situation where you have nephrostomy tubes, but then you have to decide still to do another intervention.
So that's not usually been my approach, but especially for patients, for example, I can think of a patient who might have a lot of dietary triggers where the urine is actually what is irritating because of what they consume, and there may be some kind of allergen there. What I'll recommend for those patients as opposed to diverting the urinary stream with a nephrostomy tube for example, is that they try an elimination diet. So the elimination diet is a very intense diet, and I let them know that it's difficult to accomplish diet, but that we give them specific instructions for each week, eliminating a particular offending potential allergy trigger. And they eliminate those over the course of a few weeks and then start to add them back on. And then we can identify some dietary triggers there and we have identified dairy intolerances and other things in patients that have actually improved their bladder related pain as well. So that's another strategy if we think that it's the urine itself that's contributing to the problem.
Dr. Yahir Santiago-Lastra
Dr. Yahir Santiago-Lastra is an associate professor of urology and the director of the Women's Pelvic Medicine Center at UC San Diego in California.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, July 28). Ep. 12 – Management of Cystitis & Pelvic Pain Syndrome [Audio podcast]. Retrieved from https://www.backtable.com
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