BackTable / Urology / Podcast / Episode #12
Management of Cystitis & Pelvic Pain Syndrome
with Dr. Yahir Santiago-Lastra and Dr. Jose Silva
We talk with Dr. Yahir Santiago-Lastra, director of the Women's Pelvic Medicine Center at UC San Diego Health about the management of cystitis and pelvic pain syndromes. She shares her insights on genitourinary syndrome of menopause, pain evaulation and treatment, and procedural options including botox and sacral neuromodulation.
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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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.
In this episode of BackTable Urology, Dr. Jose Silva discusses cystitis and pelvic pain syndrome with Dr. Yahir Santiago-Lastra, a urogynecologist and director of the Women’s Pelvic Medicine Center at UC San Diego Health.
The initial evaluation of a pelvic pain or cystitis patient must address the patient’s detailed symptoms and pain. On the first visit, Dr. Santiago-Lastra emphasizes the importance of discussing the frequency of symptoms, past treatments sought by the patient, and qualitative descriptions of the pain. She notes that some urologists will forget to consider genitourinary syndrome of menopause (GSM) as a cause for recurrent UTIs. Then, she outlines her 5-step pelvic examination procedure: vulvovaginal examination, urethral examination, classic pelvic examination, vaginal/cervix examination, and anal examination. If she finds something abnormal during the pelvic exam, she will use a hand mirror to show patients the anatomical location of their pain.
Next, Dr. Santiago-Lastra discusses the kinds of medical treatment for patients presenting with recurrent UTIs and consistently positive urine cultures. She prefers to prescribe vaginal estrogen over long-term antibiotics, but acknowledges that some patients, such as premenopausal breast cancer patients, may refuse vaginal estrogen. In these cases, she recommends Refresh cream, methenamine, prophylactic post-coital/nightly antibiotics, and sometimes intravesical gentamicin instillation. Aside from medical treatments, Dr. Santiago-Lastra also recommends pelvic floor therapy and sometimes additional holistic treatment, as pelvic pain may originate from sexual trauma.
Dr. Santiago-Lastra then discusses different options for treating pelvic pain and cystitis. For her, opioids play an extremely limited role for pelvic and bladder pain. She typically uses injections (nerve blocks), neuromodulation, pyridium, vaginal diazepam, vaginal lidocaine, gabapentin, and vaginal/systemic cannabis to treat pelvic and bladder pain. She does not usually prescribe NSAIDS because of their adverse effects from long-term use. For patients with confirmed localized bladder pain, she notes that IC cocktail (instillations) can provide some pain relief. In the rare case that all medical options have been exhausted, urinary diversion, an open surgery that removes the bladder completely, is a possible option.
Finally, Dr. Santiago-Lastra and Dr. Silva discuss Botox and InterStim (sacral neuromodulation), two new treatments for patients who have both pelvic pain and incontinence/urgency symptoms. Although Botox and InterStim are equivalent treatments, there are certain indications for each treatment. For instance, InterStim is recommended for patients with voiding dysfunction and severe bowel symptoms because Botox only directs its efficacy to the bladder.
To conclude, Dr. Santiago-Lastra emphasizes the importance of taking time to listen to pelvic pain and cystitis patients’ concerns and desires, as they commonly become long-term patients.
[Dr. Yahir Santiago-Lastra]
So a lot of women who are referred to the office with recurrent UTIs will actually have this genitourinary syndrome of menopause or GSM. Typically when we see patients with GSM in the office or a patient comes in with those complaints, the first thing that we do is get an inventory of their symptoms and talk about what is actually bothering them. It could be that they have a lot of urinary frequency, urgency, and dysuria only when they have UTI.
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