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BackTable / Urology / Podcast / Transcript #12
Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Initial Work-Up of Genitourinary Syndrome of Menopause
(2) Clinical Treatment for Genitourinary Syndrome of Menopause
(3) Holistic Treatment for Genitourinary Syndrome of Menopause
(4) Pain Management Options for Genitourinary Syndrome of Menopause
(5) Indications for Cystoscopy and Urodynamics Studies
(6) Interstitial Cystitis Cocktails: Indications and Components
(7) Botox vs. InterStim for Genitourinary Syndrome of Menopause
(8) Urinary Diversion for Genitourinary Syndrome of Menopause
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[Dr. Jose Silva]
Hello everyone and welcome back to BackTable Urology Podcast your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Jose Oche Silva as your host this week. We have back Dr. Yahir Santiago, she’s the director of Woman's Pelvic Medicine and associated professor of urology at UC San Diego. So welcome back Yahir.
[Dr. Yahir Santiago-Lastra]
Thank you for having me again, really happy to be here.
[Dr. Jose Silva]
Good. How you been? How's work?
[Dr. Yahir Santiago-Lastra]
I've been doing well, working hard. It's getting busier. We had a little bit of an anticipated and intentional slump last year because of the pandemic. A lot of our patients are older women, which is really relevant to our discussion now and they prefer to stay home and protect themselves from COVID-19. And now we're seeing them back just catching up with some of the treatments that they had perhaps postponed during the pandemic.
[Dr. Jose Silva]
So today we're going to talk about pelvic pain, UTI, cystitis. You mentioned that those patients are not coming back, so are you seeing that those patients are worse now than usually?
[Dr. Yahir Santiago-Lastra]
By and large, what we did was we have implemented a plan for them. We have a protocol actually for current UTI patients and for patients who have genitourinary syndrome of menopause, which hopefully we'll get to talk about today.
[Dr. Jose Silva]
Okay.
[Dr. Yahir Santiago-Lastra]
So those patients, generally, if they were established with our practice are actually pretty stable. A lot of them are doing well because we have set them up with a plan in place in the event that they should get an infection, even though they could not come into the office. What we have noticed, however, are that some patients who perhaps were not established with our practice or who had not been evaluated yet, had come into our offices after waiting for quite some time to be seen by a specialist. And they have been experiencing worsening of their symptoms, perhaps to the worst point that they've been in, just because it's such a delay of care.
(1) Initial Work-Up of Genitourinary Syndrome of Menopause
[Dr. Jose Silva]
Yeah, exactly. And usually when a patient goes to your office, what's the initial evaluation? Most of these patients, like you said, they're already frustrated seeing all our physicians, they continue with pain. So what do you do when you see a new patient in the office for these symptoms?
[Dr. Yahir Santiago-Lastra]
So we will often get women who are referred to our practice for recurrent UTIs, and there can also be some other complaints locked in there, complaints about vaginal burning, irritation, pelvic pain, and even some women who come in with a "diagnosis of possible interstitial cystitis". A lot of these women will have recurrent UTIs, legitimately, culture proven, they're symptomatic. And a lot of these women will also have what we call genitourinary syndrome of menopause. And genitourinary syndrome of menopause is a new term that describes various menopausal symptoms. It can include genital symptoms like dryness and burning and irritation. It sometimes includes sexual symptoms like lack of lubrication, discomfort, pain, impaired function, but then and very importantly, it will also include urgency, dysuria and recurrent urinary tract infections.
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. Or it could be a symptom like, "Oh, doctor, I've been experiencing UTI symptoms and I'll get antibiotics. And my symptoms just don't go away." And then it turns into this complaint of a chronic UTI that just doesn't resolve. That can all be a part of this symptom complex. So we get an inventory of what those symptoms are, what's actually bothering the patient, the frequency to which this is happening and what prior treatments have been tried. Often, patients have been prescribed multiple antibiotics. They'll have been prescribed creams, they'll have been prescribed perhaps even medications to treat pain beyond what antibiotics would treat. And they don't express that necessarily these treatments have provided them any relief. But that inventory is really important because it helps set up what treatments are going to come up in the future.
[Dr. Jose Silva]
So the AUA, there's guidelines for that, and they mention the pain evaluation. And really, they don't go into detail what pain evaluation means. So what do you do in terms of pain for those patients? What do you ask? Is there any physical exam that you do at that time to evaluate that?
[Dr. Yahir Santiago-Lastra]
Yes. So the evaluation of pain or the evaluation of what the pain symptoms are requires a lot of different questions. So first off, does the patient have painful urination or painful storage of urine? That's very important. So are the pain symptoms directly related to the bladder? And getting a qualitative description of what that pain is. Is it a burning pain? Is it a dull aching pain? Is it a stabbing pain? And often it's hard to say like, "Okay, so how do you actually make sure that pain is related to the bladder itself?" One really common question that I will ask is, "When is your pain worse? Is it worse in the morning when you wake up or is it worse in the afternoon?" That's a very telling question because when patients wake up, that is usually when their bladder is the most full. And if patients describe, "You know Doctor, when I wake up in the morning, I am in excruciating pain until I empty my bladder." That is very classic for specific bladder pain.
Now, if they tell me that the pain is actually not as bad in the morning and it crescendos throughout the day and is worst in the evening, then that to me describes more of a musculoskeletal pain or pelvic pain. Remember the pelvic floor is this big bowl of muscles, connective tissues, nerves that hold up the bladder, the uterus, the vagina, the rectum, the anus. So if any of those parts are not working in perfect harmony, there can be pain, and it may be a musculoskeletal source of the pain. It's hard to tell. But I ask a lot of questions to delineate what specifically is the pain complaint that they're describing. A lot of times, women will describe more like lower abdominal discomfort, or maybe even uterine discomfort or ovarian discomfort, and there can be a lot of things at play there.
So the questions are important. And then we can go and transition to the pelvic exam. And any woman that comes into my office with a complaint of recurrent UTIs or even pelvic pain, is going to get a very thorough pelvic exam. The first part of my exam is just looking at the vulvovaginal anatomy and looking at the tissue, the coloring of tissue, atrophic vaginal tissue will have a very pale appearance. You can sometimes as you separate the Labia, see these little micro abrasions that can be extremely painful. In fact, you have to be very careful when you do this exam so that you don't stretch out the tissue too much. You can also see labial fusion. So when the labia majora and the labia minora are fused together, there can sometimes be some clitoral adhesions that can cause painful intercourse. That's also important.
So you look at all of that. You look at the vaginal vestibule because vestibulitis and loss of estrogen can be very damaging for vestibulitis as well. So I'll look at all of that in my external visual inspection of the vulva and the vagina. After that, I'll transition to a urethral examination and verifying whether in gentle tapping of the urethra and its surrounding anatomy, there can be pain. Same with the clitoris. There can be clitoral adhesions that can be excruciatingly painful for women as well. Then we proceed to the classic pelvic examination that includes palpation of the levators. Levator myalgia can be something that causes voiding dysfunction and it causes pelvic pain. And then we proceed with the vaginal examination with a speculum inspection of the cervix, cervical motion tenderness, for example, can be another source of pain. And then we also do an anal inspection and examination because hemorrhoids, fissures and other things can also present as pain in this area.
One other little pearl that I give often to my residents is if you find something, show your patient with a hand mirror, because a lot of times women will not have looked at their anatomy and they may not even know their anatomy and it's hard for them to describe exactly where the pain is coming from. But showing them, "Look, this is a labial fusion." "This is your clitoris, I'm touching here, this is where it's painful." "These are your pelvic floor muscles. I'm touching here, there's pain there." On a deeper examination, it can be hard with a speculum but very important not to forget feeling the sacrospinous ligament and the ischial spine, which is really important for childbirth, but it's also where the pudendal nerve tracks. And a lot of women who, for example, will describe pain when they sit, an urgency and frequency when they sit down may have pudendal neuralgia. So you can have a really broad differential, and your physical exam can definitely help you narrow it down.
[Dr. Jose Silva]
Yeah. So that's extremely important. I usually when my physical exam, I do evaluate for atrophic vagina. I try to palpate some points and see. But definitely it's hard a lot of times to try to convince them that it might be muscular, neuromuscular, instead of just thinking that they haven't had the right antibiotic. Most of the time they're, "I need fixing. This just been taking so long. You need to give me the right antibiotic because nothing else works." How do you convince that patient, "Hey, it's not a UTI." They have been gone maybe to PCPs that everybody tells them, they say UTI. How do you convince that patient that it's something else?
(2) Clinical Treatment for Genitourinary Syndrome of Menopause
[Dr. Yahir Santiago-Lastra]
Well, often what I'll tell them is that it can absolutely be a UTI, but that the root cause is not necessarily the bacteria in the urine. So sometimes in that first visit, especially if I come in with a patient that's frustrated. And a lot of these patients have gone to multiple people and there is a lot of frustration there. I will explain to them that, "Look, there are a lot of treatments on this pathway. I am going to work with you to find a solution that works for you. I'm not going to have an antibiotic that's going to perfectly cure this. This is going to be a journey. It's been something that's been brewing for a long time, and it is going to take us a long time to fix it. But I can assure you that we have some treatment options that are going to give you some relief."
So we come up with a comprehensive plan to give them relief. I'll give you an example. So let's say that we are dealing with a patient that has severe vulvavaginal atrophy causing culture-positive UTI, but that we suspect that really the cause of the pain is pain in the levators. So they have a lot of levator myalgia because of all the urgency that they have. So now, their comprehensive treatment plan is going to include number one, vaginal estrogen supplementation. And it can be really hard because some women will say, "Oh, I tried vaginal estrogen and it didn't work." And what happens is that sometimes they're not applying it properly because just dabbing it in the front of the vagina is not going to be effective. So it's sometimes transitioning them to a different mode of estrogen delivery, like an estrogen ring for example. And then also explaining to them that this medication has to be tried for at least six months for it to achieve a full effect.
So when I tell them that it can be a disappointing thing to say because who wants to wait six more months for a treatment option to work? What we'll typically say then is that, "Look, this is what I think is going to be the investment that's going to keep you from getting these infections in the long-term. But in the short-term, this is what we can do." And we'll order them a standing urine culture so that whenever they have these symptoms, they can submit a urine sample and we'll treat them based on the sensitivities. For some women that are reliable, I'll also give self-start antibiotics if I can trust them to submit a urine sample before. And then for the levator myalgia, I really try to partner with them with a pelvic floor therapist so that they get pelvic floor physical therapy. And sometimes pelvic floor therapy can be really difficult for these women because of the pain.
And what I'll recommend then are also some locally delivered vaginal treatments like vaginal diazepam and baclofen. We have a really good relationship with a compounding pharmacy that will also make us some estrogen supplementation vaginally, because some commercially available estrogen products like Premarin for example, or like Vagifem, are going to be made in these moieties that can have certain components like polyethylene glycol and other sort of emollients that make them slippery. That can actually be very irritating to atrophic vaginal tissue. So in the beginning it may be really hard for them to apply. So sometimes I'll partner with a compounding pharmacy who will make me these ovules in almond oil, or even even emu oil, there's one that offers it in emu oil, but those are a little better tolerated. The other way that a compounding pharmacy can be really helpful is that a lot of these treatments can be expensive. So we'll partner with them so that they can offer lower cost options to patients who maybe can't afford the vaginal estrogen that's covered by their insurance.
[Dr. Jose Silva]
So you will start them in the estrogen cream or lotion or whatever at different methods, and also vaginal suppository like diazepam?
[Dr. Yahir Santiago-Lastra]
Yeah, absolutely. Because in the beginning, to get them ramped ... So if they try an estrogen ring, then it doesn't matter. They'll do a suppository and they'll also do the estrogen ring. The estrogen ring is really great, especially for older women who you don't trust will remember to apply the estrogen twice a week. But in women who are going to start an Estrace cream or a vaginal tablet, I will tell them that for the first two weeks, they can use it every night. And then they're going to go to twice weekly administration or three times weekly administration, and then the pain delivery, so the muscle relaxant baclofen or the diazepam, etc. That's more of a PRN medication that they can use, for example, right before they're going to pelvic floor physical therapy. So that it's easier for them to tolerate the manual and digital releases and the exercises that they'll have to do with the therapist. And most women find it very useful.
[Dr. Jose Silva]
And for those patients that have the symptoms and always have a positive urine culture, do you treat the positive urine culture always? Or do you start suppression therapy until you figure it out? Or do you try to get rid of it? How that period of time until everything's settle down, do you give them antibiotics?
[Dr. Yahir Santiago-Lastra]
It's on a case-by-case basis. But as a general rule, I will try to not put patients on long-term antibiotics. Sometimes there are exceptions to everything because medicine is an art and not everybody's going to follow the pathway that you have set out for 80, 90% of patients. But some patients, for example, will refuse to try vaginal estrogen. One common group that feels very uncomfortable with it are patients that have a breast cancer history, and patients who have recently been diagnosed with breast cancer who are on anti-estrogen treatments, because we have demonstrated efficacy and safety of vaginal estrogen supplementation in post-menopausal breast cancer survivors. But there isn't a lot of data about what we do with peri-menopausal or pre-menopausal women who have breast cancer who are on anti-estrogen treatment.
So those women, I'll often partner with their oncologist to determine whether or not they would be candidates for estrogen supplementation. Some oncologists are very much on board with that for quality of life purposes, but even so some patients are very concerned about it. So those are patients that may not want to proceed with estrogen supplementation. So for those patients, we still have to change the microbiome environment of the vagina to make it less likely that they will experience UTIs. And again, remember this assumes these women have a completely normal genitourinary tract. So it completely changes if they don't empty their bladder all the way, or if they have these other anatomical issues. But we're talking about a woman who voids completely normally, has had a completely normal urologic history who all of a sudden, with loss of estrogen or with getting older, has started developing all of these urinary symptoms associated with potentially menopause.
So for those women who do not want to do vaginal estrogen supplementation, there are other things that you can try. There's RepHresh cream that helps stabilize the vaginal pH, and that can be beneficial. But often you will have women who are having UTIs who will not use estrogen. And those women, sometimes you have to think about other suppressive therapies like methenamine, D-mannose if they get e-coli infections, and also prophylactic nightly or postcoital antibiotics, although that's not my preferred route. Sometimes I'll use these for six months at a time, reassess, see how the patients are doing and then make decisions.
The other kind of end of the line option that some of these women have who really get these serious culture-proven symptomatic UTI is starting intravesical gentamicin instillation. I currently don't have any patients in my practice that are non-neurogenic that I do that for, but I do have a lot of neurogenic bladder patients that catheterize where we use that treatment approach. But I do have colleagues who will do that in women with long standing recurrent UTIs. That is something that is within our armamentarium to implement, but I would caution that that is definitely an outlier treatment.
[Dr. Jose Silva]
Yeah, I had a patient that I used gentamicin on, and really I haven't seen any much difference. The AUA also mentions stress management, do you work with a group or something to deal with stress? How do you do this in these patients?
(3) Holistic Treatment for Genitourinary Syndrome of Menopause
[Dr. Yahir Santiago-Lastra]
So I've tried to implement holistic treatments within my practice because I do think that for a lot of women, similar to how patients can have irritable bowel syndrome associated with stress, there can be some bladder related issues also associated with stress. So for example, I'll partner with pain management if the pain component is a huge issue. And through pain management service we do have pain psychology, and they do a great job at pain mitigation and stress reduction. I will also, as part of my comprehensive history, try to get an understanding of the psychosocial environment of that woman. And another thing that I think is really understated in urology and in the evaluation of these women is that a lot of these women can be survivors of sexual trauma, and that can be a big component of the pain. So if I feel comfortable with this patient, or if there is something in the history of this patient that suggests to me that she's high-risk for some of this gender violence or sexual violence, I will ask them and you'll see sometimes that the truth is very painful for them to share, but it is something that contributes to how they feel.
So for those women, I also counsel to seek beyond the treatments that I offer organically, and to also look at not just stress management strategies, but also treatments directly related to addressing the emotional and physical consequences of that trauma. And it is more common than we think. And also getting a really bad UTI is traumatizing in and of itself. So we definitely make sure that they're cared for in that sense, and we do partner a lot with psychology. I try to do it in a way that patients don't get the impression that I'm saying that things are all in their head, because these are patients that are really symptomatic and in pain. But I just emphasize to them that this is a stressful situation, that it takes a psychological toll on them to be sick and to be needing antibiotics all the time, and that they need support not just for their pelvic floor, but also for the psychology behind it and that seeking care for that can be really useful.
In addition to that, I always encourage them to try a really healthy diet and to avoid processed foods as much as possible, because I do think that the diet does play into a lot of the ailments associated with the bladder and the bowel. One way, for example, is if they're eating foods that make them chronically constipated and constipation is a huge issue when it comes to bladder and pelvic floor health, so I'll make sure that patients have a comprehensive diet plan to control their constipation. And if there is constipation on their exam, I will recommend to them to try some kind of bowel regimen. And I always tell them the bowel and the bladder are like two wings on the same bird, and you may know that from our Puerto Rican sayings, but yes, and absolutely related and is very important to address.
[Dr. Jose Silva]
So yeah, I do give my patients a list of the diets. Most of the time they don't want to give up coffee, they don't want to do a lot of stuff until they're severely in pain, and then, "Okay, now what I want to do the sacrifices." In terms of pain management, do you usually give them also NSAIDs? Some people start looking for opioids, they say, "Oh, that doesn't work. I need some tramadol percocet or whatever. What do you do in those cases? Do you send them to the pain management specialist? Do you talk to them, try to see if the diazepam [inaudible 00:25:41] works?
(4) Pain Management Options for Genitourinary Syndrome of Menopause
[Dr. Yahir Santiago-Lastra]
So I only really prescribe opioids to my post-op patients and those patients get very few opioids. I don't think that opioids have a strong role in the management of pelvic floor disorders or pelvic pain. Occasionally, I will have patients that will ask and I typically will recommend to them if they have already been on those opioids that we collaborate with a pain management specialist, but it's extremely rare that they will prescribe them as well. We typically try to find them an alternative pain management route, either through injections. A lot of these patients will also have lower back pain issues, so sometimes ganglion blocks, pudendal nerve blocks and other things can really help. There's also neuromodulation that can be really helpful, and I partner with my pain management specialist to try dual pain stimulator and sacral neuromodulation concomitantly.
So that will be another strategy. But opioids play an extremely limited role and I honestly can't remember the last time I prescribed an opioid to a patient with pelvic pain. And then with regards to NSAIDs, I typically try not to prescribe NSAIDs because I don't want to rely on a medication that when used chronically, and this is a chronic problem, that when used chronically can cause some adverse effects. So what I'll usually prescribe them or recommend to them is pyridium for flares. And I rely heavily on the vaginally directed treatments like the vaginal diazepam or the vaginal baclofen. And I have patients who are even on this mixture of vaginal lidocaine, Gabapentin. And I've had patients come to me with even vaginal ketamine, which is really interesting and I don't tend to prescribe, but some pain management specialists will use that as well.
Another new kid on the block, as far as pelvic floor treatments for pain are concerned is cannabis. In California, obviously we have had a very strong medical marijuana treatment paradigm. I don't prescribe it, but I do have a lot of patients that I send to colleagues that specialize in medical marijuana. And sometimes vaginally delivered cannabis, or even systemic cannabis will have a relaxing effect on the pelvic pain, especially for women who have dyspareunia.
(5) Indications for Cystoscopy and Urodynamics Studies
[Dr. Jose Silva]
Interesting. So Yahir, when do you do a cystoscopy or a urodynamics in these patients?
[Dr. Yahir Santiago-Lastra]
The clear indications for cystoscopy, for example, women who have all of these symptoms and also have microscopic hematuria, I will do a cystoscopy. For women that have had treatments implemented that have not been effective and have had symptomatic culture-proven UTIs or even febrile UTIs I'll consider cystoscopy. And then in women who have, in addition to the recurrent UTI symptoms, will also have voiding symptoms. So for example, if they have painful urination or they have really bothersome urgency incontinence, or they'll have an elevated residual urine volume, and that have been refractory to the first-line treatments on the overactive bladder treatment pathway, I will consider urodynamic studies on them. Because even though in my typical OAB patients without pain or UTIs, I'll consider doing a Botox injection or a trial of InterStim, for example, without a urodynamic study, if they'd seem like an index patient. For the patients who have pain or are getting infections, I typically will do a urodynamic test before, because I want to make sure that I'm not ignoring some kind of low bladder capacity or dysfunctional voiding that might do very poorly with a trial of Botox for example.
[Dr. Jose Silva]
So for patients, for example, you do a cystoscopy, you see a red spot in the bladder, multiple red spots. Do you do biopsy on them just to make sure there's nothing else? Do you just repeat the cystoscopy a couple a month? I mean, something that looks like it's not a cancer, but what do you do with those patients? Because sometimes I have done biopsy and then it just starts bleeding, it makes it worse, and they're more in pain than before. So definitely what is the next step when you see something in the bladder that looks non-malignant, but it shouldn't be there?
[Dr. Yahir Santiago-Lastra]
So if it's a patient that has had recurrent UTIs that are culture proven, and I do a cystoscopy on them, and there's this hyperemia that doesn't look specific to anything could be a sign of a local cystitis, or it could just be an inconsequential finding, it's hard to say. It could sometimes even be ulcerations, although I've seen very few Hunner's ulcers that are classic for interstitial cystitis in my career. But let's say that it's a lesion that I would consider biopsying, I'll take a culture that day. And usually the first cystoscopy I'm doing with the patient and I'm having a conversation with them, if it's suspicious enough that I think it could change our management, I will talk to them about doing a biopsy. And I also counsel them that often cystoscopies with biopsies may put patients into a flare.
So I make sure that they have the appropriate postoperative medications. In that circumstance, sometimes I will prescribe opioids, again, because it's a post-op patient. But a very small prescription for opioids, just to get them through a potential flare. I'll use opium and belladonna suppositories a lot, for example, in those immediately post-operative patients. And then what happens after that biopsy is important as well. So for example, if they state that the pain was worse after the instrumentation, and it's more urethral pain, then I might direct the treatment more towards a urethritis and make sure they have the lidocaine treatments, or even the pyridium or the vaginal treatments to help with that. If it seemed more like an interstitial cystitis pain, where we put them into a flare, I might consider bladder installations. So the heparin, lidocaine, combinations of treatments that might help soothe those patients. I have very few patients in that category, I want to be really clear. Very few patients that I find these installations indicated, or patients that get worse when they undergo a biopsy and a fulguration. But in those circumstances, I have that.
Another thing I'll mention, because actually within my practice, I see very few recurrent UTI patients. And the reason for that is that I'll do that initial evaluation and come up with a treatment plan, but I have a fabulous, collaborative team of advanced practice providers that will follow a lot of these non-surgical patients, because as a urologist, it can be very difficult to keep your practice productive if you are seeing a lot of these non-surgical patients. But they need to be seen by somebody that knows them well and can make sure to treat the UTI flares. So I have these wonderful APPs that follow these patients, and in the event that the patients need a biopsy, or they need a treatment like Botox or InterStim, then I am available and they're plugged into my practice for me to be able to offer those things. But I do make sure that the patients have good followup to make sure that estrogen is working, that there haven't been any more UTIs. And by and large, once you get them on the estrogen, on the vaginal treatments, with pelvic floor therapy within six months to a year, most of these women are going to find improvement.
(6) Interstitial Cystitis Cocktails: Indications and Components
[Dr. Jose Silva]
You mentioned the IC cocktails. The AUA mentions the second line therapy for IC, cystitis, antipsychotics, medication, other type of medication, the IC cocktails. What do you do in those cases? I mean, do you do give them antipsychotics for example?
[Dr. Yahir Santiago-Lastra]
Very rarely will I prescribe antipsychotics or antidepressants for women with pelvic pain, because usually I'll find something organic that explains what they're experiencing and they get better. So for me, and I explain this to the patient, I see as a diagnosis of exclusion, and I actually think that in the general population I see is really rare. The problem is that a lot of times, once patients get to your office, they've already been told by many providers that they have X, Y or Z diagnosis and interstitial cystitis is a big one on that list. And they're used to getting those types of medications, they're used to needing the antibiotics, and they're used to being told that they're in that bucket. And perhaps they have tried certain treatments, just not long enough to actually get a good result. So it is difficult to partner with patients.
And honestly, if a patient comes to me and they're on Elavil for example, and that has been helping with their symptoms, I will not discontinue it. I will explain to them that I don't routinely prescribe this, but they've been on a guideline directed treatment for interstitial cystitis, and I'll continue them on that. But I also encourage them to partner with me to try some of the more standard treatments for recurrent UTIs and overactive bladder. Typically that will include for the post-menopausal woman, a vaginal estrogen supplementation. It will include pelvic floor physical therapy with a pelvic floor therapist that I trust. And it'll include some kind of therapy for overactive bladder, like a medication, although I don't love anticholinergics for that purpose. But like a beta-agonist, it'll include potentially PTMS or InterStim or Botox. And then it'll, again, include a UTI protocol so that the patients are submitting samples prior to getting antibiotic treatment for their UTIs. And we don't erase the UTIs altogether, there may be one or two breakthroughs, but they don't routinely experience that back and forth of infections like they were before.
[Dr. Jose Silva]
You mentioned at some point the IC cocktails, who do you give IC cocktails? Who's the ideal patient for that?
[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.
[Dr. Jose Silva]
And in terms hydrodistention, same type of patient has to be very specific for the bladder, small capacity, more or less the same?
[Dr. Yahir Santiago-Lastra]
Yeah. So usually the initiation of the installation therapy will begin with that cystoscopy where we will also hydrodisten. So for example, if I scope a patient in the clinic and I notice some classical findings of interstitial cystitis on my office cystoscopy, which again, isn't common, I would say it's more on the rare side, but it does happen. Then those patients will talk about different options. And one of the options that I recommend for them are trying a cystoscopy with hydrodistention. If what I notice in the clinic looks more like ulcerations, I'll also talk to them about potentially injecting a steroid, like Kenalog in the ulcers when they are fulgurated.
So those patients will go to the operating room. They'll undergo either their injection of the Kenalog if they have ulcerations or a hydrodistention, if they have some of the other findings of interstitial cystitis. And then we'll start them on a series of installations once a week, for several weeks, to see if they have improvement. I prepare them for the potential possibility of flares and also the potential for developing UTIs. And some patients will not complete the series of installations, but most will.
(7) Botox vs. InterStim for Genitourinary Syndrome of Menopause
[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.
[Dr. Jose Silva]
Yeah, definitely. I mean, I think Botox the beauty of it is in the office, pretty safe, but it has to be pure urge incontinence, it can not have [inaudible 00:43:29] or nothing else. Because those patients will go into retention, then it's going to be a problem. In terms of IC, I mean, that's how far I go. I go to the Axonics or the InterStim, Botox, but the AUA mentions cyclosporine A, then urinary diversion. I mean, definitely you get referral for those, so what's your experience on those?
(8) Urinary Diversion for Genitourinary Syndrome of Menopause
[Dr. Yahir Santiago-Lastra]
When I was in fellowship, we had a lot of patients who were on cyclosporine for ulcerative interstitial cystitis. Because my practice is not tailored specifically for interstitial cystitis patients, I currently have no patients on cyclosporine in my practice. But I did train to treat those and I would be prepared to offer it for a patient with ulcerative IC, I just don't have those patients in my practice. 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. Jose Silva]
So I forgot to ask you, are you doing two stimulations for patients with IC?
[Dr. Yahir Santiago-Lastra]
Bilateral neuromodulation?
[Dr. Jose Silva]
Yeah.
[Dr. Yahir Santiago-Lastra]
Typically I do not. I usually will partner with my pain management specialists. The reason is that I take care of a underserved patient population and I struggle enough to make sure that insurances will cover the one and the costs for two are pretty prohibitive. But I do think there would be a very strong benefit to offering it bilaterally. And there has been some data that was lower level evidence, but still compelling. I believe Shlomo Raz published it several years ago suggesting that bilateral sacral neuromodulation was definitely of benefit. So I would love to be able to offer it to my patients, but unfortunately in our current healthcare landscape, it's very hard to do that in a way that's affordable to the patient.
[Dr. Jose Silva]
Yeah. So I mean, you mentioned basically that pelvic pain is not a small as we thought there's multiple things going on, multiple muscle, multiple nerves. And really, it's not as easy as just going through a recipe of trial and error and see what works. You need to definitely focus on it, treat the patient, do the physical exam, know what's going on, have the confidence of the patient. Are there any other things you want to add, any caveat, any secret tools that we might use in our practice?
[Dr. Yahir Santiago-Lastra]
I think one thing that we have in our armamentarium as urologists is that we really know our pelvic floor anatomy, and we can use that knowledge to partner with the patient. Firstly, listen to them, to what's bothering them and what they want to accomplish from working with you. And then use that and mimic that back to them and offer them treatment options that enable you to get them to where they need to be, but also treat the symptoms for which they visited your practice in the first place. So listening to the patient is going to go a long way to building a good partnership with them because this is a problem for which you will need to work together for many months, or even years before you see that light at the end of the tunnel.
[Dr. Jose Silva]
Well Yahir, thank you for being here in the podcast. I always have pleasure having you.
[Dr. Yahir Santiago-Lastra]
Thank you so much.
[Dr. Jose Silva]
I hope to see you in Vegas.
[Dr. Yahir Santiago-Lastra]
Yes, definitely. Thank you so much and have a great rest of your day.
[Dr. Jose Silva]
Take care. Bye-Bye.
[Dr. Yahir Santiago-Lastra]
Bye.
Podcast Contributors
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
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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