Monday, June 22, 2009

Painful Bladder Syndrome

The term Painful Bladder Syndrome (PBS) has become the new “catch-all” diagnosis for women who experience pain with their bladder, and has become interchangeable and/or incorporated with the diagnosis of Interstitial Cystitis (IC). IC is a pain syndrome of the bladder that must fit a tight research definition, as is often considered in women presenting with pelvic pain or a painful bladder. PBS, on the other hand, is defined simply as the complaint of suprapubic pain during bladder filling, in addition to other symptoms of urinary urgency (day or night), when other bladders issues (such as infection) and other pelvic issues (endometriosis) have been ruled out.
PBS can be seen in teenagers as well as adults. As mentioned the main symptoms is pain during bladder filling that is relieved after voiding and can be cyclical, especially with menses. IC will often demonstrated transient relief or no relief after voiding, and is thought to be more pelvic pain in nature. PBS pain can also be experienced in the urethra or flank area (kidney), with urinary urgency, frequency or burning (dysuria).

Examination must rule out several other common problems as bladder and pelvic pain can overall with other GYN sources. Infection or irritation of the bladder with food or drink, are easy to discern with a culture and food diary. Incomplete bladder emptying can be assessed as well. Ovarian and tubal pain or pathology can be assessed on exam and/or ultrasound such as cysts, tumors or Pelvic inflammatory disease. Fibroids or painful menses are other common GYN to consider. Cystoscopy is always necessary if blood is present in the urine, and after other conditions have been eliminated from consideration.

Therapy is aimed at controlling symptoms to keep PBS “in-check”. Symptoms may wax and wane for years. Dietary manipulation to reduce acidic foods and caffeine are always helpful. Reducing urine acid content can also be done with TUMS. Relaxation of pelvic floor muscles can be achieved with stretching, yoga, warm baths, and sometime muscle relaxants. Constipation prevention helps eliminate pelvic pressure and reduce the chance for urinary tract infections.
Many medications have been tried for PBS or IC, none with smashing across the board success. Essentially, it comes down to trial and error, seeing which one works best. Some that have been used are: Elmiron, Atarax, Elavil, Tagament, overactive bladder medications, and muscle relaxants. Occasionally, instillation of medication in the bladder is effective such as lidocaine, Elmiron or DMSO. If IC is present and bladder ulcers are present, cautery of them is usually indicated.

When PBS and urinary symptoms (of urgency and frequency) are present together, InterStim bladder neuromodulation can be tried. InterStim is a bladder pacemaker-like device that can reduce the symptoms of overactive bladder (OAB) in about 75% of patients when medications for OAB fail or cannot be tolerated. There has been some secondary gain in several small trials showing reduced bladder pain with the use of InterStim when implanted for OAB.

Monday, June 1, 2009

Vaginal Mesh Erosion: Part 2

The most common and proven mesh for vaginal surgery is type I polypropylene. It is inert, soft, and has a wide weave to allow tissue ingrowth and acceptance into body tissues. All others are inferior. Many comprehensive reviews of mesh are available and have been published, including my review article in Urology in 2005. We know that mesh reinforced repairs significantly reduce recurrence rates for bladder lift surgery, but is it safe, should it be used, and what complications can occur and how can they be minimized?

Surgeon experience and patient selection are of paramount importance. A doctor who has done 10 mesh cases a year is likely not going to be as proficient as one who does 100 a year, nor as comfortable taking care of complications when they arise. This is common sense. Is the patient’s health and body appropriate for mesh placement: this answer is often easily answered with good clinical judgment based on a history and physical, but there are issues than can exist that may weigh in on a decision, such as: overall health, diabetes, prior radiation or surgeries, immune disorders, etc.

Nothwithstanding mesh properties than either enable it to be incorporated into tissue or not, surgical technique alone can lead to complications. Bladder injury, bleeding, bowel perforation, wrong suture selection are uncommon but significant surgical issues than occur even in the best of hands. That is just how statistics fall out. 99 consecutive cases may go smoothly, but the 100th will have a complication. That is the nature of surgery and human error. That is the whole reason for informed patient consent. Complications can happen to anybody and they must be addressed promptly. Patients should not be embarrassed to question the doctor or bring to light an issue, and doctors should not think themselves perfect. Honesty is the best policy, and the sooner a complication is realized, the sooner it can be addressed.

The most common place vaginally placed mesh can cause a complication is exposure in the vagina. The incision line may not heal well or promptly and mesh will be seen or felt during sex. It can give the sense of pulling or tightness, or cause infection, discharge, blood, or pain. An exam will readily make the diagnosis. Mesh exposure is not a new phenomenon and it well described. Rated can vary between 6-38%. The amount of mesh placed, how it is placed, the quality of vaginal tissue, type of suture used, dissection technique, patient activity during recovery, infection of the mesh, bleeding are all factors related to mesh exposure. Often, local excision, time and estrogen cream will fix this.

A fistula is a very rare complication of any surgery, including mesh surgery anywhere in the body, and the vagina is no different. It is so rare that it is often not clear if it’s related to the presence of mesh or an undetected injury at the time of surgery.

Pain with sex: Dyspareunia. This can occur with bladder drop and is itself an indication for surgery, but dyspareunia is a well known complication of vaginal surgery even without mesh. Overtightening the vagina will lead to pain with penetration. Pain from mesh can occur if it folds or doesn’t lay flat, is too tight or conforms the wrong way around the vagina. Many studies exist on pain or resolution of pain after vaginal surgery with slings (TVT) or bladder lifts. The overall consensus in the literature is that mesh slings improve sexual function and not worsen it. Restoring vaginal anatomy with or without mesh reduces pain with sex, yet there are studies that show a low but significant number of women who have dyspareunia after mesh repair. Some cases are mixed with other vaginal surgeries and so the true incidence is unknown. A detailed sexual history pre-operatively is important in determining the likelihood of this being a factor.

Mesh materials and patient’s bodies change over time. Most biological meshes do not last and lead to recurrence. Synthetic meshes can shrink over time after being scared in. Menopause, weight gain or loss can affect the quality of mesh repair as well.

The FDA released an alert in October 2008 to physicians and patients about potential mesh complications for transvaginal surgery. Most reconstructive surgeons were well aware of these issues and so this was nothing new necessarily, however it highlights the need for public awareness. Although excellent long term data for TVT exists (10-13 yrs), we have at best 5 year data for mesh and bladder repair. Refinement in technique, surgeon experience, product selection and patient appropriateness are all equal factors in successful management of pelvic organ prolapse.