Bladder Pain and Bowel Issues – Oy!
Highlights on these topics from the International Pelvic Pain Society Conference in Orlando, FL, October 17-20, 2013.
The 2013 International Pelvic Pain Society (IPPS) Conference was highly anticipated and with great reason! We were impressed by the excellent clinical information for first-time and return attendees to the conference. It is exciting to see how far we have come in pelvic pain diagnosis and treatment and the direction we are heading in applying current research to clinical practice. A broad variety of diagnoses and treatment strategies were presented, and it’s hard to choose just a few to showcase. This is the latest and greatest info! The Twitter hashtag was #IPPS13
We chose to share highlights over a series of posts, as to not overwhelm you with too much incredible information at once! You will see that this info is cutting-edge.
Bladder pain and bowel issues – Most people don’t enjoy discussing this topic, but let’s face it: when you have bowel and/or bladder problems (and they tend to co-exist quite a bit), they will have a huge effect on daily function AND your mood. Right!?[fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”]
Diagnosis and Treatment of Urological Causes of CPP – Amanda Yunker, DO, MSCR (Vanderbilt Medical Center, Dept. of OB/GYN)Great review of female-associated pain: UTI, Urethritis/ Urtheral Diverticulum, Bladder-related – stones, tumors, bladder pain/IC , post-mesh pain.
- One diagnosis that can be missed – Urethral Diverticulum – localized outpouching of urethral mucosa. The best way to detect this is with an MRI (best test) specifically looking at this area (sometimes can be seen visually and correlated with symptoms but not always). Some of the symptoms and signs a patient may have are recurrent/chronic UTIs, painful intercourse, stone formations, urinary incontinence; and sometimes this can lead to urethral malignancy.
- Urinary Tract Infection: Some antibiotics have an anti-inflammatory effect. This explains what happens with those patients that are assumed to have a bladder infection, the pain is resolved while on the antibiotic, the pain returns as soon as the antibiotic is done, and the urine is negative for any infection.
- Bladder Pain Syndrom (PBS) / IC : Prevalence is 4-5%. Some symptoms – painful urination, frequency, urgency, incomplete emptying, nighttime voiding, and pelvic pain.
- There is a 3-13% risk of dyspareunia after vaginal mesh placement for pelvic organ prolapse, as well as risk for Chronic Pelvic Pain (CPP). Potential risk factors include too much tension on the graft and proximity to the nerve (also discussed by Dr. Hibner). Early detection is critical for ease of removal if suspected to be the source of pain.
- CPP/ Prostatitis prevalence is 2-10% of adult men with a peak in 40’s
- Ever heard of Retroperitoneal Fibrosis (you aren’t the only one). This is rare, but may be a cause of pelvic pain in males more than females (2:1).
- Prevalence of post-vasectomy pain is 1-15%-so much for a simple procedure and an ice pack. Pain is suspected to be due to backflow of sperm and testicular fluid into the epididymis, causing swelling and chronic congestive epididymitis and is asymptomatic in most men. Pain may be worse during ejaculation and may also be related to nerve entrapment or adverse tension. Treatment may range from NSAIDS to nerve blocks to surgery.
“A warm bath is used to treat EVERYTHING. We should tell Congress to take a warm bath” – Dr. Yunker
Contemporary Management of Pelvic Pain – (focus on the bladder), Robert Evans, MD, FACS (Associate Professor of Urology, Wake Forest School of Medicine)
“IC may be a common and major cause of chronic pelvic pain in women”Dr. Bob Evans rocked a mean bowtie and shared some of the current treatments available for patients with Interstitial Cystitis (IC)/ BPS. [/fusion_builder_column][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”]
- 79% of women with persistent pelvic pain were diagnosed with bladder dysfunction consistent with IC/ BPS
- Prevalence of CPPS is 9%- similar to heart disease and diabetes and 90-95% of CPPS patients have a negative urine culture.
- Among IC/ BPS patients, the most common previous diagnosis was UTI
- IC/ BPS and vulvodynia may have overlapping symptoms due to similar etiologies
- Treatments: Include Elmiron or less expensive OTC herbal options like Cysta Q and Prosta Q if there are financial limitations.
- Medications like Singulair and antihistamines like Hydroxyzine, Cetirizine, and Cimetidine may help IC/ BPS symptoms. Those containing pseudoephedrine (labeled –D) may cause retention and are not recommended. (Isn’t this interesting that we are now seeing Singulair and Cymbalta used for bladder or pelvic pain!?)
- Vaginal valium suppositories may also be helpful but more expensive. An alternative is placing a valium tablet vaginally. (as an aside- this is a bit controversial because some medical experts state that this does not work vaginally – )
“Beware- this may result in a ‘Smurf vagina’ due to the blue coating on the tablet. It’s harmless but good to know” Dr. Evans
- Learning self-instillations for home pain management gives patients some control over pain management for general activities as well as intimacy.
- Dr. Evans advocates for conservative measures, including physical therapy. Here was the quote of the weekend. We know it’s not all about manual therapy, but it got everyone’s attention!
“If your therapist doesn’t have a finger in your vagina by the second visit, find another therapist.”
Mechanisms Underlying Urogenital Pain Syndromes in Women, Ursula Wesselmann, MD, PhD (Professor of Anesthesiology and Neurology, University of Alabama School of Medicine)Dr. Wesselmann rocks! That is all. Actually, we will post more about her research in the future. Here are just a few highlights:
- We know that there is a huge overlap between gynecological, urological, and gastrointestinal pain in the same patient (IC, Vulvodynia, Dysmenorrhea, IBS, Endometriosis).
- We must keep a global picture in mind [/fusion_builder_column][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”][and consider the cross-talk between visceral organs, the pelvic floor muscles, and the neural system] – rather than chasing a single symptom!
- There are differences between different urogenital pain syndromes, indicating that different pathophysiological mechanisms might be involved.
“There is a more than 4-fold higher risk of panic disorder (PD) in patients with IC compared to controls. First degree relatives of patients with IC are significantly more likely to have PD and urologic problems, suggesting that there might be a familial, possibly pleiotropic syndrome that may include IC and PD.”
- She highly recommends CONSERVATIVE management first or only (not immediate surgery); and supports an individualized approach that may include: pelvic physical therapy, psychological therapy, pharmacology approach (that does not include long-term antibiotics, BCG or RTX instillations, acupuncture) and more – refer to slide presentation.
- If you have a chance to read her research, it’s quite fascinating!
Bowel Highlights:Functional Bowel Disorders: Patients often presents with a history of irritable bowel syndrome (IBS) or constipation even when bowel symptoms are not their primary complaint. We are gaining a better understanding and classification of functional bowel disorders in order to treat these patients more effectively and were fortunate enough to have 2 separate presentations on IBS and constipation at this year’s conference.
Irritable Bowel Syndrome – Maryam Kashi, M.D. (Central Florida Hepatology and Gastroenterology, Orlando, FL) –Dr. Maryam Kashi broke down the essential elements of classification, diagnosis and treatment of IBS. It is the most commonly diagnosed GI condition and affects over 13 million people, females more than males at a ratio of 2:1. Many of our patients may report IBS in their medical history, but it is important to clarify that this is an actual diagnosis rather than a self-diagnosis. If their symptoms include weight loss, nighttime symptoms, worsening symptoms, rectal bleeding or abnormal blood work, it is not IBS and should be further evaluated. Rome III Criteria definition of IBS: Recurrent abdominal pain or discomfort at least 3 days/ month in the last 3 months with at least 2 of the following:
- Relief after bowel movements
- Onset associated with change of frequency of stool, or
- Onset associated with change in form of stool.
- May have subcategories of diarrhea, constipation or mixed. Be aware that some patients experiencing diarrhea are actually constipated and are experiencing overflow around the blockage.
- Dietary changes are essential for determining triggers and managing IBS symptoms (same goes for constipation). It is not enough for patients to ‘try to eat better for a couple of days.’ Dr. Kashi recommends:
- Two (yes 2!) weeks of dairy avoidance (no cheating).
- Elimination of gas-producing foods- this includes usual suspects like beans, onions, and celery but also more surprising foods like bananas, raisins, carrots, apricots, prunes, wheat germ, pretzels, and bagels. Yes- pretzels and bagels are on this list. There goes my college diet.
- Consider gluten sensitivity if celiac tests are negative.
- And if you are still reading this list with intention to try these changes, there is also a FODMAPS diet to assist those with carbohydrate malabsorption. This is EXCELLENT information because we see patients trying to do all sorts of diets for IBS or going completely gluten-free, when they may actually respond to this specific type of plan!
- Fiber (we will talk more about this when we review constipation)
Evaluation of the Patient with Constipation, Sergio Larach, M.D. (Center for Colon and Rectal Surgery, Orlando, FL)A few constipation facts:
- Most common digestive complaint
- Affects 4 million people with female: male ratio of 3:1.
- Incidence increases greatly after age 65.
- The evaluation includes assessment of intestinal transit, evaluation of pelvic floor via manometry, invasive or non-invasive EMG, Sitz marker testing, manual exam, and defecography. You may also see a patient who has had a pelvic floor dynamic MRI, but it’s not as likely- it’s not done as often as defecography (although the pictures are pretty amazing!).
- CHECK out this video of a Dynamic Pelvic Floor MRI of a rectocele![youtube=http://www.youtube.com/watch?v=RvFr_KhSnFU&w=420&h=315]
- You may be more familiar with a diagnosis of rectocele and pelvic floor dyssynergia, but what about internal rectal prolapse, known as intussusception? Symptoms that may be reported are the sensation of incomplete emptying and the need standing and walk between evacuation attempts before emptying completely.
- Non-surgical treatment includes (you guessed it) dietary changes- 30 grams of fiber/ day, plenty of liquids and exercise are all recommended aspects of care. Different laxatives may also be indicated to improve frequency, and biofeedback is indicated for short term response and may need to be repeated annually to continue positive effects.
- Just remember: There can be one or several factors contributing to constipation. It likely requires a multi-modal approach. Is it just a rectocele issue? Is it also a tightness/spasm of the pelvic floor leading to difficulty emptying? Is it a dietary issue? Much to consider.
- Surgical interventions are dictated by the differential diagnosis and severity of symptoms.
- Future direction is looking at sacral plexus stimulation for patients with true colonic inertia. In this patient group, very few dietary changes are effective.