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No. 051. Prolonged Controlled Pressure Bladder Distension for Management of Interstitial Cystitis - A technique described. Nicholas Campbell, Daniel Steiner, Richard Millard Department of Urology, Prince of Wales Hospital, Sydney, NSW. Introduction

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No. 051

Prolonged Controlled Pressure Bladder Distension for Management of Interstitial Cystitis - A technique described

Nicholas Campbell, Daniel Steiner, Richard Millard

Department of Urology, Prince of Wales Hospital, Sydney, NSW

  • Introduction
  • Interstitial cystitis (IC) or painful bladder syndrome can be an extremely debilitating condition. It seldom responds to behavioral and oral therapy. Intravesical therapy, including bladder hydrodistension has been described for the management of IC since 19221. Hydro distension has been used commonly for short periods of up to 8 minutes with mixed results. Refractory IC is defined as being unresponsive to simple short hydrodistension and oral or intravesical agents
  • Helmstein’s bladder distension was first described in 19662 where it was used for treatment of carcinoma of bladder. Hydrostatic pressure results in necrosis of the tumour. We have reported a unique technique in the treatment of IC.
  • Results
  • All patients had been diagnosed with IC with a mean duration of 10.5 years
  • A total of 57 hydro distensions have been carried out in eight patients
  • The major symptoms they were referred to the Prince of Wales Urology department were for urinary frequency and suprapubic pain
  • The diagnosis was biopsy proven in 37.5%
  • The global response assessment for prolonged hydro distension in regards to the symptoms that the patient’s presented with demonstrated markedly improved symptoms in all but two patient who had moderate improvement
  • The improvement in symptoms lasted for between 3 and 18 months with the average being 12 months. The symptoms continued to improve following hydro distension even after multiple distensions
  • One patient had 23 distensions and still achieves excellent symptomatic relief. Another patient only gained 4 months of improved symptoms
  • Following treatment the majority of patients suffered irritative voiding symptoms (dysuria, frequency) for on average two days and then their symptoms improved
  • Symptoms improved:
    • Frequency – 100%
    • Suprapubic pain – 100%
  • It had no effect on stream, urgency or post void dribbling
  • Complications
    • 1 intraperitoneal bladder rupture (managed conservatively with insertion of indwelling catheter for 7 days)
    • 1 incomplete spinal anaesthetic – patient in pain post operatively requiring patient controlled analgesia
  • Aim
  • Describe the technique of prolonged bladder hydrodistension
  • Review the outcomes from prolonged bladder distension for refractory interstitial cystitis including complications
  • Methods - technique
  • A combined spinal and epidural anaesthetic was performed. This created excellent analgesia for the 4 hour hydrodistension. A cystoscopy excluded other pathological processes. The bladder capacity was measured. The bladder was then distended for 5 minutes at a pressure of 70cmH2O. On emptying the mucosa was inspected for glomerulations and Hunner’s ulcers. The ulcers if present were then diathermied with a bugbee.
  • The modified 3 way IDC was created by securing a latex condom over then end as per figure 2 using a 1.0 silk suture. The silk was tied just proximal to the catheter’s filled 20ml balloon. This position was imperative to ensure the distended condom did not dilate the bladder neck or urethra.
  • The input channel of the IDC was then connected to a 1L bag of normal saline within a pressure bag. The output channel acts as a safety valve should the pressure rise above 70cmH2O.
  • Bladder distension was performed in recovery for 4 hours. After catheter removal bladder capacity, flow rate and post void residual volume were measured to ensure adequate bladder emptying. All cases were performed as day surgery unless for social reasons the patient was admitted overnight.
  • Questionnaire: A retrospective review of 14 patients on the prolonged bladder distension program was taken. The review looked at the reasons for requiring prolonged hydrodistension and the outcomes following the procedure..
  • All of the patients questioned had refractory IC symptoms despite behavioral, oral and intravesical theatre. All patients were telephoned and the questionnaire conducted. 5 patients were unable to be contacted.

Figure 1: Diagram of hydrodistension apparatus

Condom over end of 3 way IDC

3 way IDC balloon

(20ml water)

Silk suture

Figure 2: Photo of condom on indwelling catheter held in place with silk tie

  • References
  • Antonsen HK, Lose G, Hojensgard JC, The Helmstein bladder distension treatment for tumours and severe bleeding, Internaltional urology and nephrology 18(4) 421 – 427,1986
  • 2. Clemens JQ, et al, Validation of a modified National Institutes of Health chronic prostatitis symptom index to assess genitourinary pain in both men and women, Urologic Pelvic Pain Collaborative Research Network, Int J Urol. 2009 Dec;16(12):947-52.
  • 3. Aihara K et al, Hydrodistension under local anesthesia for patients with suspected painful bladder syndrome/interstitial cystitis: safety, diagnostic potential and therapeutic efficacy, Urology. 2008 Jan;71(1):62-6.
  • 4. Wein AJ, et al, Campbell-Walsh Urology, Saunders Elsevier, 2007.
  • 5. Hunner, A Rare Type of Bladder Ulcer in Women, Bost. Med J of Surg, 1915, 17;660-664
  • Quentin Clemens J, et al, Interstitial cystitis and painful bladder syndrome, Chapter 4, Urologic Diseases in America, kidney.niddk.nih.gov/statistics/uda
  • Conclusions
  • Prolonged controlled pressure bladder distension is a well tolerated procedure with excellent improvement in patient symptoms from IC. It has been used reliably in 8 patients on a regular basis who have been refractory to all other forms of treatment. For some patients this has avoided a cystectomy.
  • It is a safe, reproducible and inexpensive procedure which has proved useful in the long-term management of this patient group

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Acknowledgements

Nil to declare.