Irritative Voiding Symptoms and Bladder Dysfunction in the Setting of Intravesical and Systemic Therapies during Cancer Treatment and Survivorship

In Brief Objectives To evaluate the efficacy of Le Fort colpocleisis on bladder, bowel function, and quality of life (QOL) in elderly women with advanced genital prolapse. Methods Women with severe genital prolapse who were unable to satisfactorily wear a vaginal pessary underwent a Le Fort colpocleisis with concomitant anti-incontinence procedure, if required. During 2-week, 6-week, and 6-month postoperative visits, patients were examined and questioned about irritative voiding symptoms (voids > 10/day, nocturia > 2/night, urgency), incontinence, constipation, and overall well-being. Quality-of-life impact was evaluated with an instrument for pelvic prolapse, which was sent to all patients at least 12 weeks after operation. Follow-up by telephone was attempted to encourage completion of the questionnaire. Results Forty-five women underwent a Le Fort colpocleisis and high perineoplasty. Thirty-one (69%) also had a tension-free vaginal tape procedure. Mean age was 83 ± 5.2 years. Ninety-three percent (42/45) of the women had failed previous pessary use. One patient (2%) had recurrence of her prolapse. There were no significant differences in preoperative and postoperative incidence of irritative voiding and constipation symptoms. Eighty-two percent (37/45) of the QOL questionnaires were returned for analysis. The possible range of total score on the questionnaire is 15 to 75. Mean QOL score for the population was 24.8 ± 8.6. Patients with postoperative irritative voiding symptoms, constipation, or SUI symptoms had a mean score of 25.8 ± 9.1, and patients without these symptoms had a mean score of 21.4 ± 6.0 (P = 0.19). Conclusions Le Fort colpocleisis is a feasible treatment option for severe vaginal prolapse in the elderly patient. Low QOL impact scores after operation, despite irritative bladder symptoms and constipation, demonstrate the beneficial outcome of colpocleisis in elderly women who have advanced genital prolapse and are not sexually active. The evaluation of the efficacy of Le Fort colpocleisis on the bladder, bowel function and quality of life in elderly women with advanced genital prolapse.

Complications of Intravesical Therapy for Urothelial Cancer of the Bladder

Background: Irritative voiding symptoms are common in elderly men and following prostate radiotherapy. There is limited clinical data on the impact of hypofractionated treatment on irritative voiding symptoms. This study sought to evaluate urgency, frequency, and nocturia following stereotactic body radiation therapy (SBRT) for prostate cancer.Methods: Patients treated with SBRT monotherapy for localized prostate cancer from August 2007 to July 2011 at Georgetown University Hospital were included in this study. Treatment was delivered using the CyberKnife® with doses of 35–36.25 Gy in five fractions. Patient-reported urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) before treatment and at 1, 3, 6, 9, and 12 months post-treatment and every 6 months thereafter.Results: Two hundred four patients at a median age of 69 years received SBRT with a median follow-up of 4.8 years. Prior to treatment, 50.0% of patients reported moderate to severe lower urinary tract symptoms (LUTS) and 17.7% felt that urinary frequency was a moderate to big problem. The mean prostate volume was 39 cc and 8% had prior procedures for benign prostatic hyperplasia. A mean baseline IPSS-irritative (IPSS-I) score of 4.8 significantly increased to 6.5 at 1 month (p < 0.0001), however returned to baseline at 3 months (p = 0.73). The IPSS-I score returned to baseline in 91% of patients by 6 months and 96% of patients by 2 years. Transient increases in irritative voiding symptoms were common at 1 year. The mean baseline IPSS-I score decreased to 4.4 at 24 months (p = 0.03) and 3.7 at 36 months (p < 0.0001). In men with moderate to severe LUTS (IPSS ≥ 8) at baseline, the mean IPSS-I decreased from a baseline score of 6.8–4.9 at 3 years post-SBRT. This decrease was both statistically (p < 0.0001) and clinically significant (minimally important difference = 1.45). Only 14.6% of patients felt that urinary frequency was a moderate to big problem at 3 years post-SBRT (p = 0.23).Conclusion: Treatment of prostate cancer with SBRT resulted in an acute increase in irritative urinary symptoms that peaked within the first month post-treatment. Irritative voiding symptoms returned to baseline in the majority of patients by 3 months post-SBRT and were actually improved from baseline at 3 years post-SBRT.

Microscopic hematuria as a predictive factor for detecting bladder cancer at cystoscopy in women with irritative voiding symptoms

The bladder is a hollow organ that can be treated locally by transurethral catheter for intravesical drug instillation or cystoscopy for intravesical drug injection. With advancing technology, local organ-specific therapy and drug delivery is of expanding interest for treating dysfunctional bladder, including interstitial cystitis/bladder pain syndrome, overactive bladder and sterile hemorrhagic cystitis after chemotherapy or pelvic radiation. Intravesical therapy has shown varying degrees of efficacy and safety in treating interstitial cystitis/bladder pain syndrome, overactive bladder and hemorrhagic cystitis with new modalities being developed. Intravesical (regional) therapy has several advantages than oral (systemic) therapy, including high local concentration and less systemic toxicity. In recent years, intravesical delivery of biotechnological products including neurotoxins and immunosuppressive agents, and delivery platform including liposomes has shown promise for lower urinary tract symptoms. This review considers the current status of intravesical therapy in dysfunctional bladder including interstitial cystitis/bladder pain syndrome, overactive bladder and hemorrhagic cystitis with special attention to lipid based novel drug-delivery.

In Brief Objective: The aim of this study was to evaluate the role of cystourethroscopy (CUS) in patients with irritative voiding symptoms after pelvic surgery. Methods: The records of all women with urinary complaints who underwent urogynecologic evaluation and office CUS at our institution during an 18-month period were retrospectively reviewed. Results: Two hundred sixty-eight women underwent office CUS for urinary complaints. Sixty-seven (25%) patients had irritative voiding symptoms after pelvic surgery. The mean age was 64 ± 12 years. Previous surgical procedures included 35 (52%) abdominal hysterectomies, 5 (8%) vaginal hysterectomies, 1 (2%) hysteropexy, 9 (13%) suburethral slings, 10 (15%) anterior colporrhaphies, 2 (3%) retropubic suspensions, and 15 (22%) “unspecified incontinence procedures.” CUS diagnosed 49 (73%) patients with atrophic urethritis, 9 (13%) patients with interstitial cystitis, 5 (8%) patients with both findings of atrophic urethritis and interstitial cystitis, and 2 (3%) patients with intravesical sutures. Both of the patients with sutures had undergone previous reconstructive pelvic surgery. The rate of lower urinary tract injury (LUTI) was 3% (95% confidence interval, 0.2–7). Conclusions: In women with irritative voiding symptoms after pelvic surgery, the rate of undetected LUTI is low, whereas the rate of interstitial cystitis is high. In patients with a history of reconstructive surgery and irritative voiding symptoms, the use of CUS may be warranted. In women with irritative voiding symptoms after pelvic surgery, the presence of intravesical sutures is low, whereas the rate of interstitial cystitis is high.

OBJECTIVE: The objective of this study was to assess microscopic hematuria as a risk factor for detecting bladder cancer at cystoscopy in women with irritative voiding symptoms presenting for urodynamics at a tertiary care urogynecology practice. METHODS: We conducted a retrospective cohort analysis of all women with irritative voiding symptoms who presented for urodynamic testing and cystoscopy at our institution from January 2001 to March 2004. Irritative voiding symptoms were defined as urgency, urge incontinence, frequency, dysuria, and/or nocturia. Patient demographics, risk factors for bladder cancer, presence of microscopic hematuria, urodynamic findings, and cystoscopy results were recorded. Cytology and biopsy results were collected when a lesion was detected at cystoscopy. Statistical analyses consisted of univariate statistics, Student t test, chi square, Fisher exact test, and multivariate logistic regression when appropriate. RESULTS: Of 735 patients with irritative voiding symptoms, 264 (35.9%) women with microscopic hematuria defined our cases and the remaining 471 (64.1%) without hematuria represented our control group. These 2 groups were similar in age, race, parity, tobacco use, and family history of bladder cancer. Bladder cancer was detected in 3 women for an overall detection rate of 0.4%. Microscopic hematuria, urgency, urge incontinence, frequency, dysuria, nocturia, age, and tobacco use were analyzed using both univariate analysis and multivariate logistic regression. None of these independent variables was significantly associated with bladder cancer. In fact, microscopic hematuria was absent in 2 of the 3 cases of bladder cancer. To analyze cost, we accounted for the 735 cystoscopies and 31 additional cystoscopies with biopsy needed to detect the 3 cases of cancer. We estimated costs based on Medicare global reimbursements of $195 per cystoscopy and $602 per cystoscopy with biopsy, which resulted in an average cost of $220 per patient for diagnosis. Given our bladder cancer rate of 0.4% (one case per 250 patients), the overall cost to detect a single case of bladder cancer was $55,000. CONCLUSION: In this cohort of women with irritative voiding symptoms, no risk factors for bladder cancer were identified. The cases of bladder cancer were only detected by direct visualization at cystoscopy with follow-up biopsy at a cost of $55,000 per cancer case.

MAINTENANCE BACILLUS CALMETTE-GUERIN IMMUNOTHERAPY FOR RECURRENT TA, T1 AND CARCINOMA IN SITU TRANSITIONAL CELL CARCINOMA OF THE BLADDER: A RANDOMIZED SOUTHWEST ONCOLOGY GROUP STUDY

Quality of life is a major concern of patients when they are choosing treatment for prostate cancer. Health-related quality of life is a patient-centered variable from the field of health services research that can be measured in a valid and reliable manner. Using standardized questionnaires specifically developed to capture health-related quality of life data in men with prostate cancer, the effect of treatments on patients' quality of life can be studied. Patients with localized disease who are undergoing radical prostatectomy tend to have more sexual and urinary dysfunction than men undergoing external beam radiation therapy, although both groups have more impairment in these areas than age-matched controls. Men undergoing external beam radiation therapy have worse bowel function and more urinary distress from irritative voiding symptoms than men undergoing radical prostatectomy or age-matched controls. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo radical prostatectomy, but experience considerably more irritating voiding symptoms, which often profoundly affect their quality of life. Better information regarding the potential impact of prostate cancer treatment on quality of life will improve medical decision-making.

22 - Complications of Intravesical Therapy

Treatment of chronic pelvic pain (CPP), interstitial cystitis (IC), prostatodynia, and irritative voiding symptoms can be frustrating for both patients and physicians. The usual approaches do not always produce the desired results. We found that when we treated myofascial trigger points (TrP) in pelvic floor muscles as well as the gluteus, piriform, infraspinatus, and supraspinatus muscles, symptoms improved or resolved. Various palpation techniques were used to isolate active myofascial TrPs in these muscles of four patients with severe CPP, IC, and irritative voiding symptoms. Injection and stretch techniques for these muscles were performed. Visual twitch responses at the skin surface and in the muscles were used to verify successful needle piercing of a TrP. The patients were asked to verbally describe exactly where the flash of distant pain was felt, a process that permitted an accurate recording of the precise pattern of pain referred by that TrP. The findings involved with the four patients substantiate the need for myofascial evaluation prior to considering more invasive treatments for IC, CPP, and irritative voiding symptoms. Referred pain and motor activity to the pelvic floor muscles (sphincters), as well as to the pelvic organs, can be the sole cause of IC, CPP, and irritative voiding dysfunction and certainly needs further investigation.

Value of Urinary Cytology in Women Presenting With Urge Incontinence and/or Irritative Voiding Symptoms

Voiding disorders are common in urological patients. Pelvic floor dysfunction may result from overtraining pelvic floor muscles in an attempt to prevent leaking. This can further cause bladder dysfunction or weakening the pelvic floor muscles. Pelvic floor dysfunction or insufficient relaxation of the pelvic floor results in hesitancy, intermittency, and high postvoid residuals (PVR). Behavioral changes and biofeedback play a key role in urologic problems including pelvic pain, irritative voiding symptoms, recurrent urinary tract infections, and incontinence. Biofeedback involves using electrodes to transduce muscle potentials into auditory or visual signals; patients learn to increase or decrease voluntary muscle activity. Conservative behavioral and biofeedback treatments are safe and effective interventions that should be more readily available to patients as a first-line treatment for voiding dysfunction. Patient education may take time but has higher long-term success and makes the patient more responsible and less passive regarding their condition.

Sexual dysfunction in women with cancer

Intravesical therapy for bladder cancer