Treatment of Bladder Pain Syndrome
Bladder pain syndrome (BPS) was addressed in the last EAUN Meeting but little is known in clinical practice. The staff at The Centre of Voiding Dysfunction, Århus University Hospital (DK) set out to share their experience with Danish as well as European colleagues since this treatment modality is rather underestimated.
With this article the staff aims to call on attention to one alternative treatment option for BPS : The EMDA treatment. In EMDA treatment (Electromotive Drug Administration) lidocaine, adrenaline and Solu-Medrol are installed into the bladder and led into the bladder tissue through low voltage. The treatment will provide alleviation of the symptoms and perhaps even a significant reduction of bladder pains and thus a great improvement in the quality of life.
The aim with the treatment is to reduce:
1. The micturation frequency
2. The urge – the pressure on the bladder
3. Nocturnal micturation
Since 2007, 37 patients have been referred to EMDA treatment. Of these only four were men. The common experience ”in the first meeting with the patients” is that they are frustrated and have lost confidence and hope. In contrast, the possibility for treatment or reduced symptoms often represents a new hope for them.
Currently, there are nine patients in total who are treated regularly with EMDA treatment. Of these seven are women, which is in accordance with the fact that the condition is between five and ten times more frequent with women as with men. The age range between 29-80 years.
Patients referred to EMDA treatment are in need of highly specialised care and they usually reside in the western part of Denmark, which represents a population of approximately two million people. They have often had turbulent courses of clinical investigation; many had undergone all sorts of antibiotic treatment – and failed treatment attempts before they are referred to our department for evaluation and second opinion. Some patients had even been referred to psychologists to address the intractable pains.
In previous evaluations the urine has been tested with a dipstick test and urine culture several times. However, these patients need a more advanced assessment. At our centre, the patients are offered cystoscopy under anaesthesia. Additionally, the evaluation includes filling of the bladder and a biopsy of the detrusor muscle.
In some cases, mast cells are found in the biopsy indicating interstitial cystitis. In 10% of the cases, mucosal ulcers are found. This is called Hunner’s ulcer. These ulcers coagulate and some patients will experience a substantial alleviation of their symptoms during the filling phase (mostly pain) when the bladder is expanded and the urine gets in contact with the “ulcer” in the mucosa. Some will experience an improvement of their symptoms from bladder extension and in case of acceptable outcomes the procedure will be performed under anesthesia every 6 months. However, this treatment involves a risk of bladder rupture. Alternatively, it is also possible to try immunosuppressive treatment as a supplement to EMDA treatment. The final solution for these patients is a urostomy, although seldom.
Before starting the EMDA treatment, a urine culture is required and is usually done by a GP. Furthermore, the patients must have functional bladder capacities of a minimum of 250 ml in order to be able to contain the drugs as well as the urine produced during the treatment. Therefore, the patients are advised not to drink more than two glasses of water before treatment and avoid any diuretic medication before treatment. The procedure will last approximately two hours, and they will be confined to their beds. Patients may need painkillers in the form of tablets Pamol, Burana, Tradolan or sup. MAP (morphine, atropine, papaverin) before, during the procedure or after treatment. All women who have passed their menopause, will be treated with Vagifem.
Currently the standard procedure includes three treatments within a four week’s interval. The initialisation phase will be followed up by a consultation with an urologist approximately four weeks after the third treatment, where an individual consultation and a care plan will be discussed. However, in case of no side-effects or immediate improvement of the symptoms, EMDA treatment will continue without interruptions every fourth week under consultation with the urologist.
The majority of the patients, who will benefit from the EMDA treatment, will experience a relative “modest” reduction of the symptoms after the first rounds of treatment and the effects will usually appear gradually.
If the patient experiences continuous improvement the treatment interval will gradually be expanded beginning with a 3-4 days longer interval. The nurse will adjust expectations and side-effects with the patient. Patient reported outcome differs significantly and currently there is no clear recommendation on how quickly we can advance the treatment. Many patients fear that the bladder pains will return, when the intervals are expanded and therefore mutual expectations must be discussed before the interval will be expanded.
In patients treated according to standard procedure efficacy is usally seen after four to nine weeks. However, it is our experience that a few of the patients will experience an effect up to more than 12 to 26 weeks. In case of deterioration of symptoms, the interval may be reduced to four weeks again; the patient and the nurse will discuss the possibility to adjust the treatment in cooperation with the urologist. In absence of efficacy some patients quit the treatment fairly soon after initialization due to pain related to the catheter.
The treatment is performed by means of using “an electrical instrument“ that will lead low voltage into the bladder. The voltage will press the medication into the bladder tissue during treatment as opposed to GAG treatments where the drugs will only float in the bladder. The instrument is made in Italy and was originally bought to locally anaesthetise the bladder in connections with cystoscopy examinations in the OR.
The drugs are instilled through a special catheter (Ch. 16) which has a current-carrying coil installed. At the other end of the catheter, an electrode is attached which will be connected to the EMDA instrument.
Two flat electrode pads are placed on the skin over the bladder with a two-centimetre distance between them. The pads have been moistened with NaCl and coated with a thick layer of isolating electrode gel with the intention to avoid skin complications. Every pad has an electrode which will be attached to the EMDA instrument.
The treatment itself falls into two parts. The first part lasts 20 minutes and here the bladder is anaesthetised with 150 ml lidocaine 2% and 1.5 ml adrenalin 1%. Then the urine and the medication are drained from the bladder, and the bladder is now sedated. The second part represents the EMDA treatment itself, where lidocaine and adrenaline are instilled mixed with 500 mg Solu-Medrol. The mixture will stay in the bladder and the dwelling time is approximately 25 minutes. Solu-Medrol works locally in the bladder, less than 10% will go into the blood stream.
Catheter and pads are removed and the “contaminated” skin is cleaned with water. The skin may be slightly reddened but this will usually disappear on its own. Following the treatment the patients will often feel urgency and will have more frequent micturition.
The general impression (qualitative statements from the patients) is that the patients who have received regular EMDA treatment in our department report a much better quality of life and new energy on daily basis. Unfortunately, they are not completely symptom-free between treatments and mostly still cope with painkillers.
Apart from the clinical markers it is a positive professional experience that EMDA treatment provides a relative difference and can improve the quality of life to a selected group of patients. Clinical studies investigating health related quality of life and clinical outcome will add to the body of evidence of this under-reported group of patients.
Bente Thoft Jensen,
Urology Department / Centre of Voiding Dysfunction
Århus University Hospital
The Staff of Departmen of Urology, Centre of Voiding Dysfunction,
Århus University Hospital