IC Flashcards
Make sure you send your urine for both UA AND culture
Dont forget to say it explicitly.
What percentage of IC patients will have a hunner’s lesion?
5-10%
Does the presence of hunner’s lesions increase the risk of bladder cancer?
No
Your LUTS patient has atypical urine cytology.
What’s your DDx?
-chronic UTIs
-stones
-malignancy
-IC
-recent instrumentation
-intravesical medications
Describe staging of bladder cancer.
Ta- exophytic/papillary
Tis- carcinoma in situ- flat
T1- submucosa
T2- detrusor invasion
T3- perivesical fat
T4- adjacent organs
How deep of a bladder biopsy do you do?
Take mucosa and muscularis.
What is your treatment algorithm for IC?
Stepwise approach:
- diet, stress relief, PFPT, analgesics
- Medications: Oral or intravesical
- Procedure- onabotulinumA injections, cystoscopy with hydrodistention, SNM
- end stage- refer to urology to consider cystectomy or diversion
Amitriptyline
Dose:
MOA:
Efficacy:
Side Effects
Dose: 10 mg at bedtime, up to 75mg at bedtime
MOA: SNRI
Efficacy: 64-90%
Side Effects: sedation, anti-cholinergic effects, weight gain, ortho hypotension, cardiac abnormalities
Cimetidine
Dose:
MOA:
Efficacy:
Side Effects:
Dose: 200-400mg BID
MOA: H2 blocker
Efficacy: ~50% (all oral meds besides amitriptyline- 64-90% and pentosan polysulfate-10%)
Side Effects: minimal
Pentosan polysufate sodium
Dose:
MOA:
Efficacy:
Side Effects:
Dose: 100-300mg PO TID for 3-6 months
MOA: low molecular weight heparinoid which replaces the GAG layer deficiency in the epithelium
Efficacy: ~10%,
SE: Macular (stars at 3 years) , alopecia, increased bleeding, liver dysfunction
Only FDA approved
Phenazopyridine
Side Effects
Liver and renal toxicty
NOT meant for use for more than 2 days use
Effects of lidocaine toxicity
perioral numbness
dizziness
seizure,
tingling
ringing ears
hypotension
Describe your basic evaluation for IC?
H+P
PVR
UA, UCx
Bladder diary
Describe the steps of cysto hydro.
- Anesthesia
- raise the IV to 60-80 cm above the pubic symphysis
- instill sterile water gradually using bladder capacity is reached.
- observe for 5 min max
- empty the bladder and measure the volume.
- cysto again, fulguration or inject hunner’s lesion
during your cysto hydro, the bladder ruptures.
What next?
Assess:
-size, > or < 2 cm
-location,
-intraperitoneal vs extraperitoneal
-was electrocautery involved
How much triamcinolone do you inject in a Hunner’s lesion?
10cc in 0.5 aliquots
Your IC patient fails both fulguration and triamcinolone injection of Hunner’s lesion.
What else can you try?
Oral cyclosporine A
Cyclosporine A
Dose:
MOA:
Efficacy:
Side Effects
Dose: 3 mg/ kg/day divided into two doses for 3 months
MOA: immunosuppressive agent that inhibits the transcription of the cytokine IL2
Efficacy: 80-90% significant improvement in pain
SE: HTN, increased serum creatinine, gingival hyperplasia, facial hair growth
What is the efficacy of PFPT for IC?
59% showed improvement
Hydroxyzine
Dose:
MOA:
Efficacy:
Side Effects:
Dose: Anti-histamine
MOA: 10-50mg daily
Efficacy: ~50%
Side Effects: sedation, weakness
MOA of methenamine
hydrolyzes to formaldehyde and ammonia in acidic urine, which is baceriocidal
Dimethyl Sulfoxide
Dose:
MOA:
Efficacy:
Side Effects:
Dose: 50cc of 50% DMSO, hold for 15-20 minutes
MOA: replace the GAG layer
Efficacy: 93%
Side Effects: garlic taste or smell from the patient. lasting several hours; PAIN
What are the effects of sodium bicarb in a BI?
reduces acidity and increased penetration of lidocaine
Discuss the theories of IC etiologies.
- Epithelial alterations in the urothelium
- Neurogenic inflammation caused by mast cell activation.
- Infectious causes
- Centralized pain processing
- Altered brain structure and function
Indications of UDS
SUI
recurrent incontinence after surgery,
neurogenic dz,
wants surgery, but negative CST,
rule out obstructive voiding
Unclear dx
need to assess compliance, obstruction,
Indications for video UDS
-retention
-neurogenic dysfunction
-recurrent SUI after one or more procedures
-concern for poor compliance-radiation, dialysis
how do you dx bladder outlet obstruction on UDS?
max flow <12 ml/s with
Pdet at max flow >20 cm H2O
List some treatment options for pelvic floor dysfunction.
Behavioral
-stress management/behavioral therapy
-PFPT
Intravaginal
-Vaginal diazepam
-trigger point injections-buvipicane & triamcinolone or BOTOX (not FDA approved)
-topical anesthetics, accupuncture
-SNM for urinary symptoms
efficacy of PFPT on Myofascial pelvic pain
59% improvement
Botox
max dose
how long to wait in between injections in different parts of the body?
400u per 12 weeks
10 days between rounds
What’s the best imaging modality for stones?
non-contrast CT (95% sensitivity and specificity)
with contrast, you can miss small stones (3mm or less)
ultrasound for pregnant patients
Which stones are no seen on KUB?
non-calcium
uric acid stones
how long does direct treatment of hunner’s lesions last?
6-12 months
Describe the maintenance for pentosan polysulfate.
-ophtho history before you start
-baseline retinal exam if any ophtho hx
-retinal exam q 6months
your patient on pentosan polysulfate is having macular changes and wants to stop elmiron.
for how long after stopping the medication can macular changes progress?
13-30 months
MOA of pyridium
unknown, but it is a local analgesic
efficacy of heparin for IC?
50% and up
efficacy of DMSO for IC?
60% and up
DO NOT HOLD IN BLADDER FOR 15-20min –PAIN
