Charles W. Butrick, MD

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       "Hi, I'm Dr. James Carter, and I'm here in Connecticut with Dr.       Charles Butrick - we call him "Chip" - from Kansas City,       Missouri. I have a special story to relate to you, Chip is here as an       expert and a teacher on the issue of problems with pain relating to the       bladder. And we certainly see a lot of patients with that pain, but I also       want to relate to you that Chip was kind enough to take care of my niece       when my niece had moved to Kansas City, Missouri. I want to thank you. I       was able to call Chip - Dr. Charles Butrick - in Kansas City, Missouri,       and asked him if he would please take care of my niece, my family member.       He did a wonderful job, and Suzanne appreciates it still to this day.       Thank you very much again for taking care of my family."
       
       

       "Glad I had the opportunity."
       
       

       "What I wanted to ask you is - bladder pain is a big issue but       frequently we don't know that it's pain from the bladder, can you tell us       what's happening with our exam and how we are approaching the history on       these patients? Why can't we tell the difference between the bladder, the       uterus, and the vagina - in terms of those pain symptoms?"
       
       

       "The whole area of bladder pain is undergone a lot of rebirth over       the last several years. In the past, we've considered it just to be a       special disease that affected very rare women that had this special       problem with their bladder called "interstitial cystitis." We       now realize it's a syndrome that's really involving many, many more women       than we really thought. The primary symptoms being urgency, frequency, and       the symptoms similar to a bladder infection but yet, the bladder tests       show no signs of an infection. The bottom line is these patients actually       are suffering from chronic pain syndromes that can involve not only the       bladder, but the vagina, the muscles of the pelvic anatomy, and also just       the reproductive tract as well. It's a chronic pain syndrome with bladder       symptomatology."
       
       

       "So the key part of that history is urgency, frequency, and pain with       urination. A patient may just call on the phone, and their doctor just       refills medicines over and over but if they fill it twice or three times       and the patient keeps recurring - that may not be an infection. They may       be just giving antibiotics but there's no infection, so they do a culture       - there's no infection. They should be concerned about some of these other       symptoms and problems."
       
       

       "Absolutely, because in the past we used to consider this problem       something that was very difficult to treat. Now that we understand really       what causes it, our treatment modalities are very effective."
       
       

       "What does cause it?"
       
       

       "Again, very significant research has shown that it is an injury to       the lining of the bladder that is probably of a neurogenic origin that       makes a person have those bladder symptoms. What I mean by that is - if       there is an initial insult of pain, whether it comes from the bladder or       from bad endometriosis, for example, or anywhere in the birth canal of the       vagina - that insult goes to the spinal column. The spinal column at times       can become dysfunctional or abnormal in such a way that it then sends       signals back down to the pelvis. If those signals are going to the       bladder, the bladder itself literally becomes very inflamed and irritated       as if it's infected but yet no infections at all - just       inflammatory."
       
       

       "Let's go through a little bit of a list - we have the urethra       syndrome, interstitial cystitis, we have a levator syndrome, and we have       problems with nerve conduction. Now each one of these has their own       treatment - so how does the clinician make a diagnosis? What would they       look for in their physical exam, and say a cystoscopy, to evaluate and to       see the difference so they know how to treat properly?"
       
       

       "I think first we have to remember if this really is a chronic pain       syndrome that these patients often times have more than just one organ       that's involved. So we have to look at the bladder, the urethra, and if       the pelvic muscles are dysfunctional - we need to take care of that. If       they have the burning irritation at the entrance to their vagina, commonly       referred to as "vestibulitis" - we need to treat that as well.       So the key that I tell my patients is that we need to turn down the volume       on each one of those sources of noise or pain that's affecting the       patient. Now for the evaluation of the bladder - cystoscopy is important       to rule out things such as bladder cancers but we also look at urodynamics,       which are tests to determine the function of the bladder, of the urethra,       and the pelvic muscles. And those are simple office procedures that gives       us a lot of ideas concerning the function of that person's bladder."
       
       

       "Let's move to a particular therapy I know that you're very excited       about that you've begun to use - it's the nerve stimulation, a new system       for actually treating these problems that become really chronic. Let's say       you've got a patient with interstitial cystitis, I know you've had a lot       of success with Elmiron for those patients, but let's say you've got a       patient whose moved beyond that, they've got this chronic pain syndrome,       there's a new stimulation device that produced - can you give some       information on that?"
       
       

       "In patients who have failed traditional therapy, they often times in       the past have just been offered drugs such as opiates or pain medication,       and often times said nothing could be done - it's a very frustrating       disease. We now know that it really has primarily a neuropathic origin,       that is, the nerves are not working properly. Then we should go directly       to the problem by placing a wire, no bigger than a fishing line, through       the lower back into one of the sacral foramen. Those are the areas where       the sacral nerves are that are providing the nerve supply to and from the       bladder, and actually through that wire we pass a very gentle electrical       current. We can turn off the pain that is coming up from the pelvis, and       actually that same stimulation will relieve the burning of the entrance to       the vagina, and the problems with the muscles that are so commonly the       cause of the inability to empty your bladder completely, and the problems       associated with pain with intercourse. So if the office technique of       placing this wire alleviates all those problems, then we remove the wire,       take the patient to the operating room, and actually surgically implant an       electrode and a small battery pack similar to a pacemaker, if someone was       going to have a pacemaker implanted. This pacemaker device, this neuro-stimulation,       goes on for years under the same control of this battery pack with about a       50% response rate with resolution of all their symptoms."
       
       

       "So these patients who have suffered for years, and years, and years,       their pain can be resolved with this device. You've mentioned the word       pacemaker, I understand the device is made by Medtronic, it's FDA approved       for this problem with the urgency symptom that goes on, and on, and on,       regardless of the medications that have been used. It is implanted just       like electronic pacemakers. This is a big breakthrough for people who are       suffering in this area. Dr. Butrick, I understand you're writing some       chapters for a book that Dr. Howard is editing on chronic pelvic pain - Care       of the Woman with Chronic Pelvic Pain.       I wish you great success with those chapters and with the book as a whole.       Those of you who are in the Kansas City area, if you have problems with       pain, please remember Dr. Charles Butrick. He's taken care of people in my       family, he can take care of people in your family. Thank you again,       Chip."
       
       

Articles

OBGYN.net Conference CoverageFrom IPPS - Simsbury Connecticut - April/May, 1999

Bladder Pain

 "I'm Dr. Jim Carter, from Mission Viejo,       California. I'm here in Connecticut at the International Pelvic Pain       Society meeting which is very actively involved in diagnosing and treating       women with chronic pelvic pain, and I'm here with Dr. Michael Brennan. Dr.       Brennan is really actively involved in helping women with this severe       problem, and I would like him to give us some information. Where were you       trained, Michael?"
       
       

 "I did       my residency at the New York Hospital, Cornell University Medical Center       in physical medicine and rehabilitation."
       
       

 "I think       I heard Sloan-Kettering mentioned once, what was your role there?"
       
       

 "Part       of our residency training was spending a great deal of time at Memorial       Sloan-Kettering Cancer Center, and while I was at Memorial Hospital, I       integrated rehabilitative services with the pain service at Memorial       Hospital."
       
       

 "We've       heard a lot about physical medicine and its relationship to women with       chronic pelvic pain - especially one of the areas is rehabilitation       trigger points, this is a word that comes up. I know you're an expert in       trigger point therapy, could you give our audience an idea of how you       approach trigger points, how you diagnose it, and how you treat it?"
       
       

 "The       principle of diagnosing trigger points really goes back to what we were       also taught in medical school which actually talks about patients, about       their pain patterns, and physically examining them. We don't have any       satisfactory imaging studies available yet to look at trigger points, so       the best way to diagnose them is by feeling them. Most individuals can       find them on themselves. They're painful nodules within muscles, and       muscles bellies, or some connective tissue but when we feel them, we'll       palpate them with a level of force and you can reproduce pain, maybe some       sensory phenomenon, perhaps even some weakness."
       
       

 "What's       your approach with patients in whom this is a problem? I find patients       with trigger points in the levator ani muscles where you can actually feel       the cord - you can identify an area of pain. But let's say in the       abdominal wall you can find these same trigger points - what is your       approach for the treatment?"
       
       

 "My       philosophy stems from a lot of work done by several different physicians       including David Simons and Janet Travell from California, Willie Nagler in       New York City, and Hans Krause in New York. It's a combination of trying       to maximize the function of a muscle, and that's where I believe the pain       comes from - a fully functioning muscle, whether it's deconditioned or       it's been injured. So I will try and strengthen the muscle that has a       trigger point in it. We will do directed therapy use at the trigger point       itself, whether it's cold therapy or heat therapy. And then there is a       role for the injection of a trigger point using any number of substances,       different authors and physicians choose to inject into the point trying to       render it less painful. That though to me is not the end all of therapy,       if you can get a trigger point to feel better, the next step is to make       the muscle stronger, more flexible, and have better endurance to try to       stop that trigger point from recurring."
       
       

 "I       completely agree. That's a very good pearl for people to take home, and       that is that you get the immediate relief that helps you diagnose the       problem but we have to treat not only the precipitating factors but those       underlying causes, whether it be problems with recurrent or repetitive       actions that take place. I find these trigger points in women who are       doing ballet and ballet training, and if they don't cut back a little bit       or do something or change some of the things they do - they'll get       recurrences if we don't strengthen the muscle and get the muscle       rehabilitated. That's why rehabilitation - the name of your specialty,       physical medicine and rehabilitation - is becoming so much more critical,       much more than just an area you had an accident and were injured, and       therefore, need rehabilitation. But something occurred even in your daily       life which has resulted in a muscle injury or fascial injury, and you need       rehabilitation from there. Now what about the people who - the       non-responders - you have to give medical therapy for their pain directly       - could you address that for us?"
       
       

 "That's       really getting into an area that becomes very controversial. There are a       variety of medications, and we'll call them "analgesics" that       can help reduce pain and ease suffering. Depending on where one trains and       what one's perspective is - medications are either underused or overused.       From my perspective, that's a perspective supported by The International       Association for the Study of Pain, The American Pain Society, and The       American Academy for Pain Medicine, we ought to think about using certain       pain killers - especially those pain killers we initially were taught to       fear in medical school - a little more clearly, not just willy-nilly give       away pain medication but take them into our equation a little sooner. The       medications I'm talking about most are narcotic or opioid analgesics. The       use of opioids has been shown in a large data pool of first cancer       patients and now in non-cancer patients, to not make people less       functional, rather they can enhance function, reduce pain, and really       improve the quality of life. That to me is what I consider, as Albert       Schweitzer said - "My greatest calling is that I can try and ease the       suffering of some individuals." These medicines are very       controversial. There are regulatory concerns that we worry about, there       are peer concerns - the family members sometimes put upon their family       members that have to take these medicines. Also, the patients themselves       have great fears. They're worried that they're going to become addicted,       they're worried that they're going to have terrible side affects, as I       like to say they will become zombies - so they have this zombie phobia.       When in reality we know that appropriate dosing improves cognition,       improves function, and really can make the rehabilitative component that       much easier. It's a lot easier to work with an individual who feels       relatively little pain then it is to try to work with somebody from my       perspective who has terrible pain."
       
       

 "So if       you had a patient who's pain level is a ten of ten, it's hard to even work       with them to find out what the underlying cause is of that pain. Then       you've reduced that, and you will use some therapy - some narcotic       therapies - to try to reduce that pain."
       
       

       "Absolutely, especially if other therapies have been brought to bear       that haven't been able to bring that pain level down. If they've been on       high doses of acetaminophen or aspirin-like medicines or even muscle       relaxers and their pain remains fairly high, the next step, in my       equation, is to think about using medications such as opioids and       analgesics."
       
       

 "Could       you describe your protocol for us for these patients? How you give it
       a Marsh/March highly titrate levels?"
       
       

 "The       World Health Organization (WHO) has provided a wonderful model that we can       use but every clinician can follow, we call the "analgesic       ladder." Basically, the ladder has three rungs. The first rung is       that one approaching a patient who has pain - assuming you have the right       diagnosis - you would start the patient on an anti-inflammatory liquor       with acetaminophen. If that can not take the patient out of pain you would       then go to a moderate strength opioid. Typical drugs in that category       would include hydrocodone, which is commonly available in Vicodin and       Lortab and a number of other formulations. Codeine is another moderate       strength opioid. If getting up to relatively frequent dosing and high main       line doses of those medicines you still can't effect relief, the next step       would be to go to what is referred to as more potent opioids or strong       opioids, and those include medications such as oxycodone, morphine, and       hydromorphone. So my clinical practice on a day-to-day basis starts really       following that ladder. I am often a tertiary of a referral, individuals       have seen their family care physician and their gynecologist and have not       been able to get adequate relief on mild strength pain medicines. So I'm       very aggressive in getting right into some more potent opioids, and right       now I think that the use of oxycodone is probably the opioid that I use       most frequently for a variety of reasons. Most importantly - it's well       tolerated, it has wonderful side effect profile when you compare it       especially to morphine, and it doesn't have any problematic metabolites       that develop after it's been taken."
       
       

 "So you       look at this as a safe way and as a tertiary individual, the person has       been to their primary care, they've been to their gynecologist, they've       been taken to trigger points they attempted a number of therapies, they're       still rating their pain at a ten of ten. These are people for whom this       WHO-type layer is appropriate, and neither the patients nor the physicians       should really fear this because this person needs help, this person needs       the help of someone like you. I strongly encourage individuals who are       suffering like this to discuss this WHO layer approach with their       physician and to have them make available someone with your resources and       capability. Now you mentioned something about - all these medications       doesn't effect their cognition. Could you describe that a little bit for       us? You mean it doesn't really hurt their thinking?"
       
       

       "Correct. One of the things that's very interesting and it's been       studied both in cancer and in non-cancer patients is that if you give a       pain medicine to a person who's not in pain, they can become sleepy,       lethargic, euphoric, or get the high for lack of a better word. However,       when you take an individual who has pain and give them pain medicines, and       it's appropriately dosed, the incidence of euphoria is very small,       especially after they've been on the medicine for two or three days. We       can talk about incredible doses of morphine up to two or three grams every       six hours and people will not become euphoric, in fact, pain patients       might complain that they don't feel euphoric - they feel dysphoric. They       don't like the feeling necessarily but they recognize that they have to       take it. There's also been several clinical and at least one recently       published, very adequately performed, study looking at the psychomotor       function. If I took a Percocet or a narcotic right now, I would become       sleepy. I would have difficulty writing my name a hundred times and doing       a crossword puzzle because I don't have pain. When we adequately treat       patients, these studies have shown that at appropriate dosing levels not       only do they not get sleepy but their psychomotor function - they're       ability to think and do things - actually is enhanced."
       
       

 "As       physicians we've known patients who had cancer, for instance, males with       prostrate cancers, women with breast cancer - metastatic to all. I know       that these people have such incredible pain that they can't think, they       can't sleep, and they can't function. And what you're pointing out is that       when people have chronic pain that's at that level - that the provision of       these medications to reduce their pain level helps them to think, helps       them to sleep, helps them to function better. So it has the opposite       effect of what is perceived as what this medicine is going to do. They       don't become sleepy, in fact, they become alert because they're able to       sleep and they weren't able to sleep before."
       
       

 "Thank       you very much for coming to Connecticut for this program. You're going to       be speaking here on this very issue of pain management in the chronic pain       patient who hasn't responded to the therapies that we've provided and who       is in need of further therapy. Thank you very much doctor."
       
       

OBGYN.net Conference CoverageFrom International Pelvic Pain SocietySimsbury Connecticut - April/May, 1999

Pain Management

:        “Hi, this is Jim Carter, and I’m here at the AAGL meeting with 

       own Director of their Urogynecology section and one of my favorite       doctors, Dr. Richard Scotti from the Bronx in New York.        Dr. Scotti and I participated in a debate about laparoscopic versus       vaginal surgery for stress incontinence, for pelvic floor dysfunction, and       pelvic floor support problems.  Dr. Scotti again showed us how we should really be doing our       work and I really appreciate it.  I       want to thank you for the absolutely wonderful job you did.  What I want to do right now is introduce my friend to you and       have him tell you what you should look for in a doctor like him who can       help you with your problems with incontinence and support.”              

:        “I think the first thing you want to do is find a doctor who       listens a lot, understands your problems, and also understands that you       have other problems besides pelvic floor support.        For example, someone may be referred to me for urinary incontinence       and I find out in the course of talking and listening that this is not her       major problem, and I’d like to address all of her problems.        So I think finding a doctor who listens and who understands that       you have other problems besides that and then sort of helps you prioritize       what you really want to work on first is, I believe, one of the first       steps in finding a doctor that’s suitable for you.”                            

:        “I recall seeing a statistic, Dr. Scotti, it takes a patient only       thirty-five seconds to tell a doctor their problem but it only takes a       doctor fifteen seconds to interrupt her.        If you are looking for a physician in New York, look for one that       listens and Dr. Scotti is one who listens.        I want you to tell us about what the patient should expect to be       told and also what kind of an evaluation she should expect because       sometimes they come in and they don’t understand that they need a       machine to do a test, for instance.  Can       you tell us a little about what she should expect for a work-up for       incontinence?”              

:        “Urinary incontinence is a multi-foliate, multi-variable kind of       problem and sometimes just listening to symptoms is not enough to arrive       at a diagnosis so often you need other tools to triage and tease out the       various symptoms.  There are       only a few symptoms like frequency, urgency, painful voiding, and       incontinence and these four symptoms are shared by many diagnoses.        So many diagnoses share a common pool of symptoms and, therefore,       you need some instrumentation like urodynamic testing and cystoscopy, etc.       to really arrive at a diagnosis and from that point, of course, formulate       a rational treatment plan.”              

:        “So it’s important for the patient to understand that just       answering the questions may give the doctor the diagnosis but there may be       some further tests like urodynamics that are needed, and you do those       tests in your office.  These are not hospital tests; these are tests you do in your       office.  Before a person is       taken to surgery they really need a proper diagnosis.        Now Dr. Scotti, you do both vaginal approaches and laparoscopic       approaches, would you tell us a little bit about some of your approaches       to this treatment of this problem?”              

:        “Sometime people come with a particular idea; they want it       laparoscopically or they want it done all from below.        The first thing is to let them understand that there are many ways       to skin a cat, and we can probably do it by one approach or another or       perhaps a combined approach of more than one approach.        I think informed consent involves the patient understanding what       the risks and benefits of a procedure are and what the success rate might       be.  There’s a scale that       only they can measure, and I think the choice is up to them.        We’re not talking about emergency surgery, this is elective       surgery that affects someone’s quality of life and, therefore, they have       to make the decision.  Of course, we have to give them the proper information to       make an informed choice.”              

:        “That is so important, Dr. Scotti, the informed consent.        The patient needs to know how this is going to be done, what can be       done, and you brought up yesterday in our debate this issue of intrinsic       sphincter deficiency.  Now       that’s a mouthful but intrinsic sphincter is a weak muscle in the       urethra or weak support in the urethra and you talked about a procedure as       a way of curing that with a transvaginal tape.        You called it the ‘TVT procedure’ that you’re doing.        Can you describe a little bit about that because that sounded so       exciting.”              

:        “Sure, Dr. Carter, this is a new procedure that is minimally       invasive and can actually be done under local anesthesia in about twenty       minutes just for stress incontinence, this is not for other types of       incontinence.  Basically,       it’s a piece of synthetic tape that’s put under the urethra.        My finger represents the urethra and the rest of my hand represents       the bladder, the tape - the other finger - actually supports the urethra.  It’s this way, and small punctures sites are made in the       abdominal wall.  I don’t       know if you can get down about here, and it takes about thirty minutes.”              

:        “So for a patient with loss of urine from coughing and sneezing,       you place this tape in under local anesthesia, they go home that day, and       they usually can void immediately.  In       fact, the success rate on this has been 85%-90%; it’s been very, very       good in terms of skilled operator’s hands.        If you are interested and have problems with incontinence, contact       Dr. Scotti or contact through 

       the doctors who are involved in incontinence surgery.        Check this out, this transvaginal tape procedure which was invented       by a doctor in Sweden has been performed in over 100,000 cases and many,       many cases, over 25,000, in the United States now has really been a       benefit to people.  It has       been produced by one of our major companies, Ethicon U.S.A., and we’re       so excited to have this available.  Thank       you for explaining all of this to us.”              

:        “Thank you very much, Dr. Carter.”                            

:        “We appreciate it.  It’s       my pleasure, thank you.”

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsOrlando, Florida, November 2000

Charles W. Butrick, MD

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