Bladder Pain

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

Dr. James Carter: "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."

Dr. Charles Butrick: "Glad I had the opportunity."

Dr. James Carter: "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?"

Dr. Charles Butrick: "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."

Dr. James Carter: "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."

Dr. Charles Butrick: "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."

Dr. James Carter: "What does cause it?"

Dr. Charles Butrick: "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."

Dr. James Carter: "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?"

Dr. Charles Butrick: "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."

Dr. James Carter: "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?"

Dr. Charles Butrick: "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."

Dr. James Carter: "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."

Dr. Charles Butrick: "Thank you, Jim."