APP

Cystoscopic Hydrodistention

• Short lived therapy.
• Techniques variable: AUA recommends done under anesthesia

with low pressures ranging from 60-80 cm H2O for < 10 min.
• Treat Hunner’s Lesions.

• Types of fulguration: resection, laser, or ablation cystoscopically.
• Another option is steroid (triamcinolone) injection into lesion.

• Possible opportunity for bladder biopsy.

www.AUAnet.org/guidelines

Fourth-Line Therapy

Neuromodulation

• Neuromodulation may help pain, frequency,
voided volumes, and improve quality of life.

• Limited studies and long term outcomes, but
potential benefit for urinary symptoms and pain.

• Invasive and expensive, but reversible.
Wang et al. Sci Rep 2017

278

OnabotulinumtoxinA (Botox)

• May be helpful for patients
with IC/BPS, but long term
data lacking.

• Risk of retention and
recurrent urinary tract
infections.

Trigger Point Injections/Nerve Blocks

• Trigger point injections into • Pudendal nerve blocks:
pelvic floor.
• Independent or in conjunction
• 3 sets of injections 6-8 weeks with trigger point injections.
apart.
• Transvaginally or transgluteally
• Bupivacaine, ropivacaine, with or without a steroid.
lidocaine, and triamcinolone
may be used. • May be helpful in diagnosis and
management of patients with
• Botox may also be used in pudendal neuralgia.
pelvic floor muscles.

• Injections are an adjunct to
physical therapy.

Han et al. Therap Adv Urol 2018

Fifth-Line Therapy

279

Immunotherapy Agents

• Cyclosporine A (CyA)
• Inhibits calcineurin thereby suppressing T-cell activation and thought

to decrease bladder inflammation.
• Studies show improvement in quality of life, decreased pain and

increased bladder capacity.
• Hunner’s lesion IC may be more receptive to this therapy.
• Dosing 2-3mg/kg per day. Typically 100mg twice daily for 1 month

then daily. Follow blood pressure, renal function and check for CyA
levels 2 hours after dosing to minimize toxicity and improve safety.

Marcu et al. Sem Reprod Med 2018

Sixth-Line Therapy

Hyperbaric Oxygen

• Chronic radiation cystitis and/or hemorrhagic cystitis
• Pilot study showing potential better response in patients with

Hunner’s lesions.
• Save for refractory IC/BPS patients.

Wenzler et al. Ther Adv Urol 2017

280

Surgical Reconstruction/Urinary Diversion

• Bladder Augmentation
• Supratrigonal Cystectomy with bladder augmentation
• Urinary Diversion with or without cystectomy

• Patients with fixed low bladder capacity and fibrosis with or
without Hunner’s lesions.

• Last line of therapy!
• Pain may persist…

Clinical Principles in AUA Guidelines

Quillun et al. Urol Clin N Am 2012

Keys to Treatment Nurse Navigator

A Multidisciplinary Team Approach

Urologist

Physical Therapist Psychologist/Sexual Therapist

Gynecologist Urogynecologist Colorectal Surgery

Gastroenterologist Primary Care
Physician/ Integrative Medicine

Pain Clinic

281

Malde et al. BJU Int 2018

Key Points

• IC/BPS remains one of the most • www.ichelp.org
challenging conditions for providers, • www.painful-bladder.org
but be empathetic to patient. • www.ic-network.com
• www.nva.org
• Focus on the phenotypes of • www.auanet.org
symptoms to develop treatment plans.

• Rule out Hunner’s lesions in refractory
cases.

• Create a coordinated team approach
pathway to managing IC/BPS patients
and develop protocols to help the
clinic and the patient coordinate the
numerous referrals and providers
involved in their care.

282

Notes

The American Urogynecologic Society (AUGS) has developed the followin
highest quality patient care in Female Pelvic Medicine and Reconstructive
by the AUGS Guidelines and Statements Committee. This information is i
and is not intended to substitute for the treating physician's clinical judgm
upon his or her independent judgment and the patient's individual clinica

PUBLISHED CLINCIAL GUIDANCE DOCUMENTS

Best Practice and Consensus Statement

• Consensus Statement on the Use of Cystoscopy in Prolapse Surge
• Best Practice Statement on the Evaluation and Treatment of Recu
• Best Practice Statement: Evaluation and Counseling of Patients w
• Consensus Statement: Association of Anticholinergic Medication

Position Statements

• Mesh Midurethral Slings (MUS) for Stress Urinary Incontinence (J
o FAQ document by Providers on Mesh Midurethral Slings
o FAQ document by Patients on Mesh Midurethral Slings fo

• Laparoscopic Uterine Power Morcellation in Hysterectomy and M
• Power Morcellation Considerations for Physicians during the Info
• Restriction of Surgical Options for Pelvic Floor Disorders (March 2
• Urodynamic Testing before Stress Incontinence Surgery (June 201

1100 Wayne Avenue, Suite 825
Silver Spring, MD 20910

301-273-0570 ▪ Fax 301-273-0778
[email protected] ▪ www.augs.org

ng guidelines, committee opinions, and statements to promote the
e Surgery (FPMRS). The development of these documents is coordinated
intended to provide patients and physicians with general information,
ment. The treating physician should make all treatment decisions based
al presentation.

ery (January 2018)
urrent Urinary Tract Infections in Women (January 2018)
with Pelvic Organ Prolapse (September 2017)
Use and Cognition in Women with Overactive Bladder (July2017)

June 2016)
for Stress Urinary Incontinence (March 2014)
or Stress Urinary Incontinence (March 2014)
Myomectomy (July 2014)
ormed Consent Process (July 2014)
2013)
12)

283

Committee Opinions and Practice Bulletins

The following committee opinions and practice bulletins have been deve
Gynecologists (ACOG).

• Asymptomatic Microscopic Hematuria in Women (Committee Op
• Management of Mesh Complications in Gynecologic Surgery (Com
• Pelvic Organ Prolapse (Practice Bulletin, April 2017)
• Urinary Incontinence in Women (Practice Bulletin, November 201
• Robotic Surgery in Gynecology (Committee Opinion, March 2015
• OnabotulinumtoxinA and the Bladder (Committee Opinion, June
• Evaluation of Uncomplicated Stress Urinary Incontinence in Wom

Privileging Guidelines

• Guidelines for Privileging and Credentialing Physicians for Sacroc
• Guidelines for Providing Privileges and Credentials to Physicians f

Prolapse (July 2012)

FPMRS Recommendations via the Choosing Wisely® Cam

• FPMRS recommendations via the Choosing Wisely® Campaign, an
(ABIM)

CLINICAL GUIDANCE DOCUMENTS IN DEVELOPMENT

• Best Practice Statement on the Evaluation and Imaging for Defec
• Best Practice Statement on Managing Mesh Complications
• Best Practice Statement on Post-Operative Voiding Dysfunction
• Midurethral Sling Privileging Document

Last updated: August 1, 2018

eloped jointly with the American Congress of Obstetricians and
pinion, April 2017)
mmittee Opinion, April 2017)
15)
5)
2014)
men Before Surgical Treatment (Committee Opinion, June 2014)

colpopexy for Pelvic Organ Prolapse (March 2013)
for Transvaginal Placement of Surgical Mesh for Pelvic Organ

mpaign

n initiative of the American Board of Internal Medicine Foundation

catory Dysfunction

284