Genitourinary Syndrome of Menopause: Procedural & Surgical Management

[Dr. Yahir Santiago-Lastra]
The ideal patient for an installation is a patient that describes pain that is very specific to the bladder. So pain that is absolutely at its worst when the bladder is full. A patient that brings in a bladder diary, and you can see that the patient has a very low bladder capacity. A patient who doesn't describe pain in other areas as well. So the pain that's really specific to the urinary bladder. They may also be patients that upon cystoscopy, the bladder tissue looks friable, you see glomerulations. And also, is a patient that you give a test installation to who states that that first installation provided some relief. So those patients I'll talk about putting on a several weeks course, six or 12 weeks course of installations once a week. And we have highly motivated patients that do well with installations that actually learn how to administer those installations at home.

So those are the ideal candidates. Sometimes we also have patients, unfortunately, for whom none of the other treatments have worked, and we're going down that American Urological Association List of Guidelines, and we'll try them on installations. But I've found that if the pain is not very specific to the bladder, it's unlikely that installations are going to help. And I try some multimodal therapy to help them, again, including some of the other treatment options that we've discussed today.

[Dr. Yahir Santiago-Lastra]
I have had patients with ulcerative interstitial cystitis and a very low bladder capacity who have had excruciating pain, who come to the turning point of whether or not to try cyclosporine. And where the conversation also turns to urinary diversion with removal of the bladder. And I think that that ulcerative interstitial cystitis, there can be a subclassification of it that may be a vascular insult to the bladder where the bladder loses some of its blood supply because these bladders can be really low capacity, a lot of pain, they look really inflamed and ulcerated. And I have had a handful of patients over the course of my career who are so terribly bothered by their bladder that they elect to undergo urinary diversion.

And when I do a urinary diversion, I typically will do it open because I wasn't trained to do robotic cystectomy. So I'll usually partner with one of my oncology colleagues who's now doing robotic cystectomies so they can offer my patients the robotic cystectomy. Because I think for patients with pain, that's a really nice way to go. And we're so selective with those patients that the ones that we have chosen for this route have actually done really well and have been really excited to get rid of their bladder.

[Dr. Jose Silva]
Do you give a trial ... I don't know if it's worth it to do a trial of nephrostomy tubes to see if it's a urine, for example, that is causing the pain. Because some patients will just continue with the same pain afterwards.

[Dr. Yahir Santiago-Lastra]
So usually the patients that have been selected for diversion are patients, again, that have pain that's really specific to the bladder. But you're absolutely right. I think if I had the option or had a motivated patient who was willing to do that trial of the nephrostomy tubes to see whether diverting the urinary stream alone helps the patients or whether they continue with the same pain. The only doubt that I have with that approach is that I don't think it's the urine specifically that causes the pain. I think it's an intrinsic inflammatory issue to the bladder. That's why I was mentioning that I think for some patients there can be something vascular involved. And if it's neurogenic, if it's a neurogenic cause, diverting the urine stream away is not going to make a difference either. What's going to make a difference is actually removing the organ itself. And so trying with nephrostomy tubes may not help that, and you may still be caught in a situation where you have nephrostomy tubes, but then you have to decide still to do another intervention.

So that's not usually been my approach, but especially for patients, for example, I can think of a patient who might have a lot of dietary triggers where the urine is actually what is irritating because of what they consume, and there may be some kind of allergen there. What I'll recommend for those patients as opposed to diverting the urinary stream with a nephrostomy tube for example, is that they try an elimination diet. So the elimination diet is a very intense diet, and I let them know that it's difficult to accomplish diet, but that we give them specific instructions for each week, eliminating a particular offending potential allergy trigger. And they eliminate those over the course of a few weeks and then start to add them back on. And then we can identify some dietary triggers there and we have identified dairy intolerances and other things in patients that have actually improved their bladder related pain as well. So that's another strategy if we think that it's the urine itself that's contributing to the problem.