Management of Cystitis & Pelvic Pain Syndrome

In this episode of BackTable Urology, Dr. Jose Silva discusses cystitis and pelvic pain syndrome with Dr. Yahir Santiago-Lastra, a urogynecologist and director of the Women’s Pelvic Medicine Center at UC San Diego Health.

The initial evaluation of a pelvic pain or cystitis patient must address the patient’s detailed symptoms and pain. On the first visit, Dr. Santiago-Lastra emphasizes the importance of discussing the frequency of symptoms, past treatments sought by the patient, and qualitative descriptions of the pain. She notes that some urologists will forget to consider genitourinary syndrome of menopause (GSM) as a cause for recurrent UTIs. Then, she outlines her 5-step pelvic examination procedure: vulvovaginal examination, urethral examination, classic pelvic examination, vaginal/cervix examination, and anal examination. If she finds something abnormal during the pelvic exam, she will use a hand mirror to show patients the anatomical location of their pain.

Next, Dr. Santiago-Lastra discusses the kinds of medical treatment for patients presenting with recurrent UTIs and consistently positive urine cultures. She prefers to prescribe vaginal estrogen over long-term antibiotics, but acknowledges that some patients, such as premenopausal breast cancer patients, may refuse vaginal estrogen. In these cases, she recommends Refresh cream, methenamine, prophylactic post-coital/nightly antibiotics, and sometimes intravesical gentamicin instillation. Aside from medical treatments, Dr. Santiago-Lastra also recommends pelvic floor therapy and sometimes additional holistic treatment, as pelvic pain may originate from sexual trauma.

Dr. Santiago-Lastra then discusses different options for treating pelvic pain and cystitis. For her, opioids play an extremely limited role for pelvic and bladder pain. She typically uses injections (nerve blocks), neuromodulation, pyridium, vaginal diazepam, vaginal lidocaine, gabapentin, and vaginal/systemic cannabis to treat pelvic and bladder pain. She does not usually prescribe NSAIDS because of their adverse effects from long-term use. For patients with confirmed localized bladder pain, she notes that IC cocktail (instillations) can provide some pain relief. In the rare case that all medical options have been exhausted, urinary diversion, an open surgery that removes the bladder completely, is a possible option.

Finally, Dr. Santiago-Lastra and Dr. Silva discuss Botox and InterStim (sacral neuromodulation), two new treatments for patients who have both pelvic pain and incontinence/urgency symptoms. Although Botox and InterStim are equivalent treatments, there are certain indications for each treatment. For instance, InterStim is recommended for patients with voiding dysfunction and severe bowel symptoms because Botox only directs its efficacy to the bladder.

To conclude, Dr. Santiago-Lastra emphasizes the importance of taking time to listen to pelvic pain and cystitis patients’ concerns and desires, as they commonly become long-term patients.