Urology - Infection/Inflammation: Highlights From Plenary Session II

Main Category: Urology / Nephrology
Article Date: 20 Jun 2008 - 3:00 PDT

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ORLANDO, FL (UroToday.com) - Several interesting presentations on pain, infection, and inflammation highlighted the plenary session, led by a state of the art lecture by Dr. Philippe Zimmern on his approach to pelvic pain syndrome in women. He discussed the current controversy regarding the proper name of the syndrome, and pointed to the fact that pain is now considered the key symptom of interstitial cystitis/bladder pain syndrome (BPS/IC). The name and definition of the disorder are areas that the NIDDK and AUA Practice Guidelines Committee will address in the coming year, hopefully in harmonization with other international organizations.

Practically speaking, Dr. Zimmern stressed the importance of a good history, taking into account whether the pain seems to be coming from the bladder, its type, intensity, location, duration, evolution, impact on quality of life, and status of bowel and sexual function. Questionnaires like the O'Leary Sant, University of Wisconsin, and pain-urgency-frequency (PUF) can be useful for following the course of the disease. He noted that the relation of pain to the bladder cycle of filling and emptying is an important clue for the clinician. If pain is not related to the bladder cycle, be suspicious of a diagnosis of BPS/IC. A thorough physical examination looking for trigger points is also important. Unfortunately we have no biomarkers at the present time that can be used by the clinician. The place of hydrodistention, bladder biopsy, potassium sensitivity testing have all been called into question, and a good history and physical examination with urinalysis and culture forms the backbone of the evaluation. Any evidence of hematuria needs to be pursued as per the AUA guidelines for that condition.

The overall question is whether the symptoms are urological, non-urological, or both. Dr. Zimmern emphasized that one should be careful of not making an incorrect diagnosis of BPS/IC, as that can have devastating effects for the patient. He discussed confusable disorders including trigonitis, urethral obstruction, urethral diverticuli, infected Skene's gland, urethritis, and stricture. If BPS/IC is diagnosed, one should have a low threshold for involving a pain clinic in the patient's care. But he emphasized always conducting your own thorough evaluation and not depending on outside opinions and previous physicians when seeing a pelvic pain patient for the first time.

When patients with BPS/IC have failed all standard therapies, he recommended referral to a center specialized in the care of these patients. He discussed options of oral therapy, intravesical therapy, experimental protocols, neuromodulation, and surgery as a last resort.

Dr. Anthony Schaeffer gave a superb state of the art lecture on "How we should manage complicated urinary tract infections in the debilitated patient: the role of antibiotics, biofilm therapy, stents". He began by noting that we have good evidence but no guidelines, and must individualize therapy. He specifically discussed patients with cancer, immunosuppression, diabetes, chronic renal failure, neurological conditions like multiple sclerosis and Parkinsons disease, and the elderly, all of whom should be viewed as at risk for complex urinary infection. Debilitating factors can coexist and can increase the frequency and severity of urinary tract infection. Certainly any functional or structural abnormality of the urinary tract or instrumentation increases the risk of infection.

The incidence of bacterial colonization in patients with a urinary catheter is 7% per day. Colonization is not synonymous with infection, and one should be careful not to over-treat. Past antimicrobial exposure, institutionalization (virulence, antibiotic resistance, cross-contamination), and renal impairment (dehydration, reduced antimicrobial concentration) can all lead to complicated urinary infection. Dr. Schaeffer discussed how antibiotic resistance develops and the major problem that has become. He went on to the subject of biofilms that can form on catheter surfaces, protecting bacteria from the effects of antibiotics. One should not attempt to treat a biofilm, but rather try to get the indwelling catheter out as soon as is feasible. He mentioned work by Scott Hultgren, who has identified intracellular bacterial communities surrounded by a biofilm that may be instrumental in the pathophysiology of recurrent urinary infection in some patients.

Irritative voiding symptoms, fever, and even malaise, mental status changes, and anorexia may be symptoms of a urinary tract infection in the debilitated patient. Urinalysis should be viewed in relation to the specific case, and culture and sensitivity provide critical data. Imaging of the upper tract is useful for following the course of infection and identifying obstruction, stones, and abscess.

With regard to management, Dr. Schaeffer noted that one should not treat colonization or contamination. Initial empiric therapy should be based on local data on common organisms and sensitivities in your area. One attempts to maximize the status of the urinary tract by relieving obstruction and trying to remove catheters and all foreign bodies. Once culture reports are available, it is recommended to reconsider the antibiotic and treat with a narrow spectrum drug if possible, adjust the dose as indicated, and stop therapy as soon as possible. As a rule of thumb, Dr. Schaeffer recommended a 7 day course of treatment for a complicated lower tract infection, and 14 day course for patients with pyelonephritis. He concluded that complicated urinary infections should be suspected in high risk patients and/or settings. Aggressive evaluation, antimicrobial therapy and intervention to eliminate or minimize abnormalities are mandatory. Careful follow-up to reduce risk and recurrence is essential for long-term success.

Late breaking news was presented concerning ongoing NIDDK clinical trials. Dr. J. Curtis Nickel shared the results of alfuzosin treatment of recently diagnosed and/or newly symptomatic alpha-blocker naïve patients with chronic prostatitis/chronic pelvic pain syndrome. An NIH randomized multicenter double-blind placebo controlled trial compared 12 weeks of treatment in 138 patients on alfuzosin with 134 patients on placebo. All patients were newly diagnosed within 2 years and alpha blocker naïve. The primary endpoint was a 4 point decrease in the NIH chronic prostatitis symptom index. The withdrawal rate was 14.3%, and there were no significant adverse events related to therapy. Results showed no efficacy of drug over placebo, with a 49% response in each group. A secondary endpoint was global response assessment. Placebo response was 34% and alfuzosin response was 35% with no statistical significance.

Dr. Kenneth Peters presented results of a randomized multicenter pilot trial of manual physical therapies in the treatment of chronic pelvic pain. In this single blind study, physical therapists randomized treatment between manual physical therapy versus global therapeutic or "western" massage. Forty-seven randomized patients participated in this pilot trial, all with a history of chronic pelvic pain of 3 years or less duration with tenderness in trigger points on pelvic floor examination. They received one of these two therapies weekly for 10 weeks. A 7 point, balanced global response assessment was the primary endpoint. Patient moderately or markedly improved (6 or 7) were considered a success. There were 23 men with chronic pelvic pain syndrome / nonbacterial prostatitis. There were 24 women with interstitial cystitis. Ninety-four per cent completed the study. Overall, 57% responded to physical therapy and 21% responded to global therapeutic massage, a statistically significant difference, even in this small pilot trial. No females responded to massage, but surprisingly, 45% of males responded to massage. Further expansion of this trial is planned through NIDDK trials group.

Presented by at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Philip M. Hanno, MD, MPH

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