SCOTTSDALE, ARIZ. — Many women diagnosed with gynecologic disorders actually have a bladder condition that causes frequency, urgency, and lower pelvic pain, Dr. C. Lowell Parsons told physicians at the annual meeting of the Central Association of Obstetricians and Gynecologists.
Dr. Parsons, a professor of urology and surgery at the University of California, San Diego, said the underlying etiology is a condition he calls lower urinary dysfunctional epithelium, or LUDE. The term refers to a compromised mucous barrier that fails to protect the bladder wall from irritants such as potassium in urine.
Recurrent urinary tract infections, dyspareunia, endometriosis, vaginitis, and vulvodynia as well as interstitial cystitis are among the conditions that present with symptoms of LUDE, according to Dr. Parsons.
Dr. Parsons treats new interstitial cystitis patients with a solution containing heparin or pentosan polysulfate sodium (Elmiron) and lidocaine. “If it takes away the symptoms, you know what the cause is,” he said.
His work contributed to the development of Elmiron, which the U.S. Food and Drug Administration approved in 1996 for relief of bladder pain or discomfort associated with interstitial cystitis. He disclosed that he has received research support and serves as a lecturer for Ortho-McNeil Inc.
He recommended the following intravesical therapeutic solution for patients with LUDE symptoms: 40,000 units of heparin or 100 mg of pentosan polysulfate sodium, 8 mL of 2% lidocaine, and 4 mL of sodium bicarbonate (8.4%). The bladder should be empty when the solution is used, he said.
In a trial reported earlier this year, 33 (94%) of 35 interstitial cystitis patients treated with a variation of the solution containing 2% lidocaine had 50% or greater symptom improvement. In another group of 47 patients given a variation of the solution with 1% lidocaine, 35 (74%) experienced relief of symptoms (Urology 2005;65:45–8).
Younger women may be able to go off heparin or Elmiron therapy after 3–6 months, according to Dr. Parsons. However, older patients have to stay on treatment indefinitely.
Interstitial cystitis starts early in life, Dr. Parsons said, but is not noticed until the symptoms become severe. “It begins in 15− and 16-year-old females with frequency—frequency they don't pay attention to,” he said, describing the disorder as a continuum.
“I think [potassium sensitivity] is the initiating event,” he said. “You don't have pelvic floor reaction until the patient is in her 30s and has had the disease for more than 10 years.”
“Pain from the bladder can refer anywhere from the navel to the interior thighs, front or back. You can't trust where the pain is. It can be anyplace,” he said, suggesting that some conditions actually are symptoms of LUDE. “It is all about how the lower urinary tract handles potassium,” he said, adding, “If you have a healthy, intact membrane, you won't react to potassium. If you do react, you have a problem.”
Dr. Parsons cited a study based on a potassium sensitivity test he developed for interstitial cystitis. He and his colleagues found 197 (81%) of 244 patients with pelvic pain were sensitive to potassium. He said the highest rates of positive response were 100% of patients with interstitial cystitis, 89% of patients with dyspareunia, and 86% of patients with endometriosis. Not one of 47 patients in a healthy control group was sensitive to potassium (Am. J. Obstet. Gynecol. 2002;187:1395–400).
In other studies cited by Dr. Parsons, patient responses on a Pelvic Pain and Urgency/Frequency questionnaire were predictive of potassium sensitivity in gynecologic patients. He said he no longer tests patients for potassium sensitivity, however, but initiates Elmiron instead.