Balancing risks and benefits of hydrodistension for IC/BPS
Panelists emphasize individualized treatment decisions and careful patient selection for this operative procedure.
The 2022 guidelines for diagnosing and treating interstitial cystitis (IC)/bladder pain syndrome (BPS) state that hydrodistension treatment for IC/BPS is supported only by low-quality evidence. However, many doctors believe it can be an effective treatment option for carefully selected patients.
Experts outlined the pros and cons of hydrodistension during Sunday’s Crossfire Debate: “Controversies in Urology: Hydrodistension Should be Used for Therapy for IC/BPS.”
“Hydrodistension is grade C evidence. It is an operative procedure and, as such, does carry risks. We balance them against the benefits. If we take a look at the risks, we're talking about infection, potential bleeding problems and even bladder perforation in some specific instances,” said Robert Moldwin, MD, professor of urology at the Zucker School of Medicine at Hofstra-Northwell in New York.
Other factors to consider for this operative procedure include the potentially long waiting period. Durability is another consideration; although the literature shows significant disparities across studies and endpoints, the average observed duration is about three months.
It's also important to consider success rates, which vary across the literature but generally range from 30% to 50%.
The panel emphasized the need to carefully choose patients for IC/BPS, considering other chronic pain conditions and comorbidities.
“When it comes to the impact of other chronic pain conditions, we think that's a little different immune type, where those patients may respond better to systemic therapies, whether it's amitriptyline, pregabalin or others like that. So maybe we would try a medicine like that before a hydrodistension, but there's certainly nothing wrong with hydrodistension if they prefer that because it can help those patients,” said J. Quentin Clemens, MD, Edward J McGuire professor of urology and urology associate chair for research at the University of Michigan.
Another factor to consider is that hydrodistension may temporarily worsen symptoms, with patients experiencing significant pain right after waking up from the procedure.
“I think that is certainly one of the issues, and to be honest with you, why I tend to favor other modalities over hydrodistension in this patient population. I tend to favor Botox or sacral neuromodulation because the postoperative period is not so straining and painful for the patient. A lot of these patients are already on some kind of pain management, so I'll oftentimes communicate with their pain management physician ahead of time to see what additional regimen they would be on board with,” said Elizabeth Rourke, MD, assistant professor of clinical urology at LSU Health New Orleans.
Finally, the panel highlighted the importance of distinguishing patients with a truly bladder-centric role from those with pelvic floor dysfunction.
“I believe the patients who are best suited are those who have a more bladder-centric role. Studies have shown that if you get a sense of what their bladder capacities are, which you can certainly gauge from a bladder diary measuring voiding volumes, you could potentially make a case for taking someone with a smaller bladder capacity to the operating room and doing that hydrodistension,” said Christopher Chermansky, MD, chief of urology at UPMC Magee Women’s Hospital, University of Pittsburgh.
