The Benefits and Harms of Pharmacological Treatment for Postradiation Pelvic Pain: A Systematic Review by the European Association of Urology Chronic Pelvic Pain Panel with Recommendations for Clinical Practice

Context

Radiotherapy of the pelvis is a widely used method for the treatment of malignancies, and local complications including pain following pelvic radiation therapy are acknowledged complications.

Objective

The primary objective is to assess the clinical effectiveness and safety of pharmacological therapies on postradiation pelvic pain.

Evidence acquisition

A systematic review of the use of different pharmacological treatments in the management of post-radiation pelvic pain was conducted (PROSPERO-ID: CRD42021249026). Comprehensive searches of EMBASE, Medline, and Cochrane library were performed for publications between January 1980 and April 2021. The primary outcomes were improvement in pain and adverse events following treatment. The secondary outcomes included quality of life, bowel function, and urinary function.

Evidence synthesis

After screening 1514 abstracts, four randomised controlled trials were identified, enrolling 355 patients with bladder and anorectal subtypes of postradiotherapy chronic pelvic pain (CPP). A narrative synthesis was performed as heterogeneity of included studies precluded a meta-analysis. A single study reported a significant reduction in pain after 6 mo in patients with bladder pain syndrome treated with hyaluronic acid or hyperbaric oxygen. Anorectal pain was reported to be reduced by the application of 4% formalin, but the use of hyperbaric oxygen in postradiotherapy anorectal pain remains controversial. Adverse event reporting was generally poor. Studies looking at medications used routinely in guidelines for neuropathic pain, such as gabapentin, pregabalin, amitriptyline, and duloxetine, were absent or of poor quality when it came to postradiation pelvic pain.

Conclusions

Beneficial effects of hyperbaric oxygen or formalin on pain, quality of life, and functional symptoms were seen in patients with certain CPP subtypes, but the current evidence level is too weak to allow recommendations about the use of any pharmacological treatment for postradiation pelvic pain.

Patient summary

Different pharmacological treatments are used to treat pain after radiotherapy, but current studies are of insufficient quality to determine whether these should be recommended and many chronic pelvic pain subtypes are not covered. Further research is needed.

Management of chronic primary pelvic pain syndromes

Management of chronic pelvic pain (CPP) remains a huge challenge for care providers and a major burden for healthcare systems. Treating chronic pain that has no obvious cause warrants an understanding of the difficulties in managing these conditions. Chronic pain has recently been accepted as a disease in its own right by the World Health Organization, with chronic pain without obvious cause being classified as chronic primary pain. Despite innumerable treatments that have been proposed and tried to date for CPP, unimodal therapeutic options are mostly unsuccessful, especially in unselected individuals. In contrast, individualised multimodal management of CPP seems the most promising approach and may lead to an acceptable situation for a large proportion of patients. In the present review, the interdisciplinary and interprofessional European Association of Urology Chronic Pelvic Pain Guideline Group gives a contemporary overview of the most important concepts to successfully diagnose and treat this challenging disease.

The Benefits and Harms of Botulinum Toxin-A in the Treatment of Chronic Pelvic Pain Syndromes: A Systematic Review by the European Association of Urology Chronic Pelvic Pain Panel

CONTEXT

Patients with chronic pelvic pain syndrome (CPPS) may have pain refractory to conventional management strategies. Botulinum toxin A (BTX-A) is a potential therapeutic option.

OBJECTIVE

To evaluate the benefits and harms of BTX-A injections in the treatment of CPPS.

EVIDENCE ACQUISITION

A systematic review of the use of BTX-A in the treatment of CPPS was conducted (PROSPERO-ID: 162416). Comprehensive searches of EMBASE, PUBMED, Medline, and SCOPUS were performed for publications between January 1996 and May 2020. Identified studies were screened and selected studies assessed for quality prior to data extraction. The primary outcomes were improvement in pain and adverse events following treatment. Secondary outcomes included quality of life, global response assessment, sexual function, bowel function, and bladder function.

EVIDENCE SYNTHESIS

After screening 1001 abstracts, 16 studies including 11 randomised controlled trials were identified, enrolling 858 patients and covering a range of CPPS subtypes. Most studies showed high risks of bias and confounding across all domains. A narrative synthesis was performed as heterogeneity of included studies precluded a meta-analysis and calculation of pooled effect estimates of measured outcomes. BTX-A reduced pain significantly in patients with bladder pain syndrome in two studies and in patients with prostate pain syndrome in one study, but no included studies showed benefit for patients with gynaecological pelvic pain. Adverse event reporting was variable and generally poor, but no serious adverse events were described.

CONCLUSIONS

Beneficial effects of BTX-A on pain, quality of life, and functional symptoms were seen in patients with certain CPPS subtypes, but the current evidence level is too weak to allow recommendations about BTX-A use for treating CPPS.

PATIENT SUMMARY

Botulinum toxin A is used to treat different pain disorders, but current studies are of insufficient quality to determine whether it reduces pain and improves quality of life in patients with chronic pelvic pain. Further research is needed.

Sex: the new postcode lottery

Background:

A list of all the Primary Care Trusts (PCTs) in England, Scotland and Wales was obtained from the websites of National Health Service (NHS) choices’, NHS Scotland and NHS Wales.

Methods:

Each PCT’s website was visited to find the email address for their Freedom of Information (FOI) department. FOI requests were made to each PCT asking questions regarding their criteria for funding and the number of requests made and implants funded in the previous 12 months.

Results:

A total of 129 PCTs were emailed with a 95% response rate. Thirty-one per cent of the PCTs that replied funded penile prostheses and 22% did not. A further 45% of PCTs would fund under exceptional circumstances, but only 20% of these had any clinical criteria on which to base their decision making. Twenty-three per cent of clinical criteria used were based on guidelines. Non-funding PCTs were spread in patches throughout the country, but the West Midlands stood out as a particularly black spot. On reviewing PCTs that had received requests for funding in the preceding 12 months, 46% did not fund any of the requests, 17% funded 50% or less and 37% funded all the requests received. Of the PCTs funding under exceptional circumstances, only 37% actually funded any of the requests received.

Conclusion:

Despite guidelines on the management of erectile dysfunction, there remains variability in access to penile prosthesis surgery. The West Midlands and the Southeast (excluding London) are the worst places to live with regards to access to prostheses; Scotland and Wales appear to be the best. Guidelines are rarely used in decision making. Funding remains an important factor in determining who receives potentially life-changing treatment for erectile dysfunction refractory to all other management options. A patient’s address and personal wealth appear to have a larger impact than guidelines.

TRPM8 agonists modulate contraction of the pig urinary bladder

The transient receptor potential melastin-8 (TRPM8) channel is activated by the “cooling” compounds menthol and icilin. Pathophysiologically, it is implicated in the overactive bladder and bladder cooling reflex, but the activity of TRPM8 in normal bladder physiology is poorly understood. We investigated the distribution of TRPM8 channels and the effect of TRPM8 agonists on the contractile function of pig bladder (n = 35) strips and whole bladders. The distribution of TRPM8 was examined by immunohistochemistry. The effect of vesical or intravascular menthol (0.1–0.3 mmol/L) or icilin (50 μmol/L) on carbachol-induced isolated whole bladder contractions was monitored by recording vesical pressure. Strips of denuded detrusor or mucosa were mounted in organ baths to study the effect of TRPM8 agonists on the contractile responses to 10 μmol/L carbachol. TRPM8-like immunoreactivity was detected on pig urothelium. Intravascular menthol (0.3 mmol/L) and icilin (50 μmol/L) significantly decreased the magnitude of carbachol-induced whole bladder contraction, whereas vesical administration significantly increased the response. In detrusor and mucosal strips, both menthol (0.3 mmol/L) and icilin (50 μmol/L) inhibited carbachol-induced contractions. We conclude that the TRPM8 channel is expressed on the urothelium of pig bladder. In the whole organ, exposure of the urothelium to menthol or icilin increases the contractile response to carbachol. Where detrusor muscle is exposed directly to these compounds, the contractile response to carbachol is reduced.

The validation of a functional, isolated pig bladder model for physiological experimentation

Characterizing the integrative physiology of the bladder requires whole organ preparations. The purpose of this study was to validate an isolated large animal (pig) bladder preparation, through arterial and intravesical drug administration, intravesical pressure recording, and filming of surface micromotions. Female pig bladders were obtained from the local abattoir and arterially perfused in vitro. Arterial and intravesical pressures were recorded at varying volumes. Bladder viability was assessed histologically and by monitoring inflow and outflow pH. Arterial drug administration employed boluses introduced into the perfusate. Intravesical administration involved slow instillation and a prolonged dwell-time. Surface micromotions were recorded by filming the separation of surface markers concurrently with intravesical pressure measurement. Adequate perfusion to all bladder layers was achieved for up to 8 h; there was no structural deterioration nor alteration in inflow and effluent perfusate pH. Arterial drug administration (carbachol and potassium chloride) showed consistent dose-dependent responses. Localized movements (micromotions) occurred over the bladder surface, with variable correlation with fluctuations of intravesical pressure. The isolated pig bladder is a valid approach to study integrative bladder physiology. It remains viable when perfused in vitro, responds to different routes of drug administration and provides a model to correlate movements of the bladder wall directly to variation of intravesical pressure.

Success rates for learning intermittent self-catheterisation according to age and gender

PURPOSE

Voiding dysfunction becomes increasingly prevalent with ageing. Clean intermittent self-catheterisation (ISC) is associated with a lower morbidity than indwelling transurethral or suprapubic catheterisation. However, doctors and patients sometimes fail to consider ISC as an option because of a perception it will be unmanageable or poorly tolerated. This study aimed to determine how age and gender affect the success rates of patients being taught ISC.

METHODS

Six years retrospective study (January 2004-January 2010) of non-neurogenic patients referred to be taught ISC by urology specialist nurses in a tertiary referral hospital. Patients were sent information about ISC in advance of their appointment, were given additional information at the appointment, received training under supervision and had access to follow-on support. Successful patients were those who continued to perform the technique independently at 6-week follow-up.

RESULTS

Three hundred and nine patients (209 men, 100 women) with a mean age of 63 years (range 17-95 years) were taught ISC during the study period and had documented follow-up. The main reasons for needing ISC were incomplete bladder emptying (46%), urethral stricture disease (20%) and inability to void (18%). The overall ISC success rate was 84% for all age groups, 86% for patients under the age of 65 and 82% for those aged 65 years and over. Men had a higher success rate than women (88 and 76%, respectively).

CONCLUSIONS

Older patients can successfully be taught ISC in a high proportion, and it can be offered as an alternative to an indwelling catheter irrespective of age.

Emerging treatment options for benign prostatic obstruction

Benign prostatic obstruction (BPO) affects an increasing number of men with age. It can cause troublesome lower urinary tract symptoms, can have a negative impact on quality of life, and may be associated with significant morbidity. Currently available medication and surgical treatments are limited by adverse events, invasiveness, and patient compliance. This has driven research into the pathogenesis of benign prostatic hyperplasia and led to the development of novel pharmacological agents and minimally invasive therapeutic interventions. This review highlights emerging treatment options for BPO.

Effects of changing work patterns on general surgical training over the last decade

BACKGROUND There is concern across all medical specialties that shift patterns and reduced working hours are detrimental to training, and that craft specialties have been most affected. This study aimed to examine the effects of these changes to training on the quantity of operating performed by surgical trainees in a UK teaching hospital. METHODS This retrospective study of prospectively collected computerised theatre data examined elective and emergency general surgical operations performed over four time periods: 1996 (Calman), 2001 (New Deal), 2004 and 2009 (European Working Time Directive). Procedures were analysed according to grade of surgeon and time of day. RESULTS In 1996, most appendicectomies (72.2%) were performed by senior house officers (SHOs), compared with 3.8% in 2009. By 2009, SHOs did not perform any emergency procedures other than abscess drainage and appendicectomy. The proportion of emergency operating performed by specialist registrar (SpRs) has remained constant, but elective operating has reduced from 34.6% (1996) to 15.7% (2009). Supervision of both SHOs and SpRs has increased between 1996 and 2009 in both elective and emergency work. CONCLUSIONS The proportion of operating performed by SpRs and SHOs has fallen over the last decade, coinciding with implementation of structural changes to training, the advent of minimally invasive techniques, and the drive for a consultant led health service. Trainees may therefore require increased supervision as well as protected theatre sessions to balance operative training with ward based duties. Education must be integrated into working practice in order for trainees to achieve expected competencies and ultimately produce adequately experienced consultants.

Animal models in overactive bladder research

Overactive bladder syndrome (OAB) is a symptom-based diagnosis characterised by the presence of urinary urgency. It is highly prevalent and overlaps with the presence of bladder contractions during urine storage, which characterises the urodynamic diagnosis of detrusor overactivity. Animal models are needed to understand the pathophysiology of OAB, but the subjective nature of the symptom complex means that interpretation of the findings in animals requires caution. Because urinary urgency cannot be ascertained in animals, surrogate markers such as frequency, altered toileting areas, and non-micturition contractions have to be used instead. No model can recapitulate the subjective, objective, and related factors seen in the clinical setting. Models used include partial bladder outlet obstruction, the spontaneous hypertensive rat, the hyperlipidaemic rat, various neurological insults and some gene knock-outs. Strengths and weaknesses of these models are discussed in the context of the inherent difficulties of extrapolating subjective symptoms in animals.