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Diane Newman: Welcome to UroToday's Bladder Health Center of Excellence. I am Diane Newman, the center's editor. And here with me today is Dr. Jeannette Potts. She's co-founder of Vista Urology in San Jose, California. And Dr. Potts specializes in pelvic floor disorders including pelvic pain. So I've invited Dr. Potts because she's been doing several lectures in Central and South America, and we actually have quite a large audience there. So she's going to present some lectures on chronic pelvic pain as well as nocturia. Thank you, Dr. Potts.

Jeannette Potts: Thank you. And now I will take it away in Spanish. And in Spanish things go a little bit longer because of the words but also because it is my second language. And so to my Latin American brethren, I thank you for your patience with any kind of grammatical errors I may commit.

Jeannette Potts [en Español]: This afternoon, we are going to talk about micturition-related symptoms that are associated with pelvic pain. We have to keep in mind that this sign of CP/CPPS (Chronic prostatitis/ Chronic pelvic pain syndrome) is not a diagnosis. Prostatitis is extremely rare. Prostatitis is a true and different diagnosis. Pelvic pain is common, and pelvic pain as a syndrome is merely a syndrome caused by different diagnoses.

So, we can’t diagnose a patient as having a syndrome. A syndrome is just a constellation of symptoms. We have to define what are the diagnoses that cause the patient’s symptoms. Logically, micturition symptoms are also not merely symptoms of pelvic pain. Each patient can have a certain problem. And each patient can have a very different problem.

The symptoms that are associated with pelvic pain match with the symptoms that 50 percent of the patients experience. And not everyone has them. 50 percent only experience pain. But 50 percent of patients have both things: pain and micturition symptoms. There still is a controversy about using alpha-blockers as if everyone had the same diagnosis.

This was the answer reached from the NIH-NIDDK collaboration. But what we found by randomizing 272 patients was that the symptoms were the same. Relief on a 4-point scale occurred on both sides in 50 percent of patients who were given the medication and in 50 percent of patients who were given the placebo.

We see that the value of p is 0.99, and all of the quality of life changes, and so on, also showed no difference. So this supports what I’m saying: That this is a syndrome with many different symptoms and many different causes.

The conclusion of this study is that we cannot justify using alpha-blockers for this problem in patients with pelvic pain. Nevertheless, the authors of this article continue to publish and to conduct studies with alpha-blockers. But it is not really a panacea. The differential diagnosis in these patients can be functional obstruction.

Such as detrusor-sphincter pseudo-dyssynergia (Pseudo DSD). It could be pelvic floor muscle dysfunction. Pudendal neuralgia can also cause micturition symptoms. An overactive bladder, as well as an underactive bladder. Obstruction due to benign prostatic hyperplasia. Also, obstruction due to hypertrophy of the bladder neck, and also interstitial cystitis.

There are many more. What we have to do in the office is get a complete clinical history. The urinary, bowel movement, sexual and ejaculatory history. And also the micturition or bladder diaries. I ask the patients to complete a 24- or 48-hour diary. The physical exam, of course, and urinalysis. In some cases, we will need the uroflow (Qmax) with or without electromyography. And an ultrasound to measure the residual urine (PVR).

But the most important thing in this diagnosis is the micturition diary. And if you can get an ultrasound or a Doppler ultrasound, it will help you a lot. Most patients do not require invasive studies. In other words, most patients do not require a urodynamic test or a cystoscopy.

Here is the micturition diary. The most important thing in the diary is to document the precise time of urination and also document the quantity of urine. For each consecutive urination. Here is an example of a 44-year-old man with a 20-year history of pain and urinary urgency. Increased urinary frequency and intermittency.

We can see here how this patient has very low micturition volumes of about one or three ounces per micturition, but his micturition volume, especially at night, has a normal volume of 10 to 12 ounces. And these micturition volumes don’t cause him any problems. No pain or anything. To me, this says that he has a bladder with normal capacity, and he might have a functional problem.

What we see here is more consistent with someone who has nocturia and pollakiuria, but we can recognize this nocturia and pollakiuria with more history, due to the fact he drinks too much fluid before going to bed.

The important thing here is that in this man’s bladder diary, we see that his capacity is normal. But during the day, it’s abnormal because of his functional problem.

Here is another 27-year-old man who has a burning sensation in the perineum, hesitancy, straining, and nocturia. But we will see that he also has a bowel dysfunction; he has trouble evacuating his colon, and he feels incomplete evacuation, and he has a decrease in the ejaculate volume. Do you think this diary shows increased urinary frequency?

I think so. He urinates more than six or seven times a day. But does he really have nocturia? I would say no. Because at bedtime, he urinates a lot because of his anxiety. But then he sleeps until seven in the morning. And then, again because of anxiety, he urinates several times, but then he gets up in the morning. Could it be a capacity problem? I would say no, because the first micturition in the morning is normal in volume, which reflects a good bladder capacity and he has no symptoms with that micturition episode. We have seen, throughout history, first with Meares, who identified a urinary dysfunction, which he defined as acquired. And that these problems, these dysfunctions, were 50 percent associated with prostatodynia.


In 1999, Zermann identified that 81 percent of his patients with prostatitis had detrusor sphincter dyssynergia (DSD), confirmed by urodynamic studies, and this should also be noted in these situations.


Kaplan, in 1997, showed that men previously diagnosed with prostatitis, had a bladder outlet functional obstruction, and responded to pelvic floor muscle biofeedback. Something very curious that he found in this study was that 91% of the men with this diagnosis were the firstborn child. The first-born male in the family, something we also know to be often associated with obsessive-compulsive syndrome or disorder.


This is the urodynamic study of a patient with detrusor sphincter dyssynergia. The electromyogram is shown in green. And when relaxing the sphincter to urinate, the detrusor activity is in pink, and we see that the micturition is interrupted by the activity observed in the electromyogram. Which is the sphincteric muscle that works against micturition. And this can respond well to pelvic floor muscle and biofeedback.


I treat these patients with a bowel regimen. I use a special diet, a bowel evacuation plan, and I also take advantage of the gastrocolic reflex. Most people have a stronger gastrocolic reflex in the morning, after eating breakfast, and also self-biofeedback. Which can also be done manually. The patient can touch his perineum and learn how to relax it.


It can be done visually, or with the help of an electromyogram, and lastly, the pelvic drop exercises. I tell my patients how this exercise allows them to stretch the pelvic floor muscles. You have to pretend you are sitting in a hammock and stretching all of those muscles of the pelvis and perineum.


In this ultrasound, it shows a woman doing this exercise to relax and stretch her pelvic floor muscles. It is something that anyone can practice after micturition. Here, I have another patient; this is a 41-year-old patient. He has pain in his groin and perineum, increased urinary frequency, and post-urination dribbling.


This man was diagnosed with prostatitis. He had an ultrasound showing a post-void residual volume of 100 ml. He received months of antibiotics and, secondarily, he has balanitis, skin candidiasis, or tinea cruris. But here is his bladder diary. And look how amazing it is. Look at those urine volumes: 800 ml, 500 ml, 1000 ml...


This man was drinking eight liters of water a day. So I advised him, and this man already had had many diagnostic tests done, a urodynamic study, a cystoscopy... And they thought it was prostatitis. He stopped taking the antibiotics. I asked him to reduce his fluid intake from 8 liters to 2 liters. He started physical therapy. I reassured him, and I cheered him on. He improved and had a residual urine volume of 20 ml. Imagine drinking 8 liters of water daily. This man had a lot of problems, a lot of pelvic pressure, and a lot of post-void dribbling. And that caused him a lot of anxiety.


We have also seen cases of pelvic pain due to bladder-neck hypertrophy. It is more common than we think. And this is something that was also shown by Dr. Kaplan in 1994. Most of these patients, misdiagnosed with prostatitis, were treated with antibiotics for an average of 24 months. And it turns out they had bladder neck hypertrophy. Here is a 32-year-old patient.


In 2012, he was diagnosed with prostatitis. Then, in 2013, he was diagnosed with interstitial cystitis. In a twenty-something-year-old male. His micturition pattern when I saw him was like this and he had this bladder diary.


This diary is not normal, but it is also not abnormal. The truth is that, with 350 ml here, this man does not have interstitial cystitis. But he does have something odd. So, we did a uroflowmetry. His urine flow (Qmax) was 15 ml per second, with a 320-ml voided volume. And then, he had a residual urine volume of 90 ml. This is abnormal for a 32-year-old male. When we performed the urodynamic study, the Qmax was shown to be 3.5 ml per second. With a maximum detrusor pressure (PdetQmax) of 108 cm of water. This is compatible with bladder outlet obstruction. And then afterward, he improved.


This is another 46-year-old patient. He had endured 23 years of pain and micturition problems. He was diagnosed with prostatitis and then pelvic dysfunction. He had six urologists and five therapists.


Here, we see that he was very symptomatic. This is an ultrasound that I did during the clinic visit. We see that he had approximately 600 ml of post-void residual urine. His bladder, his bladder wall was very thick, extremely thick. And here we also see hydroureter.


And this is his cystoscopy. It’s the worst case of benign hyperplasia that I have seen. But after a transurethral prostate incision (TUIP), his symptoms improved a lot.


Here is his flow max (Qmax) of 30 ml per second, with a bladder capacity of 800 ml. It went down a bit to maintain good bladder capacity and good detrusor function. And his post-void residual urine went down more or less to a more normal level.


And here is another patient whom I recently saw. This man is 60 years old and came from Sweden. For the past six years, his pain and urinary urgency/frequency have been getting worse. He had seen three urologists. His diagnosis was prostatitis.


But look at this bladder diary. This man suffers a lot. He cannot sleep. He has interstitial cystitis. A cystoscopy was performed on this man, before he came to the United States, along with a biopsy to check that he did not have carcinoma in situ (CIS) of the bladder. Since they ruled out CIS, they gave him no treatment and no diagnosis was made.


Only the diagnosis of prostatitis. This happens everywhere in the world. It’s something we see very often during office visits, and I’ll say this: interstitial cystitis is rare, and it is not a disease that women have. It is a disease suffered by both men and women to the same extent. We’ve just wasted the word by using it for all of the other symptoms that the patient has.


But this diagnosis really occurs in both sexes. Interstitial cystitis is rare. It is a very specific diagnosis. And it occurs in both sexes.


I will not stop emphasizing this. And I think I'll be the first person attributed with saying this. Lastly, you have to keep a micturition diary. It’s the most important thing. It costs nothing. It is not invasive. Most patients don’t need anything invasive. Ultrasound helps us rule out an elevated post-void residual volume or urinary retention.


As I already said, we do not need invasive studies in most patients. And here are some pearls: Many patients drink more fluids than they should, and we should be able to notice that. At the same time, there are patients who don’t drink enough. And if they have an overactive bladder, they will be predisposed, for example, to having bladder or kidney stones. With the bladder diary, it’s very important to recognize whether the amount of fluids being taken by each patient is more or less than they should be taking. Discussing defecation or bowel movements helps a lot in making the diagnosis. It is also worthwhile understanding the bowel movement of the patient.


How are their bowel evacuation and intestinal habits?


Micturition functional disorders usually do not involve nocturia. When the patient is asleep, everything is turned off. That is also a key to it being a functional problem. Patients who have non-functional pathology urinate frequently day and night. It doesn’t matter what they’re doing. They have low bladder capacity and there is pathology. It doesn’t matter whether they are awake or asleep.


Patients with interstitial cystitis consistently urinate small volumes, as they have a low bladder capacity. This is very important. And when the volume of urine increases a bit, these patients really notice that there is a problem, that there is more pain, and sometimes there is blood.


The micturition diary can be used not only for diagnosis but also for follow-up and monitoring the patient’s progress.


It is extremely valuable. And that’s it. Thank you.

Diane Newman: Thank you so much, Jeannette, that was very interesting. I know that you presented this at a recent meeting. Do you want to talk a little bit about that?

Jeannette Potts: Yes, at the meeting, there were many young urologists who came to tell me afterwards how frustrated they were that many of their colleagues were not performing the diary, and that a lot of people still think that the diary is a waste of time. To make the problems worse. Just like in the United States, one of the Central American countries, recently, has insurance authorization for urodynamics. This has now caused more people to undergo urodynamics than before and sadly, urodynamics without the voiding diary. And in fact, we know this happens in the United States all the time. That the procedures are happening before the actual intellectual diagnosis and things like a voiding diary. And in fact, my husband, Dr. Chris Payne, reminds me all the time that no one is allowed ethically to perform urodynamics without a voiding diary. And I can tell you we've seen many, many urodynamics in our practice from all over the country and the person and the patient will say I don’t know what a void diary is, what do you mean by a voiding diary. Nowhere in the records either.

It's sad to say that in other countries, I wish we could step in and say, don’t make our mistakes. Because we do take for granted everything we do in the United States, we are the thought leaders, and it's incredible that one publication can have such an impact abroad. And it's actually really tragic that people don’t take their publications or their words seriously. Because as we see it impacts our own practice and then in other countries they can't help but to follow our example. Our bad example.


Diane Newman: But you know, when you do urodynamics it doesn't necessarily reproduce what the patient's symptoms are and the diary really does tell us kind of what is happening to that individual on a daily basis. If they keep at least a 1, 2, or 3-day diary. Right? So it's a shame we are eliminating one for the other.

Jeannette Potts: Yes.

Jeannette Potts [en Español]: The question is that the urodynamic study can only show us a brief moment of the patient’s micturition, but the bladder diary shows us days of the patient’s real life.


Jeannette Potts: And the thing that I also want to say about that is that urodynamics are so fraught with artifact too.

Jeannette Potts [en Español]: When the urodynamic study is done, there are many artifacts. And sometimes, we are interpreting artifacts, and then we don’t have time to repeat the urodynamic study. And then we’re left with the same question we had before the urodynamic study was done.

Sometimes, we can’t reach the conclusion or the diagnosis we wanted and the micturition diary would have been an even greater advantage.


Diane Newman: Well thanks so much, this has been and I know will be very helpful to our viewers. Like I said, we have several that come from the Latin countries, and I know that they're interested in a lot of your knowledge, especially in this area of urinary tract symptoms and chronic pelvic pain. So thank you so much.

Jeannette Potts: Thank you.