All right. Good evening, everyone. Welcome to the Augs Urogynecology Webinar Series. I'm Dr. Mary Duarte Thibault, a member of the Augs Education Committee and the moderator for today's webinar. Today's webinar is titled, Let's Talk About Urethral Pain. Our speakers today are Dr. Sana Ansari and Dr. Jessica Hirosh. Dr. Ansari hails from New Jersey. Her education journey includes a medical degree from the University of Illinois at Chicago, OBGYN residency at Cooperman Barnabas Medical Center, and FPMRS fellowship at the University of Cincinnati. And she's recently transitioned out of Emory University. Dr. Hirosh was born in Montreal, Canada and grew up in Israel. She obtained her medical degree from Tel Aviv University and she completed her OBGYN residency and urogynecology fellowship at the Albert Einstein College of Medicine in the Bronx. She is currently part of a large urogynecology group associated with the Northside Hospital System in Atlanta, Georgia. A few reminders before we start. The webinar presentation will run about 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. Also some housekeeping items. Augs designates this live activity for a maximum of one CME credit. To claim your CME credit, you must log on to the Augs e-learning portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live streamed. A recording of the webinar will be made available through the Augs e-learning portal. Please use the Q&A function of the Zoom webinar to ask any of the speakers questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues and the Augs staff will be monitoring the chat and can assist. Dr. Zansari and Dr. Hirosh, please begin. Good evening, everyone. My name is Jessica. Sana and I will be presenting to you on what we think is a hot topic, treating urethral pain. This presentation really is an extension of the round table discussion that Sana and I led during Augs PFD week this year. She and I have been friends and colleagues since 2017 when we worked together in Atlanta and we really shared curiosity for patients suffering from urethral pain. And so this webinar truly developed organically from multiple discussions that we have had on the topic over the last few years. We appreciate your opportunity to let us share our approach with you. Next slide. We have no disclosures. Next slide. These are our objectives. We're gonna look to discuss a different approach to the patient with urethral pain and we'll be reviewing treatment options for patients with urethral pain. We do make some assumptions about the audience for this webinar in order to really be able to focus on the practical aspects of the treatment options. We assume that our audience is familiar with conditions related to the bladder and the urethra. And we also assume that you're familiar with published guidelines for treatments such as bladder pain syndrome and interstitial cystitis. Next slide. So the patient that we're focused on this evening is a patient who reports symptoms specifically related to her urethra. She may be in her 20s, in her 40s, even in her 80s complaining of urethral burning, urgency, just severe pain and pointing to the urethra. There may be some associated symptoms like urinary retention or hesitancy, sometimes frequency or urgency. This is a patient that many of us encounter regularly in our practices. These patients can be very difficult to treat at times and it often feels like we've tried everything and nothing is really helping. Next slide. When a patient presents with urethral pain, just like any other patient, we start with a thorough history. Sometimes there can be an acute event that precipitated a specific episode related to urethral pain. This can appear to be related. For example, if a patient underwent a cystoscopy recently or it can appear to be unrelated, but the patient has in their minds a very specific point in time. So for example, they had a virus and they were vomiting for three days and then all of a sudden they started with these UTI-like symptoms. It's not uncommon to identify an event that may or may not obviously be a source of trauma because typically when we ask about trauma, we think about sexual trauma, about physical trauma, but in many cases, instrumentation with a speculum or a transvaginal ultrasound that they were having for a different condition can lead to trauma response that starts a pain cascade. We also ask about associated vaginal and urinary symptoms. Anything from urgency, frequency, bladder pain, vaginal dryness, and vaginal pain. We typically will pay attention to certain pain clusters that the patient may have. Maybe they have associated conditions like fibromyalgia or chronic migraines. We really wanna take a look at that. We'll also look at comorbidities like mental health issues or perimenopausal symptoms. And taking a good history really helps us start to develop a picture of what type of patient we have in front of us. When it comes to the exam, of course, we look at the urethra, the vaginal texture, the presence of atrophy, but we also really pay careful attention to the pelvic floor muscles and the pelvic floor structures. We're looking for point tenderness, areas of hypertonicity that may be elicited just on pelvic exam, even if the patient doesn't report it. We'll often take a moistened Q-tip and just gently touch the urethra and the introitus to see if just the touch of something even soft can trigger the pain. Sometimes patients will feel pain with gentle touch and others, they won't notice the pain unless they're standing or walking or urinating. So we try to see on a physical level what triggers the pain. And again, this helps create a profile of what category of urethral pain we're going to be dealing with. When patients describe retention-like symptoms and if they can tolerate it, we may consider doing a little bit of instrumentation, maybe with a small straight catheter, 10 or 12 French if you have in the office, if you think that they're gonna tolerate it, but obviously make sure that you're not recreating or re-traumatizing the urethra. And we can use that as a way to see if they might have a stricture, for example, after a previous instrumentation. Sometimes this type of test is reserved at the time of a cystoscopy if it's otherwise indicated. Of course, we'll send a urinalysis and more often than not, we'll send a urine culture as well since the patient already has symptoms. We may not necessarily perform a cystoscopy just for urethral pain, but if there are other indications, for example, microscopic hematuria, of course we would proceed. And once again, we're very careful with that instrumentation since it can trigger more of the urethral pain or trauma. We have ureaplasma and mycoplasma on here because we have historically used them. That said, it is quite controversial as many of you know, and there's not great data to support routine testing for this. And then keep in mind that if you find a positive result, then you may end up with a downstream chase of a potentially sexually transmitted infection. And so we typically reserve these types of testing for younger patients. Maybe we warn them that if there is a positive outcome, then we may want to treat, but just treat once and not something that we want to start to chase down the line. Sana, I was going to ask you how you felt about the ureaplasma and mycoplasma. I go through phases, honestly. There are times where I would say it's mostly age related or triggered with younger patients, but sometimes I really regret opening that Pandora's box. So I go through phases, I would say. Same, same. Okay, next slide. All right, so for this talk, we wanted to present urethral pain in a way that would be understandable for a lot of patients, for you to be able to kind of organize them in your mind. So we have three different types of phenotypes. One is vaginal atrophy, the other is myofascial, and the next is interstitial cystitis, the subtype of urethral pain. And here is just another way of looking at it, but this is more of an algorithm with the treatments included. And it's important to remember that your patient can have more than one of these going on simultaneously. So there may be more than one treatment ongoing at the same time. But we'll delve now further into each of these treatments. So first with vaginal atrophy, we really like to consider treating vaginal atrophy in patients who are peri or post-menopausal as vaginal atrophy or genitourinary syndrome of menopause can be often a cause of urethral pain as well as vaginal pain. I tend to start my patients on the vaginal estrogens cream if they're not already on it. And depending on what I prescribe, it could be half to one gram, two to three times a week. I counsel my patients that it's for at least a six month trial before we decide whether to continue it or not, and that it can take three to four months for it to really take effect. Here we've also included some other options for discounted pharmacies, because we do come across patients whose private insurances or Medicare do not cover the estrogen cream very well. So these may be really good options for them. And of course, if you come across a patient who does not respond or has side effects with one formulation, to just consider a different formulation. So here, we're gonna open it up to everyone. And in this case, you use the chat box. How do you advise a patient complaining of burning with vaginal estrogen application? So if you have any kind of tips and tricks, you can put them in the chat box here. I'm reading in the comments. In the meantime, you can add Amazon Pharmacy to that list, also true. And some of these pharmacies, like the Cost Plus Pharmacy, patients have to create a profile, but then it's pretty easy to prescribe to the appointment formulation. Insert with finger after measuring it. Patient may use their finger if uncomfortable with the applicator. Absolutely, I more often than not tell patients not to use their applicators. I show them on their finger from the tip to the first line, a ribbon amount, and then gently start at the urethra and then put the rest straight all the way in. Apply with finger in the vagina and then a little on the urethra. Compounded formulation with olive oil. Sana, I think you compound with, is it Vaseline? I don't compound. I just tell patients to mix it with a little bit of petroleum jelly at a one-to-one ratio and apply. I love these. Minor irritation may be more intense from particularly dry tissue during the nightly loading dose timeframe. So sometimes I will start with the maintenance therapy in those scenarios for persistent or severe irritation. Then I go to the compounded pharmacy versions. I love that too. We'll wait another couple seconds to see if we have some good answers here. Love it, okay. So I think we had some good examples. Thank you. All right, so now moving on to a different phenotype, the IC or bladder pain syndrome subtype of urethral pain. One of the most important things to remember is addressing and optimizing the mental health component. I tend to bring this up after the patient has failed a couple trials of therapies. That's only because of my personal experience of having brought it up soon or early on and patients reacted in a negative way despite my careful wording. But you don't want a patient to think that we're saying it's in her head, but rather that this is that pain, just like any other chronic pain condition is a burden on the mind and it can really burden our emotions, our emotional wellbeing and our social wellbeing. And that this is a part of treating the pain syndrome, especially in those who've been dealing with this for a very long time and have not been able to get any kind of adequate relief from this problem. It's also important for patients who already have anxiety and depression to talk to them about whether they feel that it's controlled and to work with their therapist or psychiatrist to make any adjustments that are necessary to make sure that whatever their mental health component issue is, is better controlled. I also like to talk to patients about methods of de-stressing. And so maybe taking up yoga, doing more exercise. I heard jujitsu is actually a really good exercise for a de-stressing and, or just doing more of whatever seems to make her happy. And like if I had a patient, for instance, who loves watching comedy shows. So I said, maybe pull up some on YouTube and watch more comedy. The other thing to remember is very basic to identify food triggers. The way that I do it, I think we all have probably different ways of doing this, but the way that I do it is I do a two week washout period where I have the patient on a very bland diet with minimal spices, mostly vegetable heavy. And after those two weeks, I tell her, I give her a list or I send her over to a website that has a list of food triggers. I tell her to identify the foods that you take in the most in your diet regularly and bring one back in after that two week period, washout period, bring one back in and eat it a few times a week. And if it doesn't seem to cause things to get worse, then keep it in your diet. And hopefully going through this long process that takes a while, maybe we can find a food trigger or maybe two to try to avoid. Over the counter options are also very good for patients either for maintenance purposes or for flare-ups. So taking medications that are like chewable acid relievers like your Tom's Pre-Leaf acid reducers that are over the counter, like famodidine for instance, is also good just to take on a daily basis. Antihistamines are going to be really important, I think, to try and I explained to patients how histamine can also promote pain in the urinary tract and in this case, in the urethra. You could do the prescription versions like hydroxyzine. I tend to counsel patients to just take over the counter antihistamines. And that's because they often come with non-drowsy formulations. And so for my patients who already are dealing with polypharmacy, I don't want to add to anything else. So I tell them to try that first. I will say though that I do like hydroxyzine for nocturia and if your patient has urethral pain with nocturia, maybe that's something to try, hydroxyzine. For flare-ups, peridium NSAIDs like ibuprofen are going to be very helpful as well as other medications like UroNP or Urobel that are methenamine and hyosimine, methylene blue combinations. And Jess, you had a patient who had, you have to be careful for assignment, you had that patient once. Who had met hemoglobinemia from taking too much, I think it was too much Urobel at the time. I love what you were saying about changing habits. So everybody has a different approach to elimination diets and food triggers. And as physicians, we're always trying to get patients to adjust their habits. And for me, especially those who initially will say, no, this is not related to anything. I have them just kind of keep a diary of what's going on without making any changes. I'm going to say for two weeks, you're just going to write down what you ate, what you drank and how your pain was, and then try to see if they can come up with a correlation. And it might not necessarily be food, it could also be function or something that they're physically doing during the day or encountering and so, or another environmental trigger. So sometimes that some people might find that helpful to start off without any changes and then we can initiate the changes. I think we're at, you got that slide? Okay, perfect. So often for these patients, water installations are really a near next step for us. I am, and we are all mindful that instrumentation itself, again, it can be very painful, especially with the tenderness at the urethra. So I will start off by warning them that it might take two or three sessions before they even see a positive effect. The first couple may not be pleasant at all. But after two or three sessions, really, if it's causing more harm than good, I will typically stop at that point in time, I will put them through a full six sessions. It's not uncommon for me to use the 2% lidocaine gel first or Eurojet, and then to do the installation. And this is the typical cocktail that we use in our office. It's a modified Whitmore. So it's one example. There are multiple examples out there, and I'm sure each of you are using different types. So ours has 40 milligram of transinolone, 40 cc's of bicarbonate, 40,000 units of heparin, and then 20 cc's of either 1% lidocaine or a quarter percent bupivacaine. And I put on there plus or minus gentamicin. Some physicians will use this for patients who also have recurrent urinary tract infections or just use it at baseline. So that's one of the common cocktails that you'll see. And then for maintenance. So typically if a patient has success after two or three sessions, I'll continue for weekly sessions to complete six weeks. And then after that, we'll have a discussion about what the maintenance is gonna look like. If they had a positive effect of this, some patients tend to want to have a regular follow-up that's already scheduled. Like they'll want to know that they have a visit in four to six weeks to have a repeat installation. That may help with their anxiety around the urethral pain. And it just may help just from the ease of getting an appointment as well. So that might also be beneficial for patients. And then they don't have to go about calling and then making the appointment. And then we have some patients who actually don't like to schedule appointments. They just want to come as needed at PRN. And I'm fine with that. Typically in our practice, we're able to get them in pretty quickly if they have symptoms coming on and they want to have an installation. So for us, it does work either way, but it's really a shared decision-making with the patient. And if they're not sure at first, I'll start off at four weeks and then we'll try to spread it out over time. Maybe they go to five, maybe they go to six and try to figure out how long of a window they can go without an installation. And then that usually organically will set itself. The patient will learn to push it a little bit further out. I have some patients who ask to do this at home on their own. Historically, I have found it difficult for them to get the formulation at home, just because some things need to be kept in a certain environment. Sometimes it can't be dispensed at that particular volume in a particular pharmacy. So I have found it difficult in my practice, but other practices might've had a little bit more ease with that. Next slide. So we wanted to put it out there to the chat. What else do you guys use in your bladder installation cocktails for urethral pain? Oh, sorry. I think I missed part of that. Okay, got it. Heliorhonic acid. Interesting. So do you mix that with anything else? Like with the rest of the cocktail? So this one says- Just 50 cc's. 50 cc's, interesting. Okay, got it. DMSO, thoughts on DMSO in cocktails. You know, I've never used DMSO in the cocktail. Oftentimes I think it's one of the issues I had back when I was interested in using it was that it was in back order. So it wasn't even something that was available. But I mean, the research shows that it's equivalent in terms of efficacy. So, but I personally never used it. Jess, have you? No, I have not. Let's see. We use hurricane jelly at the urethral opening pre and post installation. Okay. And see, sorry. No, it's the same. And when I get it, one to two capsules Elmeron in heparin solution. Okay. And then two milligrams of 2% lidocaine. I know there is a wide variety. Do you all have recommendations of reference with different regimens listed? So I'm just trying to read these out so that when you do come back and visit this recording, so you can kind of hear, hopefully hear everything, what everyone's saying, but I'm not sure if this is gonna be available. The chat itself gets recorded, the chat box. I don't think so. And how do you treat women with urethral pain without myofascial pain, GSM or IC? So we'll get to that towards the end. All right. So, and then last one here, we do 2% lido, bicarb, 10,000 units of heparin, sterile water and gents. Okay, nice. And the question was, is there a way to tweak the formulation to make it last longer? Good question. I find that that's really patient associated. It's how the patient responds. Some patients will be able to go wild with the same formulation, and other times they don't. I don't necessarily tweak it. Sometimes I may add a little extra lidocaine if the patient complains of burning post-installation, and that might actually help her have that effect last longer, but not necessarily with every patient. Is that the case? All right. So we're gonna move on. Yeah, so just to clarify, when we say interstitial cystitis in quotations, that doesn't necessarily mean that the patient has interstitial cystitis. We're, again, using our history and physical exam to try to phenotype a little bit of what the urethral environment looks like when the patient is presenting with urethral pain to try to help guide us into how we start to treat them. So hopefully that provides some clarifications. We do use topical treatments, and some of them are self-administered. So we'll instruct the patient to use their finger and gently apply to the urethra first. As we talked about earlier, applicators can cause discomfort. We can use something like 2% lidocaine jelly. They can apply it at the urethra a couple of times a day. Now, again, trial and error. For some patients, that provides a soothing experience, and then for some patients, it actually can worsen or cause more burning. So just be mindful of that and pivot if you have to pivot. And then if that is the case, I will quickly switch to a trial of a compounded gel. And I do, and we all do work closely with local compounding pharmacies. This is just one example of one of the compounds that I use, a combination of gabapentin, lidocaine, ketamine, and cyclobenzaprine. I put a little print out of what one of my prescription pads looks like, and you can see that we also have compounds that include amitriptyline, for example, that can also help with some patients. So again, you want to have a wide enough gap to do a trial period, but if it doesn't work or it makes the symptoms worse, then you'll move on to a next compound. Okay, next slide. And so also for patients who have urethral pain, you may want to consider PO medications. Nortriptyline is one that I may try on patients. I prefer nortriptyline over amitriptyline just because I feel that the side effect profile is a little bit better, but it is still quite limited by its side effect profile. And then also I consider offering gabapentin. Data is quite limited in using gabapentin with urethral pain or even with interstitial cystitis, if that's the diagnosis. But in a setting where there's so few options or perhaps logistics or other medical issues or drug interactions may play a role, I want to be able to offer something else for patients. And gabapentin has been used quite frequently in patients with different types of chronic pain. So this again does come with the downsides of side effects that may be a cause of discontinuation. And also it is a potentially good option for patients who may already be on antidepressants or anxiolytics, and you don't want them to be on a TCA, especially if they're well-controlled or maybe a little bit more complex. You may want to avoid a TCA to interact with anything else. Now, something that I do few times, few times is potentially starting a patient on an alpha receptor antagonist. And this is in a particular type of patient. This will be in a patient who has urethral pain, but also has some sort of dysfunctional voiding, perhaps incomplete emptying or stop and go flow. This is the patient where I may trial her on something like Flomax and see if she responds. I have had a couple patients respond well. And so in that setting, you may want to consider this as a potential. Again, you do have to counsel the patient on the side effect of hypertension and possible syncope. And I have had patients discontinue that for those reasons. We are starting to understand the overlap between overactive bladder and interstitial cystitis, and perhaps certain overactive bladder components could trigger urethral pain. And so if she does have overactive bladder or perhaps she has urine retention, you may want to consider PTNS or sacral nerve modulation in a patient who has urethral pain and then something else like stated before. So these are treatments that we do not typically offer urethral dilations, because again, we should have already ruled out urethral strictures, chronic antibiotics are out and PO steroids are out. Okay, so now if we go back to the way that we think about these patients with urethral pain, one of the categories when we do examine them is if we start to see that there is a myofascial component, then we will start to add on some of the treatments that may help with that as well. Be mindful that even though you may not think or feel that there is a myofascial component just based on the initial account, you have to remember that when someone has chronic pain or pelvic or pain related trauma, then they can develop a myofascial component as well. So it might not be something that you see at the beginning, but develops over time and is worth potentially addressing. So we work very closely with our pelvic floor physical therapists. And in our opinion, the quality matters, not all pelvic PTs are created equally. We do tend to vet them and identify the ones who have a special interest in patients in that particular population and who are going to take the time to trial and error and use location specific treatments to help with some of their urethral pain symptoms. And so of course, if they have associated voiding dysfunction or levator hypertonicity or movement triggers, this is one way to go. But specifically for urethral pain, look for physical therapists who do dry needling, for example, or who do e-STEM. They may be able to help, again, some very localized type of pain like urethral pain. With those patients, oftentimes we'll also use vaginal suppositories. So for example, vaginal diazepam, about 10 milligrams QHS or 30 minutes before they have a pelvic floor physical therapy session where some of these treatments might be used. So this helps for my patients, particularly the ones who can't sleep due to the pain, seems to help with those. And so I will oftentimes just prescribe for them the 10 milligrams tablets because it's the cheapest way for them to place it in the vagina. Be mindful of side effects of dryness. They often use it in the evening. And then you can also use that in compounded formulations. And again, those compounded formulations that we looked at earlier can be applied first at the urethra and then further up. And then for patients who also have other pain symptoms and who had experience with cannabinoid derived products, for example, there are some serums on the market that have come out. Again, trial and error. Sometimes it feels like desperation, but I've had a lot of patients who are open to trying this and have found some success using these for urethral pain. Next slide. So to go further down into the myofascial treatments, trigger point injections are commonly done. We both do them commonly in some of these patients. I tend to inject the botulinum toxin and a trigger point injection in the same areas. And it all depends on what we find on the vaginal exam. So placement of these injections may be along the puborectalis, which is gonna be about two to three centimeters in from the introitus, or the pubococcygeus, which would be five to seven centimeters within the vagina from the introitus. I can also sometimes inject the internal obturator intravaginally, and you can do that with a spinal needle and just bend it just a little bit to get a good angle. I also, depending on the exam, may inject the external obturator muscle, and that may be useful to do more on the external side. Similar to where you would put in a trans-obturator tape trocar, that's where you can safely get the external obturator muscle. In terms of chemodenervation, I like to do these in the office. I use Xeomin, and I dilute that with lidocaine. And again, I base my injection of where I'm going based on my vaginal exam. And then the hope is that if we can try to relax this complex of pelvic floor muscles, that that may also help with that urethral pain if it's due to the myofascial component causing these spasms in the urethra and pain because of thereafter. We wanna also consider that perhaps this urethral pain may be part of a bigger pelvic pain issue or even a pudendal neuralgia. And in those cases, you could opt to do the pudendal block yourself in the office. Other times, there's some providers who would prefer referring them to pain specialists, pain management for injection, or even potentially interventional radiology. There are some institutions where interventional radiology will do these. And if it works as a block, they may cryoablate. So now we wanna just kind of come back to where we started as a final look at this algorithm again, because having gone through the different phenotypes and the treatments for each, understanding that some patients may have more than one phenotype and may require more than one therapy to be started simultaneously. Yeah, and I really think that it's a good place to just take a step back. Like a lot of these patients come in and they're saying that they have urethral pain. You're gonna dig a little bit deeper and you're gonna see if you have any other findings that may guide you to think maybe they also have a phenotype that sounds a little bit like IC. Maybe they have some pain triggers. Maybe they have something that sounds a little bit like IC. Maybe on pelvic exam, you're seeing a myofascial component that they didn't describe. You're seeing severe atrophy that they were unaware because maybe they're not sexually active. And so this algorithm just helps guide us, gives us a visual of where to start because it can be very overwhelming because all you wanna do is just to give them one medication or one serum or one cream that's all gonna make it go away. But we have to remember that when it comes to pain, there's a tissue component. What does the tissue look like? There is a nerve component. Something may have triggered this nerve response, this pain response, and something else is perpetuating it and you have to identify it. There's a muscular component to it. The pelvic floor muscles are connected to that whole area to the urethra and those also may be involved. And then there's a psychological component. And so for any patient who has really localized pain, I try to give them that picture so that they can understand that we're gonna be trying different things in those four different boxes. And a lot of those times, we're gonna have to use some things in boxes concomitantly. And so the same way that we would do with any type of pain, ask them for kind of a buy-in, some patient, there may be some trial and error and if something doesn't work, then we're gonna move on. But obviously these are difficult patients. That's why there is no one and done answer for these patients. And so we do follow these patients in short intervals at the beginning until we can get them some relief. So I use a systematic tracking to see what has worked and what hasn't worked. Sometimes I'll even print out the algorithm for myself and circle what we've tried and then kind of add on from there and remove and adjust. And then remember that it's a shared decision-making with what happens as far as next steps and frequencies. Sometimes patients need a break. Sometimes they want more frequent appointments. And so it's easier to sometimes to give them a known follow up and known possible next step as opposed to them wondering what's going to be potentially next. And it's also easier because these patients can take up a lot of your time and your clinic visit. So if you already think about what you're going to do next, and put that in your plan, then when you come, they come back and see you and something's not working, then you already know what you were thinking about trying next. And then we did so you put the next slide on. Oh, yeah. I'm sorry. Yeah. So when we put this slide here, when nothing seems to be working, because I feel like a lot of us do feel that way. Sometimes with these patients, we feel like we've tried all the things that we said, and really nothing seems to be working. A second pair of eyes can really help because sometimes we get tunnel vision, and then we forget that, maybe you didn't try the nortriptyline, for example, and just kind of go back to getting a fresh pair of eyes. A lot of us are using crowdsourcing these days, a lot of groups of other urogynecologists, there's an aux group, and then there's other informal ones as well. And then, again, going back to the beginning and seeing where maybe you may have skipped a step. Um, next slide. These are references. Yeah, and I think we're right about at time, though. Yeah, it was perfect timing. I thank you all for joining us, but we're open for any comments. I see we've got a lot of questions in the Q&A box here. Thank you, Mary. Yeah. All right. Thank you both so much for that very insightful presentation. And like we said, now it's time for questions. So please use the Q&A feature like most of you have already been doing on the webinar to ask questions. And I will read out each question and then I'll give the presenters an opportunity to answer them. So let me scroll up to the top here. All right, we'll just start at the beginning and get through as many as we have time for. The first question is, do either of you have a lot of patients who complain of breast tenderness with using vaginal estrogen? And how do you manage that? Um, I have some patients complain of that. And really, I leave it up to the patient's comfort. Most patients become very worrisome of the breast tenderness, despite my counseling that it's it's, you know, a common side effect, it's okay, it doesn't mean anything bad's happening. But if she's uncomfortable, I tell her, okay, fine, just drop it. You don't have to do it. How about you, Jess? Oh, I was gonna say the exact same thing. It's, it's, even though it more likely is fine, it's very hard to convince a patient that this kind of symptom, everything is going to be okay. So yeah. Okay. Um, next question, any thoughts or experience with the many over the counter bladder repair supplements such as CysterProtect, CystaQ, or freeze dried aloe vera? Oh, I haven't heard of these. This is this is what we like, you know, when you guys bring new things to the table. So I'd like to find out more about these things. I'm not sure if the original commenter wanted to give any of your own personal experience on these over the counter supplements. I'll say if something seems benign and a patient's tried it and it's helped, I say go, I say go for it typically. Okay. All right. And then what is your threshold for And then what is your threshold for considering Elmeron given the known issues with the retinopathy? I don't prescribe it. I don't prescribe it either. Okay. How do you handle post bladder installation pain? So I counsel my patients ahead of time that they're going to get a flare up with the first installation and that may occur in a fraction of patients. And to ride it out, it takes 72 hours to go back to baseline. And baseline is baseline. It doesn't mean you're any better than when you walked into the office. I have very few patients who continue to have post installation pain. But if each one of their installations about three installations, and she's still having that post installation pain, then I feel like I'm just making it worse with installations. And at that point, I may discontinue. Yeah, and hopefully that if you're doing the jelly at the beginning, that can help some sometimes I asked him, what do you typically take for pain if you take ibuprofen, I'll tell them take that 30 minutes before. And then I also don't have them hold it for so long. So with with I see sometimes we have patients hold their bladder installations, you know, a minimum of 30 minutes, and then sometimes maybe longer to see if that helps kind of give a little bit of but this is more I've envisioned that they have to use it has to go through the urethra with without an over descended bladder and as comfortably as possible. So I typically will also not let them hold it for more than 30 minutes. Is there any known addiction for gabapentin? Do you worry about using it frequently? Not that I know of. I haven't come across that. Next question, are you familiar with postural after contractions of skeletal muscle? This can be a source of voiding dysfunction, like start and stop voiding or incomplete voiding. If, if I understand the question correctly, might have to do with like breathing exercises to help with pelvic floor relaxation. So I don't know if that's how you're reading it as well. I'm just reading as as a yet different different positions can bring on a pelvic contraction involuntarily. So if that's the case, then I think it even in that case, pelvic floor PT would be a good treatment option. Along the lines of pelvic PT, someone asked for clarification about E-STEM, if you could describe it a little bit. So it's, it's basically like a muscle stimulate stimulator. Oftentimes it has to do with pads, like stimulating pads that are attached. And then if you think about almost as if you disconnected, like when you're doing urgent PC or PTNS, you have the needle and then you have the stimulator attached. They don't, the needle is separate. So that's the dry needling. And then the stimulator is separate. They're not actually connected in, in pelvic floor physical therapy offices. Got it. We had someone present a case or ask about a case. So they're asking about a 15 year old with occasional urethral burning and pressure not related to menstrual cycles. Urine culture has been negative and other cultures, vaginal culture is also negative. What else should they be doing to manage this type of young patient? Don't do a urethral dilation. I think, yeah, I would just be careful because this is kind of the beginning of the story of a lot of these patients where they've had these issues as a pediatric patient, and then they end up in, you know, some offices where they're getting, you know, urethral dilations. And I tend to see them, you know, 30 years later when they're now traumatized, like, there's this kind of like trauma. And now the pelvic floor remembers and the urethra remembers. So I would start with topical probably, I mean, of the list that we went through. And probably her diet. I mean, she's 15 years old, I wonder what she's taking in. Trying to reduce anything that may be pro inflammatory fried foods, highly processed foods, soda, or caffeine. And then also maybe stress level, I don't know what kind of 15 year old is she is, if she's, you know, one of those who's who always wants to get straight A's, maybe this is a way that the stress is coming out. I'm not sure. But that may be something to talk to her about, too. Another question, would you rule out a diverticulum for this 15 year old? For sure. I mean, absolutely. I mean, you want to do an exam, like that's the beginning, right? So thorough history, physical exam. And we had, you know, we talked about imaging when we did our roundtable, we talked about imaging and patients, and then we ended up kind of taking it out, because we assume like, Oh, if you if you're considering something structural, then you may want to consider imaging, but that might be someone. All right, our next question is, are your physical therapists dry needling the urethra? Or what exactly are they use? Where exactly are they doing the dry needling? The dry needling will probably be along the levators. And the idea here is that, that this is a whole complex of muscles that are integrated with each other. And so if we can relax one component, that that may then also translate into relaxation around what may be spasming around the urethra. So I don't think that they're dry needling the urethra directly. A question about injections in the office, are you using anything for anesthesia, like local anesthesia or some nitrous oxide? How do your patients tolerate it? I don't, I just counsel them on what it's going to be like. And oftentimes, I give them the worst scenario. Somehow, they still agree to do it in the office. But they're, they're, you know, women, so they're brave. And, and oftentimes, they'll say it was a little bit better than than what they expected, because it's really the anticipation, the anxiety of the, the anticipation that, you know, you're not going to be the anticipation that I think creates more pain in their mind. But I don't do anything extra. Jess, how about you? They don't either, they typically tolerate the injections. Well, I mean, I also select the patient, right? Like if it's a patient who can tolerate enough of an exam that I can, I can do it, then sure, it's not going to be the first, you know, line for urethral pain, they have to be situational. I'm assuming they're talking about trigger point injections, or we had talked, I think we had talked a little bit about having used urethra, periurethral injections in the past, even almost like as a semi diagnostic, semi therapeutic intervention that in very particular patients that may also be helpful. There was a comment about the office injections that use of an Iowa trumpet helps to make them easier. Do you, either of you use a trumpet when you're doing your pelvic floor injections? I don't know what a trumpet specifically is, but I just take a spinal needle and I cut, I just cut the sheet, the plastic sheet about a centimeter short, and then I use that as a guide and then safe, easy, cheap. Yeah, I use, I do the same thing as Jessica, or I have, if I have a pedundal block kit, I'll use it and that comes with a trumpet. Yeah. Okay. And are you locating the trigger points? Sorry, how are you locating the trigger points in the various muscles by palpation? Yeah, digitally on a, on an exam. So you go in and and you locate each muscle group, right? Your puborectalis, your pubococcygeus, your iliococcygeus, bilaterally internal obturator, you can locate that by having the patient abduct her thigh. So I place, or my MA will have her knee on the outside, her, sorry, their hand on the outside of her knee and the patient will push out towards the hand. And then the internal obturator bulges out. And if you poke at that, and she jumps, you found a trigger point. Same thing with the external obturator by just palpate that as well, you can identify it. So that's how we, I think we both do the same thing, Jess, right? Next question is about insurance coverage and the codes that you're using for Botox and pelvic floor injections in the office. So for Botox, again, I use the Xeomin. It's not covered. So the patient, the way that we do it here in the office is that the patient will create an account with CVS Care Mark. We found that to be very reliable pharmacy. And I, once she creates that account, I prescribe the Xeomin 200 units, and they send it directly to my office. But in that the patient has to pay for it out of pocket, and it's about $1,100 per vial. And, and then I coded as a trigger point injection. And that's how the office will get reimbursed with that coding. Yeah, sometimes I'll, it's typically not the first thing that we'll try. We'll try the trigger point injections without the Botox. The patient has a lot of relief and want something that may last longer than we talked to them about how we can do that. And of course, there's going to be an out of pocket expense for those particular type of patients. They asked if you guys could go back to the reference slide just to review while we're finishing questions. Okay. And then how do you treat women with urethral pain who don't seem to fit into the three overarching themes that you discussed today? What would you do next? I think it's to me would start local localized. So, you know, you know, again, not, I see not diagnosed with IC, but you'll start with topicals, you'll start with Gabapentin, you'll start with the nortriptyline. So it's like the PO and the topical compounds that we talked about, those would probably be the ones if it's, if it feels to you just pure urethra. And I think that it would also be important at that point to let the patient know that understanding the ideology of this pain may be impossible. And I think that that's often what patients are looking for is the, why is this happening to me? And so if that can be explained, perhaps she'd be a little bit more open to trying other therapies that she may not have already tried. And then if you could mention again, the type of patient that you utilize Flomax for. So it would be the patient who has urethral pain, as well as some level of dysfunctional voiding, like a stop and go flow, or, or she says she feels it's spasming, which some patients will tell you that maybe incomplete emptying that is intermittent. And, and I know I've come across those patients where I'll do a bladder scan, and there's a lot left over catheter, there's a lot, you know, not not retention level, but, you know, incomplete emptying, like anything less than 300. And then next time she's there, because I want to check it again. It's fine. But some of these patients will say that when they're having the pain, they're not able to empty completely. So those are the types of patients where you might want to consider trying the Flomax. And next is if you when you've run through all of these options, and you see that there's significant urethral inflammation on urethroscopy, is there any role for ablative therapy? Sorry, can you repeat that question one more time? For sure. Let's say you've run through all of these options, and there is significant urethral inflammation when you're doing your systole urethroscopy. Is there any role for ablative therapy? Ablative, like to ablate what? Like to ablate the urethra? I'd love to hear more details about that question. Let me see if the commenter will ask it or give us some follow up information. Moving on to the next. Speaking of crowdsourcing, can you share your email with us if we ever want to discuss a case in the future, or it would just be best to go through the AUGS Communication Board? I think we're supposed to promote the AUGS Communication Board. We have Women in FPMRS Facebook group that I know where we do some crowdsourcing on there. I don't know if there's any other Euroguide Facebook groups. We can always share our email. Thank you. We just have time probably for one more question. Quickly, what has been your experience with the Xeomin, and how do you inject it, or why choose that over Botox? The Xeomin is a pure form of botulinum toxin. Which is different than Botox, because Botox has preservatives. It does not have to be refrigerated like Botox, which does have to be refrigerated. That's what makes it so easy when it's getting mailed over, and then we're calling the patient to come in once we've received it, because it can stay at room temperature. Also, because it is a more pure form of toxin A, it may trigger less side effects or reactions, and may also trigger less antibody formation. Those are the reasons why I like using the Xeomin over any Botox. All right. Well, we had a really wonderful discussion. On behalf of AUGS, I'd like to thank our two faculty for this excellent webinar. Everyone, please be sure to register for our upcoming webinars. On April 24th, the joint coloplast sponsored webinar titled, How do single incision slings compare to retrocubic and trans-obturator slings? And then on May 15th, Dr. Roseanne Koh will present a webinar titled Incorporating Vaginal Hysterectomy into the Armamentarium of the Minimally Invasive GYN Surgeon. Just as a reminder, please follow AUGS on Twitter and Instagram, and check out our website for information on all of the upcoming webinars. Thank you all for joining in this discussion, and have a great evening.

urethral pain

women

treatment options

phenotypes

multidisciplinary approach

vaginal estrogen

trigger point injections

mental health

Xeomin

collaboration