Lidocaine-refractory interstitial cystitis patients may be aided by bupivacaine

May 15, 2010

Don't give up on instillation for interstitial cystitis when lidocaine doesn't help. Bupivacaine can come to the rescue.

St. Petersburg, FL-Don't give up on instillation for interstitial cystitis when lidocaine doesn't help. Bupivacaine can come to the rescue.

The patients for whom neither works also have a new treatment option-or a newly considered one-that IC specialists talked about here at the Society for Urodynamics and Female Urology winter meeting.

Dr. Quillin, a resident in the division of urology, presented the results of her and her team's retrospective chart review here. The study included 14 women and one man given 20-mL instillations of 0.5% bupivacaine after lidocaine instillation failure.

Of those, four patients achieved complete immediate relief (within 30 minutes) of their bladder pain and eight achieved partial relief. Only three experienced no relief.

The reason? "Bupivacaine is more lipophilic and more potent than lidocaine," said Dr. Quillin, who worked on the study with Deborah Erickson, MD, and Gwen Hooper, ARNP.

Because it's a single ingredient, bupivacaine has the added advantage of being easy for patients to use at home if they choose, noted Dr. Erickson, professor of surgery at the University of Kentucky.

Although patients who experienced partial or no relief tended to be older and to have had symptoms for a longer time, their one statistically significant distinguishing characteristic was having pelvic floor dysfunction (PFD).

Although the differences didn't reach statistical significance, those patients also tended to have constipation, which can be related to PFD, and back pain, which often accompanies PFD. In contrast, no patient who achieved complete relief from bupivacaine instillation had PFD or constipation.

Diazepam effective in PFD patients

For the patients with PFD, another simple treatment option may be very helpful: intravaginal diazepam (Valium).

Donna Carrico, NP, MS, working with Kenneth M. Peters, MD, at William Beaumont Hospital in Royal Oak, MI, presented a prospective study of 11 cases of women with PFD who used this treatment. Two of the women with PFD had IC, five had vulvodynia with PFD, two had vulvodynia (no PFD), and two had PFD only.

Although sometimes diazepam is compounded into creams or hypoallergenic suppositories for intravaginal use, some simply inserted the oral tablet into the vagina. The dosages ranged from 5 to 10 mg inserted up to every 8 hours.

Before treatment and after 1 month, the clinicians assessed levels of levator and vulvar pain. After 1 month of treatment, a global response assessment was completed, and serum levels of diazepam for the six daily users were measured. Seven of 11 (64%) of the women said they were markedly improved, mean pain scores for levator pain dropped from 7.2 to 3.5, and vulvar pain decreased from 3.1 to 1.9.

The effect is apparently local, and side effects were minimal. Serum diazepam levels in all the daily users were below normal or low normal (mean=0.29 μg/mL, norm=0.2-1.0 μg/mL). Seven of 11 women reported no side effects; four (36%) reported mild drowsiness.