Submucosal injection of the steroid triamcinolone (Kenalog) is a safe, effective alternative to fulguration or laser ablation for treating Hunner's ulcers in interstitial cystitis patients.
Genoa G. Ferguson, MD, a resident at Washington University, St. Louis, reported that injection of triamcinolone at the lesion sites produced significant reductions in symptoms. The technique also avoids bladder perforation, a definite risk with fulguration.
In this prospective study, 30 patients underwent the cystoscopic procedure. With the patient under general anesthesia, the clinicians injected triamcinolone, 10 mL (40 mg/mL), in 0.5-mL aliquots through an endoscopic needle into the submucosal space at the center and periphery of the ulcers.
The team is now assessing longer-term results, which they hope to present at the 2010 AUA annual meeting, but the response at as much as a year looks durable, senior author Carl G. Klutke, MD, told Urology Times. In addition, the response to reinjection seems to be as good as the initial response, according to Dr. Klutke, professor of urologic surgery at Washington University.
When Dr. Klutke and his team have looked at the lesions again 1 or 2 months after injection, they seee the areas look much more normal. When symptoms recur, the lesions take on their typical appearance again.
Agent addresses inflammation
The rationale for triamcinolone injection is that Hunner's ulcers are thought to be focal areas of chronic inflammation, and the procedures used to treat them today-fulguration, lasering, resection, and even partial cystectomy-really aren't addressing the underlying problem of inflammation.
"So why not inject something that settles down inflammation?" Dr. Klutke said. In the long run, he argued, fulguration will injure more tissue.
The team doesn't know whether triamcinolone is the ideal drug for this application, but it is inexpensive, readily available in every hospital pharmacy and operating room, and is a drug urologists have considerable experience using in the OR.
Dr. Klutke said that a multicenter study is being planned to compare the results of fulguration with this technique.
"When it comes to pain, we feel steroids are going to stack up very well, if not better, than fulguration," he said.
But even before the team has the results, for Dr. Klutke, the procedure of choice is clear. Certainly, resection is an invasive procedure that's risky for older patients, but even with fulguration, there is a risk of bladder perforation.
"If you can get good response for a year and then duplicate that response in a repeat procedure that takes no longer than 15 minutes and doesn't involve any incisions at all, I don't know too many people who would opt for the more aggressive approach," Dr. Klutke said.
"This is less invasive, has fewer potential complications, and the benefits are very high. I personally would recommend doing this for anybody who has a Hunner's ulcer."