Urethral pain syndrome is pain around or inside the urethra at rest or before, during or after urination. Urologists have considered that those are urethritis or cystitis. Nowadays other idea is widely held – urethral pain could be pain due myofascial reaction of pelvic floor muscles as well as other types of pelvic pain.
Hypertonia of muscles, listed below could be reason of urethral pain and dysfunction:
- m. bulbospongiosus
- m. puborectalis
- external sphincter urethrae
- m. obturatorius internus
- m. puboperineal
- Compressor urethrae
- Urethrovaginal sphincter
The botulinic toxin’s (BTX)injections widely used in urology for treatment overactive bladder and other voiding dysfunctions. BT injections for treatment of overactive pelvic floor are not so well known but it goes up. We use BT injections in our clinic for treatment of urethral pain due myofascial reaction with promised results. Particularly in female cases. The trouble is price of BTX. 70% of our patients can’t afford it. Recently we’ve started use the cryolesion procedure for pudendal neuralgia’s treatment. We have the device “Cryo S Electric” (Metrum Cryoflex,LLC) , supplied thin needle-like cryoprobes.
The freezing and further defrosting leads to neuropraxia of sensory fibers, that in turn can provoke reflectory muscle’s relaxation. Also, we can suppose, that direct impact to motor fibers can leads to muscles relaxation too. We decided to check this hypothesis with female patient, with good response for BTX.
Introduction: Female patient 41 years old suffered of painful urination and pain after urination. Pain intensity is 6-7 VAS. Urodynamic investigation showed: FDV 509 ml, MCC 850 ml, Urethral Pressure (UP) 112 cm H2O.
After injection of 100 U botulinum toxin into four spots around urethra (12, 3, 6, 9 clock dial), pain intensity reduced to 1-2 VAS and UP reduced to 58 cm H2O.
Cryolesion (cryoanalgesia) is promised method of pain treatment as well as myofascial reaction's treatment. Wide range of cryoprobes now available in the market. (www.metrum.com.pl) We are beleived that urethral pain syndrome is kind of myofascial pain. So, we decided to cure this patient with cryolesion.
Method: A year after last botulinum toxin injection we evaluated the patient. Pain intensity was 6, UP - 98 cm H2O. We performed local anaesthesia with 1% lidocaine injection into four spots (12, 3, 6, 9 clock dial). Depth of injections was 25 mm. Urethral length was 38 mm. After that we insert the cryoprobe G16 (1.3 mm) with 10 mm triangle working tip into spot, located at 12 clock dial, 5 mm from meatus. Depth of cryoprobe placement was 20 mm. For the purpose of urethra protection we put cystoscope in urethra and checked probe placement. Also, urethra was irrigated warm saline through cystoscope, even cryoprobe manufacturer informed that it is not necessary. Cryoprobe was frozen two times in 2 minutes. The procedure was repeated with another three spots (3, 6, 9 clock dial).
Results: patient was evaluated a week after procedure. Pain intensity reduced to 2 VAS and UP decreased to 65 cm H2O. Now follow-up is three months and VAS intensity is 1 - 3.
Conclusion: cryolesion (cryoanalgesia) can be promised method for urethral pain treatment. Certainly, further trial is needed.
Y.Mirkin, A.Karapetyan, S.Shumoff (URO-PRO Clinics)
Global congress on LUTD