Introduction

This is an outpatient procedure during which a tube (catheter) is first inserted into the bladder, and a medication is infused through so that it can coat the inside of the bladder for a short time.

In Urology, this procedure is primarily used to treat superficial bladder cancer, bladder pain syndrome and also to prevent urinary tract infections.

Treatment of superficial bladder cancer

There are 2 classes of medications used to treat superficial bladder cancer: chemotherapy (Mitomycin C, Gemcitabine) and immunotherapy (BCG) drugs.

Mitomycin C or Gemcitabine

• Mitomycin C and Gemcitabine are two examples of chemotherapy drugs that can be instilled into the bladder to treat low-grade, superficial bladder cancer. It is sometimes given immediately after an operation to resect a bladder tumour (transurethral resection of bladder tumour – TURBT). It can also be given on a weekly basis for 6 weeks.
• It can prevent new bladder tumours from reforming after all known ones have been resected.
• It is generally well tolerated but can cause more frequent urges to urinate and burning during voiding. If it comes into contact with the skin, it can also cause irritation or rashes.

Bacillus Calmette-Guérin (BCG)

• BCG is a vaccine used against tuberculosis, which is made of a weakened strain of the tuberculosis bacteria. In the 1970s, it was shown to be effective in treating bladder cancer, when instilled into the bladder. It is the more commonly used immunotherapy drug for bladder cancer and acts by stimulating the body’s immune system to destroy tumour cells.
• BCG can reduce the new formation of cancer and also the progression of a superficial tumour into an invasive one. It can also treat a more aggressive form of superficial bladder cancer called carcinoma-in-situ (CIS).
• BCG can be given as a weekly treatment over 6 weeks (induction course) and also given as a 3-week course every 3 to 6 months over 3 years (maintenance course).
• BCG is not suitable for those who have poor bodily immunity (e.g., diabetic, chronic debilitating illnesses, on long-term steroids, HIV / AIDS, blood cancers).
• BCG is more toxic compared to Mitomycin C and can cause side effects ranging from mild (burning during urination, frequent urges to urinate, fatigue, low-grade fever) to severe (infection of the blood system – sepsis in 0.4% of cases). The symptoms of sepsis include fevers, chills, confusion, nausea, and vomiting. If you develop these symptoms, you need to go to the hospital to be admitted for special antibiotic treatments. Other side effects include blood in the urine, infection of the urine and rarely, shrinking and stiffening of the bladder (bladder contracture).

How do I prepare for Mitomycin C, Gemcitabine or BCG treatment?

• You do not need to fast for this. Avoid drinking too much before you come. Your temperature will be taken when you arrive – if you have a fever, the procedure may be abandoned. A urine test is also done prior to the treatment to check for blood and infection in the urine. If these are present, the procedure is also postponed.
• With you lying down, some local anaesthetic gel is applied, and a catheter is then inserted using sterile techniques to drain your bladder. The medication is instilled into the bladder via the catheter, which is then clamped off for 2 hours. You will be asked to change your position every 15 minutes to ensure the whole inner lining of the bladder is coated with the medication. At the end of the treatment, the medication is drained from the bladder and the catheter is also removed and disposed of appropriately.

What do I do after Mitomycin C, Gemcitabine or BCG treatment?

• After the treatment, you should be able to go home and resume normal activities. If you were given BCG, you need to ensure that your first few voids at home do not come into contact with others in your family. Sit down on the toilet to urinate, flush the urine, then pour some bleach into the toilet and let it stay for about 2 minutes and then flush again.
• You will be given your next appointment for either another treatment, a consultation, or a cystoscopy (inspection of the bladder with a tube-like camera) check. Look out for the side effects of the drugs as described above. If you develop any problems, do not hesitate to contact us.

Treatment of bladder pain syndrome / interstitial cystitis (BPS / IC)

BPS / IC is a chronic, debilitating condition that is characterised by bladder pain amongst other symptoms. There are no known cures but there are many treatments that can help alleviate the symptoms. Bladder instillation therapy is one of several treatment options that may be effective. There are many drugs that can be instilled into the bladder; DMSO and Clorpactin are two drugs that will be discussed here. iAluRil can also be used for this indication (see below).

Dimethyl Sulfoxide (DMSO)

DMSO is a purified version of a chemical used as an industrial solvent that was found to have properties to treat BPS / IC. It is thought to reduce inflammation and works in about 50% of cases.

DMSO bladder instillation therapy protocols can vary but with us, DMSO is usually given once a week for 6 weeks, and then once a month for 3 months. Additional treatments may be needed if the symptoms relapse in the future. In those who respond, some patients notice an improvement immediately, and others improve a few weeks after the treatments.

Most do not get any discomfort. Side effects include bladder spasms and the frequent need to urinate (1 in 10) and also a peculiar garlic-like taste in the mouth and smell in the breath and body, which can last up to a day after a treatment.

How do I prepare for DMSO treatment?

• You do not need to fast for this. If you are possibly pregnant, please inform your doctor as DMSO can be harmful to the foetus and therefore should not be used in this case. Your urine will be checked for infection and if you have one, the procedure is postponed until your infection is treated.
• With you lying down, some local anaesthetic gel is applied, and a catheter is then inserted using sterile techniques to drain your bladder. The DMSO solution (50ml) is instilled into the bladder via the catheter, and the catheter is then clamped for about 15 – 20 minutes. You will be asked to change your position every few minutes to ensure the whole inner lining of the bladder is coated with the medication. At the end of the treatment, the DMSO is drained from the bladder and the catheter is also removed and disposed of appropriately.

What do I do after DMSO treatment?

• You should be able to go home and resume normal activities. Drink lots of water. Expect to have the garlic-like taste and smell for up to a day after treatment. Signs of a bladder infection (cloudy, smelly urine, frequent need to urinate, burning during urination) may be difficult to differentiate from a normal reaction to the DMSO (about 10% will have similar symptoms). But if the symptoms persist, see your doctor to have the urine tested.
• You will be given your next appointment for either another treatment or a consultation. If you’ve had this done before and this is a repeat treatment for symptom relapse, then we will wait to hear from you if you need another set of treatments in the future.

Clorpactin

Clorpactin solutions have been used in medicine to clean or irrigate wounds. It has also been shown to be effective in treating some patients with PBS / IC, when instilled into the bladder. Clorpactin is less well tolerated (more painful) than DMSO and therefore is usually given only if the patient does not respond to DMSO. The exact mechanism of action of Clorpactin is unknown. Some theories state that it causes partial sloughing of the inner layer of the bladder with subsequent regeneration of new nerve fibres. At higher concentrations, Clorpactin can be painful and is usually performed under anaesthesia.

There are 2 described protocols for using Clorpactin:

• Clorpactin 0.1% to 0.2% solution is instilled into the bladder one treatment per week for 6 weeks. This is done under local anaesthesia as an outpatient, with the patient awake. A catheter is first inserted to drain the bladder. Then the Clorpactin solution is instilled into the bladder to capacity, taking care not to over-distend it. This is drained after about 2 to 3 minutes. 2 to 3 instillations are done during every treatment. Because of the lower concentration used, most patients do not find this too uncomfortable.
• Clorpactin 0.4% solution is instilled into the bladder straight after a cystoscopy procedure during which the bladder has been stretched with fluid. This is drained after a dwell time of 2 to 3 minutes. About 3 to 4 instillations are done altogether. This must be done under general anaesthesia because the higher concentration of the solution used can be painful. The patient is usually admitted overnight for pain management. This is done as a single treatment only as compared to the previous regime.

How do I prepare for Clorpactin treatment?

If you are having general anaesthesia for this treatment, you will need to fast for at least 6 hours before surgery. Advise your doctor if you are taking any blood thinners or newer diabetic medications, as some of these must be stopped before the surgery.

You will usually stay one night after the surgery for observation and pain relief if needed.

In rare cases, Clorpactin has been described to cause scarring in the ureters (tubes draining the kidneys to the bladder). Therefore, before Clorpatin is used, an X-ray test needs to be done to exclude a pre-existing bladder condition in which urine can back-flow (reflux) up the ureters. This X-ray test can either be a voiding cysto-urethrogram or a video-urodynamics. Clorpactin can also cause chronic scarring and shrinkage of the bladder and hence prolonged administrations should be avoided.

What do I do after Clorpactin treatment?

Drink lots of water at home. You may expect mild amounts of blood in the urine. Take the pain relief medications if needed. You may have some bladder area pain initially after the procedure. Relief of the usual bladder pain may only occur a few days to a few weeks after the procedure. If you suspect symptoms of a bladder infection (burning, cloudy smelly urine, frequent urination), then see your GP to have the urine tested.

Treatment of recurrent urinary infections

Bladder instillation therapy may be a suitable option in some cases of recurrent urinary tract infections. There are different types of medications that can be used. Here, we will discuss the use of iAluRil.

Solution of sodium hyaluronate and sodium chondroitin sulphate (iAluRil)

The inner lining of the bladder (urothelium) is covered by a layer of small molecules called glycosaminoglycans (GAGs). This forms a protective barrier against toxic substances in the urine like bacteria, hence preventing them from getting absorbed. Hyaluronic acid and chondroitin sulphate play an important role in the GAGs layer. Imbalance of these can result in the onset of different bladder conditions such as recurrent infections, radiation cystitis or interstitial cystitis. iAluRil can help to re-establish the GAGs layer.

The Australian distributor is Actavis Pty Ltd (Phone: 1800 678 302).

How do I prepare for iAluRil treatment?

You will need to learn intermittent self-catheterisation first, to be able to give this treatment to yourself at home. In some patients, this can be done by a continence nurse who can insert the catheter.

Empty out the bladder first.

Via the catheter, the prefilled 50ml syringe of iAluRil solution is instilled into the bladder with a clean technique:

• Once a week for the first month.
• Once every 2 weeks the second month.
• Once a month until remission of symptoms.

For each treatment, keep the solution in the bladder for as long as possible (minimum 30 minutes).

What do I do after iAluRil treatment?

Most people do not get any discomfort. You may experience slightly worse urinary frequency or urgency for a short period. Drink lots of water after the treatment. Watch for a small risk of bladder infection and if you have symptoms (painful voiding, burning, cloudy smelly urine, frequent need to void), see your GP to get the urine tested and antibiotics if indicated.