00:00 – Dr. Zimmern: It’s a wide open balloon of space so the cauterization on the surface doesn’t create
00:04 – any problem, you have a very nice thin scar on the surface like you see after
00:09 – any types of fulguration.
00:25 – Melissa: There were a few questions about whether for some people they would need to repeat the procedure.
00:30 – You just mentioned that that’s likely, especially in that case. How far apart would these procedures
00:35 – usually be or how long do you have to wait? Dr. Zimmern: Yes, so we’ve published on that, so we have some
00:40 – data that we can provide to you, but I typically wait six months after the fulguration to make that
00:47 – decision on repeat treatments, just because I know it takes that time to heal in the bladder.
00:53 – The bladder is a very obviously wet environment, the healing takes forever,
01:00 – the scab takes some time. People will notice, you know, some pieces of tissue coming out
01:06 – in urine, sometimes with the blood as well, for a long time and so after the scab comes off, new
01:12 – tissue has to regrow. And I’ve used six months as a fairly safe timeline to re-evaluate everybody.
01:19 – Six months is where you have what we call endoscopic success or endoscopic failures. The success is a
01:26 – good prognosticator for me that they’re going to probably do quite well, but they could still
01:31 – get reinfected later on. We’ve had a few people like that where they were fine and then you go
01:35 – back and look five, six, ten years later and a new lesion has formed, so that’s fine, I mean if
01:41 – you have a chronic condition like diabetes where you’re more exposed to having infection or
01:45 – you’ve had chemotherapy or whatever happened in your life, you could have another infection
01:50 – in your lifetime because you still have plenty of bladder tissue in which bacteria can attach.
01:56 – If, on the other hand, they have some lesions seen at the time of that cystoscopy in the bladder,
02:03 – not everybody will necessarily progress. We’ve had people with some lesions that we saw but
02:07 – there were not that many and we just do nothing about it because the volume of
02:11 – infection sites in my opinion is not enough to really provoke a lot of infection. But
02:16 – I’ve been proven wrong on that, some people have progressed no matter what.
02:20 – These are the people who will continue to repeat fulguration but typically there is
02:25 – probably another three to six months between that six months check and when we go back just to see
02:30 – what the evolution is, and you see very quickly people keep recurring like they did before
02:36 – and especially if it’s the same bacteria again, then I will go back and and try to help them
02:41 – out the second time or a third time. We’ve added to those long as many times as we need.
02:47 – Melissa: Okay. Dr. Zimmern: Most of these patients by then cannot rely on
02:50 – antibiotics. They don’t have too many antibiotic choices, so we know it’s not something that the antibiotics will fix.
02:58 – That has been proven by their current history up until now, so what do we have left?
03:04 – It’s either I keep fighting at it with the cauterization which is the only tool I have
03:08 – right now until the better options come along, or in some desperate cases we end up having people
03:14 – requiring the bladder to be removed which is obviously a major decision. That happens a few times a year
03:20 – because we have nothing left and people are left with only one or two, you know,
03:23 – sometimes you just want to try the antibiotics for treatment, so they’ve been septic,
03:28 – hospitalized, you know, their life isn’t on the line. That’s a different story. Partially, extremely
03:35 – rare. I don’t want your readership to think that happens every five minutes, but you know.
03:41 – Melissa: Right. A couple of people asked about infection in the bladder neck and the urethra and whether
03:46 – that can be fulgurated. Dr. Zimmern: You have to be very careful when you do that because
03:51 – you can create scar and that can lead to stricture, so the answer in general I would say no.
03:57 – Some people have fairly large what we call polyps, inflammatory polyps, at the bladder neck.
04:02 – Cautious, you know, very cautious there when you cauterize, you only have to be very selective.
04:08 – If you end up cauterizing the whole area you will get bladder neck scarring.
04:15 – Melissa: Why isn’t scarring an issue in other areas in the bladder? Dr. Zimmern: Well because you’re flowing through that
04:20 – area so if it scars down and tightens the area you’d have trouble to empty your bladder.
04:25 – Melissa: And does this not happen in other areas in the bladder away from there?
04:30 – Dr. Zimmern: The bladder is a wide open balloon in space so the cauterization on the surface doesn’t create any problem.
04:37 – It heals and you have a very nice thin scar on the surface like you see after any type of fulguration, and that doesn’t cause any problem
04:45 – whatsoever because it’s just a superficial process. It doesn’t affect the deeper layers of the bladder.
04:51 – Melissa: So for people that do have infection in the bladder neck and the urethra, what would be the approach
04:55 – that you would take there if fulguration is not possible? Dr. Zimmern: It’s very infrequent, Melissa, that we
05:01 – see that, to be honest with you. I’ve seen a few cases that we call urethritis and that responds
05:07 – pretty well to antibiotics. At the bladder neck, it’s, as I said, you see sometimes
05:14 – polyps and you can leave them alone or just cauterize them, but again be very careful there.
05:21 – Melissa: How deeply does fulguration penetrate the lining of the bladder?
05:25 – Dr. Zimmern: Not much, it’s just on the surface. We have in fact some upcoming data on a few biopsies of
05:31 – those areas after they heal so
05:34 – I can reassure you it’s very very superficial. Melissa: Okay. And you mentioned that it’s done under anesthesia.
05:40 – Does it hurt when you wake up? Dr. Zimmern: No not really when you wake up. We’ve done a few in the office
05:46 – when there are a few spots recently under local, so I think if you had only a few lesions you could
05:53 – try it in the office setting and the local, but not everybody’s going to tolerate that so I would say
06:00 – it’s so easy, you know, this a very light anesthesia and not feel anything and when you wake up now
06:05 – you don’t feel anything. Some people will feel like a burn, they will feel like it’s
06:11 – maybe more frequency and urgency, maybe. I think the number of people that have it done that
06:19 – say they really didn’t feel much is still the majority. We’re looking at that by the way, so
06:25 – we’ll have some data for you in the coming months. Melissa: Oh that’ll be good.
06:29 – Dr. Zimmern: I’ve been looking back at our
06:31 – first six months’ data to look at how many people have
06:36 – symptoms, need treatments or whatever afterwards, so because as a clinician you always remember
06:43 – a couple of people recently, you don’t necessarily remember the whole group.
06:46 – Melissa: Of course, that would be difficult. Dr. Zimmern: I tasked one of my students to go back to all my charts
06:52 – and electronic records and just
06:54 – tell me what happened to my patients based on their, my chart messages and phone calls and
07:03 – so I’ll be able to have a more scientific answer to your question. But I would say
07:08 – I ask people to take some time off, I don’t want them to have to drive.
07:12 – If they feel like they have to stop or pull over every 20 minutes
07:19 – But, you know, many of them come back and say “you forewarned me it’s going to be
07:23 – terrible, but it was really not bad at all.” I guess when you’ve been through bad bladder infections,
07:30 – it’s probably, you know, you’re ready for so much worse than what it is. So if you never had anything,
07:36 – it might be, you might feel it differently, but when you’re accustomed to having had problems
07:41 – in that area and a lot of pain and discomfort, you know,
07:47 – it’s very little compared to that prior experience, if what I’m saying makes sense?
07:52 – Melissa: Yeah, that makes sense, definitely. During the procedure, are nerves damaged and could this
07:57 – somehow provide more pain relief right afterwards?
08:01 – Dr. Zimmern: Well, you know there are nerves everywhere in the bladder, even very superficially.
08:05 – So obviously those nerves are going to be, you know, the end part of those nerves are going to be gone.
08:11 – I don’t know when there, if there is regeneration in the long term. That’s a good question.
08:17 – I have not heard anybody complaining of, you know, nervous pain or anything afterwards. If anything,
08:23 – it may decrease the sensitivity and make you more able to tolerate things in the future.
08:29 – You don’t have this, you know, super sensation from all this information being there anymore.
08:35 – Melissa: Yeah, I think that’s what what the question was around whether it could be beneficial in that way
08:40 – to have less sensitivity. Dr. Zimmern: Yes, people have really claimed that in some reports
08:41 – that there is less urgency, less frequency afterwards. It would be a way to treat people with this problem, so
08:56 – yeah it’s fairly understudied because we don’t have really great
09:00 – tools to assess that. We don’t have any great sensitivity tests or assays right now.
09:05 – Melissa: Okay. Dr. Zimmern: So keep that in mind for a future question in a few
09:08 – years when we revisit together. Melissa: Well we’ll keep an eye out, that’s for sure. Could fulguration
09:14 – be of benefit for those diagnosed with chronic UTI even if their bladder looks fine because they’ve been on long-term
09:20 – antibiotic treatment?
09:24 – Dr. Zimmern: I have not been in that situation. I’ve seen the opposite. People on long-term antibiotics have this
09:31 – chronic infection and that’s why every time they stop, it comes back. I don’t remember seeing too
09:37 – many people with completely normal bladders I have seen, and if they have normal bladders then I don’t
09:41 – know why I would fulgurate them. Nothing that I can see that seems wrong, I would leave
09:46 – them alone. So either on the day I scoped them they were better, because the bladder will
09:52 – change obviously from day to day, we do see people, I do see people that are placed on antibiotics
09:58 – chronically for like three months or six months, when you do sequential cystoscopy in the office
10:03 – you can notice an improvement, less redness, less debris floating in the bladder, it’s not as cloudy,
10:11 – they feel better. So you know, you can see that the antibiotics do work for some people
10:19 – more than others. And some you look, you take the pictures three months before or six months right
10:24 – now and you wouldn’t know which one is which because they look exactly the same. The antibiotics have
10:28 – done absolutely nothing. So, you know. Melissa: Are there any cases where the bladder is so
10:34 – damaged that you wouldn’t recommend fulguration? Dr. Zimmern: I’ve never given up on that because I know that
10:40 – the only alternative would be to remove the bladder if I did that, so… And I think most patients have
10:47 – been through that, so you know, they were glad they tried a simple approach like fulguration
10:54 – before committing to lifelong without the bladder. So no, I’ve never had this sentiment that
11:00 – you can tackle it, but it’s a much more complicated procedure, it takes a much longer time.
11:07 – So you schedule it, it’s not going to be 10, 15, 20 minutes. You have to schedule an hour and a half,
11:13 – possibly up to two hours. Much longer recovery, potentially more discomfort afterwards,
11:22 – so this becomes one of the exceptional situations, not the most
11:31 – common situation that we encounter. Melissa: Someone also asked the question about whether fulguration
11:37 – could help with non-bacterial infections, so potentially caused by virus or parasites.
11:45 – Dr. Zimmern: I wish I can answer that but we are far away from that. We will have an upcoming publication
11:50 – with Dr Donisko that will describe a little bit of the virome and what we find,
11:57 – but whether the fulguration helps, that’s a totally different question.
12:04 – That’s a big area of unknown right now. Melissa: And we do have one other question,
12:09 – it’s around fecal and urinary incontinence and how someone could keep the area clean in order to
12:15 – help prevent infection. Dr. Zimmern: Yeah, every time there are bowel issues, fecal
12:20 – incontinence, diarrhea,
12:23 – you really have to do your best to try to handle that.
12:26 – I defer to a colorectal team in those domains, that’s not something I practice, you know,
12:31 – on a daily basis, but it’s true that the increase of bacteria in the area
12:36 – can lead to infection. Now, I don’t know if you had kids and changed their diapers, but you
12:41 – could think that every kid should have a raging infection with the mixture of urine and poop that you
12:46 – have there, and they don’t, so obviously our bodies can handle lots of bacterial load without having
12:52 – problems with it. And that goes back to the discussion we had on the microbiome
12:57 – and your own natural defense mechanism, so I think there’s more to it than, you know,
13:03 – I don’t want to oversimplify that. We have women who have fecal incontinence who don’t have bladder
13:07 – infections, we have women who have both and that’s a problem and obviously we
13:12 – try to eliminate that problem by asking them to visit with the proper experts on that.