You Are Here: IC
Network : Guest Lectures : Bruce Kahn, MD
- The Gynecologists Perspective"
& The Relationship of IC to Endometrosis, Vulvodynia, Vulvar Vestibulitis
Kahn, MD, FACOG,
Department of Obstetrics & Gynecology
Scripps Clinic & Research Institute, La Jolla CA
November 23, 2003
Dr. Kahn is a member of the Department of Obstetrics and Gynecology at
Scripps Clinic & Research Institute in La Jolla, CA. He completed
his undergraduate studies in Biological Sciences at the University of
California, Irvine. He received both his master's degree in physiology
and his medical degree at Georgetown University. He completed a medical
internship at St. Joseph Hospital and Healthcare Center in Chicago, Illinois
and then began a residency in the Division of Radiation Medicine at George
Washington University Medical Center in Washington DC. He then switched
career paths to Obstetrics & Gynecology and completed residency training
at Cedars-Sinai Medical Center in Los Angeles, CA and at Abington Memorial
Hospital, near Philadelphia, PA.
training, Dr. Kahn was commissioned as a Lieutenant Commander in the United
States Naval Reserve. He served on active duty as a staff physician in
the Department of Obstetrics & Gynecology at the Naval Medical Center,
San Diego. His duties there included patient care as well as teaching
resident physicians and medical students. During his "tour of duty",
he was appointed as Director of the Chronic Pelvic Pain Clinic. He also
received an initial appointment as a Clinical Instructor for the Department
of Reproductive Medicine at the University of California, San Diego (UCSD).
Following his active-duty
assignment, Dr. Kahn was recruited to the full-time faculty in the Department
of Reproductive Medicine at UCSD, where he was appointed as an Assistant
Clinical Professor of Reproductive Medicine and Director of Ambulatory
Gynecologic Services in Hillcrest. A major focus of his work at UCSD was
strengthening the residency-training program in primary healthcare for
Dr. Kahn joined the Department of Obstetrics & Gynecology at Scripps
Clinic in 1999. Soon after his arrival, he pioneered work in the department
and the region on the technique of laparoscopic supra-cervical hysterectomy.
Over one hundred patients have successfully undergone this procedure at
Scripps Clinic. Those patients have benefited in a much shorter recovery
from surgery compared with those who require traditional abdominal hysterectomy.
Dr. Kahn continues to work on the latest advances in medical and minimally
invasive surgical techniques for his patients.
Dr Kahn's commitment to teaching also continues. At Scripps Clinic, he
developed a clinical teaching program for advanced gynecologic surgery
for senior residents in obstetrics & gynecology. As part of this work,
he was appointed Assistant Adjunct Professor of Obstetrics & Gynecology
at the Uniformed Services University of the Health Sciences. He is currently
Director of Graduate Medical Education in Obstetrics & Gynecology
at Scripps Clinic. He also lectures nationally and internationally about
his research on chronic pain as well as other topics.
Dr. Kahn is a Fellow
of the American College of Obstetrics & Gynecology. He is a diplomate
of both the National Board of Medical Examiners and the American Board
of Obstetrics & Gynecology. He is a reviewer for the journal Obstetrics
& Gynecology. His clinical and research interests include the diagnosis
and treatment of pelvic and vulvar pain disorders, as well as the evaluation
and management of menstrual disorders, adnexal masses, pelvic relaxation,
vaginitis, sexually transmitted diseases, infertility, cervical dysplasias/HPV,
premenstrual syndrome, and menopause. He has several clinical research
trials currently underway.
he joins us to discuss IC from the gynecologist's perspective and also
to discuss the potassium sensitivity test and the relationship of IC to
endometriosis, vulvar vestibulitis, vulvodynia... etc. etc. Welcome Dr.
you very much for having me. It's really a pleasure and honor to be
invited to take part in this discussion group.
did you first become interested in IC?
my residency, I received a commission in the Naval Medical Corps and
was stationed at Naval Medical Center in San Diego (NMCSD). This was
one of the first medical centers in the country that described using
a multi-disciplinary approach to treating chronic pelvic pain (CPP)
in women back in the early 1980s. I started working there in the mid
90s and that's really where I began my journey learning to diagnose
and treat chronic pain in women. From there, I moved to UCSD and continued
to learn about treating pain in a multi-disciplinary fashion. It was
at UCSD that I met Lowell Parsons and he suggested that the bladder
might be involved in the chronic pain in many of my patients. This was
almost five years ago. Since then, I've been participating in clinical
trials exploring this association. The results we have uncovered have
been truly fascinating. My patients seem to be enjoying the results
was your first first reaction to Dr. Parson's theory. It is fair to say
that some obgyns don't believe in IC??
was interested and curious, but skeptical. Gynecologists generally don't
know about IC. They traditionally have not been trained to consider
the bladder when diagnosing and treating patients with chronic pain.
Most gynecologists don't focus on the bladder symptoms when they see
patients with chronic pain. As our research progressed, I learned that
the symptoms of IC very often overlap with other syndromes such as endometriosis,
vulvodynia, irritable bowel syndrome and fibromyalgia. Further, treatment
for one of these syndromes often helps symptoms in other body systems.
For instance, Elmiron has a common side effect of loose stools. This
is often a nice side effect for the patient with symptoms of IBS
worked with Dr. Parsons in conducting some ground breaking studies using
the potassium sensitivity test to diagnose IC in women with pelvic pain.
Can you tell us more about these studies?
first study was on a large group of women at four different gynecology
centers across the country. Women with complaints of chronic pelvic
pain were first assigned a "clinical diagnosis". That is,
we assigned a diagnosis after talking with and examining patients, before
any diagnostic procedures were performed. The diagnoses assigned included
common gynecologic problems such as endometriosis, vulvar vestibulitis,
recurrent yeast infections as well as IC and other conditions. We then
administered a questionnaire to screen for IC - the "PUF
Questionnaire". The PUF questionnaire was developed by
Dr. Parsons and can be filled out by patients in less than a minute.
It asks about frequency, urgency and pain as well as other symptoms.
It then rates their response numerically. A low PUF score suggests that
the bladder is not involved. A high PUF score indicates that the bladder
may be involved. We've found that this small survey helps us quickly
identify patients that may have IC. It's not a perfect screening test,
but it is a very helpful tool to quickly identify those patients that
may have IC. (link here to PUF questionnaire)
we administered a potassium sensitivity test (PST) to better identify
bladder involvement in chronic pelvic pain. The PST can help diagnose
patients who may have IC and/or a damaged bladder lining. Two solutions
are instilled into the bladder (H20 and KCL) to check for sensitivity
to either of these solutions. Water usually does not cause any reaction
(though sometimes it does). If a patient reacts to the KCL solution,
that suggests that their bladder wall is damaged and that they may be
an IC patient. (link here to KCL info) If patients have any reaction
to the potassium, then a third "rescue" solution containing
heparin and an anesthetic (lidocaine) is quickly instilled into the
bladder to relieve any symptoms the potassium may have caused. Some
feel that the test might be unduly painful or uncomfortable. At Scripps
Clinic, we take care to recognize any reaction to potassium quickly
and stop that part of the test immediately if a reaction occurs. We
have found that the test really only causes minimal discomfort, especially
when compared with the classic diagnostic test for IC - cystoscopy with
In our study, we
found that over 75% of women had significant urinary symptoms (nocturia,
frequency and urgency) and that over 85% reacted to the KCL test. Surprisingly,
we found that our original clinical diagnosis didn't matter. The rate
of positive testing on the KCL was fairly constant through all the clinical
diagnoses we had given to the patients. This suggested that the bladder
may be involved in other pelvic pain conditions or that these patients
may actually have IC rather than these other conditions.
Our second study
involved a larger group of patients evaluated in the same way. Their
symptoms and findings were compared with a control group of women. The
control group included volunteers with very low "PUF" scores
(2 or less). That is, these women had no urinary symptoms or pain. None
of the 47 women in the control group reacted to the potassium. I personally
did ten of these in my clinic. Before completing this study, I honestly
wasn't convinced on the relationship of the bladder to chronic pelvic
pain... These findings however, changed my understanding of the connection
between the bladder and chronic pelvic pain.
Currently, I don't
need to use the KCL test to diagnose IC. However, the notion that the
bladder is part of the problem is often a very "new" concept
for patients in my office. (Remember, I am a gynecologist.) I have found
the PST is often helpful for women to better understand the connection
between their bladder and their pain. Moving forward with treatment
for IC then makes more sense to these patients.
there women who don't believe that their bladder is causing some of these
I see a lot of women coming to see me with chronic pain problems who
think they have "ovarian" pain or recurrent yeast infections
or have intense pain with intercourse. These same women usually get
up several times at night to urinate or urinate 15 times a day (which
is high). They have had urinary symptoms for years and just never made
the association between these two things. They think their voiding habits
are normal. So, if I can reproduce the symptoms for which they came
to see me by simply instilling a potassium solution into their bladder,
it helps to make the connection more clear.
sounds like this has become a wonderful new clinical tool. Are other gynecologists
using it as well???
believe that the more gynecologists learn about the diagnosis and treatment
of IC, the more comfortable they will become helping women with this
problem. I have been giving lectures nationally to gynecologists across
the country and have been amazed at the interest doctors have shown.
Unfortunately, this is new territory for a lot of gynecologists, so
it will take some time before this becomes a routine part of patient
care and again, I don't truly think it is necessary prior to treatment.
walk a patient through a first visit in your clinic...
percent of a patient's first visit in my office is spent discussing
her medical history and the history of her pain. It's important to check
for symptoms in all the different organs in the pelvis, and to screen
for things such as endometriosis, IC, IBS, fibromyalgia, trigger points
as well as for symptoms of depression or anxiety. If I find that a patient
has symptoms from two or more organ systems, I begin to suspect that
IC may be involved, especially if their PUF score is higher than about
After our discussion,
I start with a gentle abdominal exam. I explore for the presence of
trigger points or generalized hypersensitivity in the muscles of the
abdominal wall. If a trigger point is present, I often will anaesthetize
this small area (like a dentist anesthetizes a tooth) before doing a
pelvic exam. I probably perform 12 of these a month and 9 or 10 of the
injections will result in significant and immediate pain relief. This
indicates that muscles are commonly involved in chronic pelvic pain.
A few trigger point injections given over a several weeks can often
result in long-lasting pain relief in that small area. (This is an example
of multi-modal therapy for chronic pain.)
I seldom find that
the whole problem is in one organ system. More often, I find evidence
of multi-organ dysfunction.
Then, I perform
a traditional pelvic exam but I also check for things such as pelvic
muscle and bladder tenderness. Finally, if the history and physical
exam indicate that IC may be involved, I finish up by discussing this
possibility. I then direct the patient to places such as the ICN and
ICA to learn more about IC. I point them there first before diagnostic
testing because I think it's important that they learn about the problem
first. I strongly feel that one of the best ways to treat IC is to put
women in charge of managing the problem. Knowledge is power. I see myself
as a facilitator of that process.
of the "dark secrets" of IC is that some patients experience
this very odd sensation of arousal that can come and go. It can be very
uncomfortable and painful. Because it's embarrassing, patients often don't
tell their doctors about it. Have you seen anything similar to this??
must admit that I don't ask specifically about this, though I do always
ask about pain women have during and/or after intercourse and have seen
a lot of women with this problem. Pain associated with sexual activity
can range from arousal pain to flares of pain that last several days
after intercourse. I think that this is probably part of IC, but sometimes
there are discrete trigger points in the vulvar area that can be treated
The PUF questionnaire
is a good tool for exploring pain associated with sexual function. It
contains questions specifically related to this. Often it is difficult
for women to openly talk about this problem. The PUF questionnaire however
is just a piece of paper. Some women find answering a question on a
piece of paper much easier than discussing the problem verbally.
Kahn, one of things that patients ask about all the time is if there is
a relationship between IC and endometriosis. Could you please give us
your thoughts on this?? Let me qualify that by saying that some patients
feel that their endometriosis may have contributed to the onset of their
IC, while others have been mistakenly diagnosed with endometriosis only
to discover that they had IC instead. Talk about confusing. Your thoughts?
think the relationship between endometriosis and IC is pain. I further
believe these syndromes are different manifestations of the same problem
- visceral pain.
a painful syndrome diagnosed mostly by gynecologists that includes symptoms
of cyclic pelvic pain related to the menstrual cycle, pain with intercourse,
and the presence of endometrial tissue outside of the uterus - on the
lining of the pelvis, on the ovaries or fallopian tubes. Endometrial
tissue is usually found only on the inside lining of the uterus. The
presence of this tissue type outside the uterine lining is what "defines"
currently think the only way to correctly diagnose endometriosis is
through laparoscopic surgery. The problem with this model is that many
women with severe endometriosis have NO pain whereas women with very
little endometriosis can have severe pain. Yes, the treatments for endometriosis
do work. But perhaps they work in ways we do not yet understand
I personally doubt that the endometrial implants in the pelvis are the
cause of pain. I think pain is the problem. Pain can be manipulated
with hormones or with surgical treatments. I usually favor medical therapy
over a surgical approach to chronic pain.
IC is "defined"
as the presence of abnormalities in the bladder wall that can be seen
during cystoscopy. Many urologists feel that the only way to diagnose
IC is through cystoscopy with hydro-distension. However if the diagnosis
of IC is restricted to women with surgical evidence of disease, then
a lot of women with IC will be missed. I think that this model of IC
has the same problems as the model for endometriosis described above.
Personally, I believe
that the findings that gynecologists observe in the pelvis at surgery
(endometrial implants) are about as significant as the findings of urologists
at cystoscopy (petechial hemorrhages) for IC. In other words, I don't
think that they really matter. What matters is the PAIN. These women
feel pain. The pain is visceral pain - pain that is mediated through
the nerves of the visceral (abdominal) organs.
did a year long survey of patients asking them what they felt triggered
their symptoms. The results were very interesting. The #1 correlation
that we saw was with a UTI. Some patients developed IC after having a
UTI that was treated with antibiotics but their symptoms remained. Other
patients reported that their symptoms began after some type of abdominal
surgery or after having a baby. Does that correlate at all with what you've
think that endometriosis, IC IBS and sometimes fibromyalgia are all
different manifestations of visceral pain. The nerve fibers that transmit
pain signals in the pelvis run through visceral nerve pathways. These
are the nerves that run next to the motor nerves for the viscera - the
bowel and bladder and the gynecologic organs - and that's why you the
see the overlapping conditions of constipation, diarrhea, frequency,
urgency or pain related to sexual intercourse.
There are several
possible causes of visceral pain. I think that most pelvic pain begins
with an injury or a trigger of some sort. The nerves in the pelvis that
transmit pain then become hypersensitive. That is, they become and remain
more sensitive than normal. What results is that a sensation that should
feel like "soft-touch" is then perceived as pain.
The triggers of
chronic pain in the pelvis can be from any physical injury or psychologic
trauma. The triggers you mentioned or others such as an ovarian cyst,
a tubal infection or even a history of sexual abuse or rape are just
a few examples of triggers for chronic pelvic pain.
There is a large
body of data indicating that women with a history of sexual abuse or
rape have an increased incidence of chronic pelvic pain. This does NOT
mean that most women with chronic pelvic pain (or IC) have been a victim
of sexual assault. But I do believe that the trauma of sexual abuse
can cause nerves in the pelvis to become hypersensitive every bit as
much as can a physical trauma like a urine infection or an ovarian cyst.
Sexual assault is a physically painful event associated with terrible
psychologic trauma. Compare this with childbirth: This is a physically
painful event that is usually associated with an emotionally wonderful
experience. This is why childbirth is not usually associated with chronic
pelvic pain. Most importantly, it is not "all in her head".
It is real physical pain.
move on to vulvodynia. Many IC patients struggle with vulvar sensitivities
and pain. In fact, for many years, we've called vulvodynia "IC on
the outside." Do you see vulvodynia as more of referred pain from
the bladder ... or just a totally separate visceral pain event??
also believe that most vulvar pain has a bladder association. My partner,
Dr. John Willems, is a national expert on vulvodynia. He started his
work with Dr. Friedrich, the person who first described vulvodynia in
the literature. Working with Dr. Willems, I've seen a lot of patients
with vulvar pain.
There are two main
categories of patients that I see with vulvar pain.
in whom the entire vulvar region hurts - (e.g., vulvodynia)
· Patients with pain in very small discreet areas of the vulva
- (e.g., vulvar vestibulitis)
Some have pain constantly
and other have it only when the area is touched or stimulated. There
is also a large group of women I see that have symptoms of recurrent
"yeast" infections. They have the burning and itching of a
yeast infection but they don't have the characteristic thick white discharge.
In our studies,
we've observed women with all these types of vulvar pain and we found
that most of them also have IC. So, the answer to your question is that
I think that a lot of women with vulvodynia have IC. I have a manuscript
in preparation focusing on these findings. My hope is that other gynecologists
will start to consider IC in women who have these symptoms. Vulvar pain
is a truly difficult area for many gynecologists. Uncovering this relationship
will potentially help thousands of women receive more successful treatment
for their vulvar pain.
patients with vulvodynia flare??
Common causes of flares can be related to a variety of stressors such
as menstruation, intercourse, diet, chemical sensitivities, travel,
clothing, just to name a few.
do you normally treat vulvodynia???
a pure gynecologic perspective, calcium supplementation (calcium citrate)
is thought to be helpful. Some believe that oxalates in the urine can
trigger vulvar sensitivity. Calcium is believed to bind with the oxalates
and reduces the potential for irritation. Estrogen creams also can be
very helpful for treating vulvar pain. We also utilize biofeedback,
physical therapy, and even acupuncture. While there is data supporting
the use of surgery for vulvodynia, I have not utilized this mode of
therapy for patients with vulvar pain.
you find that women with vulvodynia have pelvic floor muscle issues??
sometimes. Many women have what is called "pelvic floor dysfunction"
which is a chronic contraction of the pelvic floor muscles. There are
theories that this is related to potassium leak from the bladder, but
no direct evidence of this connection exists. Many women find relief
through biofeedback and physical therapy for these particular symptoms,
though I think that treatment for IC often helps as well.
Audience Questions Begin ----------------------------
[icnmgrjill] Morgan asks "Do you think that some women have had
hysterectomies for their IC that they really didn't need? (i.e. that they
had the same pain symptoms before and after the surgery)"
[DrBruceKahn] Yes, but I don't think that the doctors have necessarily
done something "wrong". The practice of medicine changes as
new information becomes available from studies. Hysterectomy has been
a standard treatment for pelvic pain for many years. There also is a
fair body of published research data supporting the effectiveness of
hysterectomy in the treatment of chronic pain. This doesn't mean that
it works all the time or nor that it is the best way to treat the pain.
As we learn more about pelvic pain, we are learning that non-surgical
treatment sometimes works better. This is however, relatively new territory
in gynecology. Most doctors honestly do the best they can for their
patients. As our knowledge advances, our treatments change.
says... Fibro and endo are autoimmune. Do you think that IC is also an
There is a fair body of evidence that the immune system is involved
in IC. Mast cells are immune system cells that have been found in increased
concentrations in the bladder walls of IC patients. Other immune system
cells have been found in increased concentration in the pelvises of
women with endometriosis. These cells release substances like histamine
that generate an inflammatory reaction. Inflammation causes pain. Hopefully,
over the next several years, we will gain a better understanding of
the connection of the immune system with chronic pain. I hope to be
involved in this research. I am optimistic that new treatments that
modulate the immune system response and decrease pain will emerge from
would be best way that a patient can work with their gynecologist to get
the best treatment possible?
in charge of the problem is the best thing that you can do. Physicians
will have varying levels of knowledge about IC. If you have a physician
who is open to the idea and interested, there are resources available
where he or she can learn more about IC. I'm happy to speak with any
other doctors and would be happy to facilitate any practitioners who
are just learning about it.
My doctor has suggested that I have a hysterectomy to reduce my pelvic
pain. But, I'm confused
because my urologist says it's in my bladder.
Do hysterectomies reduce pelvic pain and/or bladder pain?
hysterectomy can help reduce pain. But it is more complicated than that.
I do not usually recommend hysterectomy as a treatment solely for pain.
My patients having hysterectomy most often have another reason for the
procedure such as recurrent cysts, large fibroids, or bleeding that
cannot be treated adequately with hormones. Removing these sources of
pain often relieve or reduce pain. But I seldom resort to hysterectomy
for endometriosis alone. Remember what I said about the relationship
of pain to ALL of the organs in the pelvis. What I have found is that
the more organ systems involved in the pain, the higher the likelihood
that treatment without surgery will be successful. This is why 90% of
patinet's first visit in my office is spent reviewing the history of
their pain and their symptoms in all their body systems.
How can we, the patient, help in the education of gynecologists for IC??
What can we do to help??
in charge of your care. Understand that different doctors will have
different levels of expertise in dealing with chronic pain. Visiting
a local or regional clinic that specializes in helping patients with
chronic pain can often be helpful. These clinics often will be able
to offer a multi-disciplinary approach to treatment. If you are in an
area where this is not feasible, and you have symptoms in multiple body
systems consider consulting with different specialists in your area
and ask them individually to help you integrate the treatments they
offer. Finally, understand that there are no one-size-fits-all treatments
for chronic pain. Patience and perseverance are often necessary to find
the combination of treatments that will work best to relieve pain. Further,
treatments will often vary with time (due to flares and remissions).
But know that there are lots of different treatments available to treat
chronic pain and most people CAN find long-term pain relief.
------------------- Audience Question & Answer Session Ends -------------------
Dr. Kahns Contact
Bruce S. Kahn, MD, FACOG
Department of Obstetrics & Gynecology
Scripps Clinic & Research Institute
Assistant Clinical Professor (Vol)
Department of Reproductive Medicine
University of California San Diego
10666 N. Torrey Pines Rd, MS-314
La Jolla, CA 92037
The necessary disclaimer:
Active and informed IC patients understand implicitly that no patient,
or website or presentation on a web site should be considered medical
advice. We strongly encourage you to discuss your medical care and treatments
with a trusted medical care provider. Only your personal provider can
and should give you medical advice. The opinions expressed by our speaker
may not represent the opinions of the IC Network.
© 2004, The IC
Network, All Rights Reserved.
This transcript may
is copyright protected and may not be reproduced or distributed without
written consent from the Interstitial Cystitis Network. For information,
please contact the ICN at (707)538-9442.