John Park, Contance Houck, Nevil Sethna et al

A & A 2000;91:11-5

Bladder spasms have been a particularly difficult aspect of pain control in children that have had open bladder procedures. Epidural anesthesia has worked well for controlling most of the somatic pain but has been very inadequate to control the pain associated with bladder spasms. Opioids and anticholenergics have only been partly effective treatment modalities. Locally produced prostaglandins have been implicated as sensitizers of capsaicin sensitive C-fibers that are involved in involuntary bladder contraction. Prostaglandin production is increased in the setting of inflammation, outlet obstruction and mucosal injury. This study was designed to see if the NSAID, ketorolac,  a NS - cox inhibitor, could reduce the incidence and/or severity of postoperative bladder spasms in children.

Methods: A prospective, double-blinded, randomized study of 24 children (30 enrolled but 6 eventually excluded) greater than 4 years of age undergoing intravesicular ureteroneocystoscopy.  All patients had an epidural infusion (0.1% bupivacaine and 2 mcg/ml of fentanyl) for postoperative pain. Half the children received ketorolac, 0.5 mg/kg at the conclusion of surgery then q 6h for the next 48 hours. The other half received a saline placebo. Break through bladder spasm pain was treated with oxybutynin or diazepam. Bladder spasm incidence and severity were recorded.

Results: The groups were statistically similar.  Incidence of spasm was markedly reduced in the ketorolac group [25% (3/12) incidence vs. 83% (10/12) incidence with placebo].   Frequency of spasm also was also reduced, average of 1.9 episodes/patient compared to 5.9 episodes/patient with placebo. Severity of spasms and need for additional medication was also reduced.  No adverse effects of ketorolac noted.

Comments: Ketorolac is clearly effective in reducing the incidence and severity of bladder spasm after intravesicular ureteroneocystostomy.  Bladder spasm has been a challenge to control regardless of the form of postoperative pain management chosen. Epidural analgesia is excellent for the somatic discomfort but does little to alleviate the acute, sudden onset/offset of bladder spasm pain. This study has provided us with excellent evidence of the utility of a multimodality approach to postoperative pain management. It should be noted that at UNC, Dr. Bukowski has largely abandoned the intravesicular approach and usually does an extravesicular repair. The extravesicular repair may be less efficacious, but is associated with a much lower incidence of bladder spasm which is one of the primary reasons for its preference. Dr. Bukowski may reconsider using the intravesicular approach in some patients in light of this study.