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Banthine in Urologic Disorders
THE JOURNAL OF UROLOGY
Vol. 68, No. 3, September 1952 Printed in U.S.A.
BANTHINE IN UROLOGIC DISORDERS LESTER A. RISKIND
AND
HARRY A. ZIDE
Banthine is a quaternary ammonium salt with an anticholinergic effect acting in clinical doses on the parasympathetic autonomic ganglia and blocking the action of acetylcholine at the postganglionic nerve endings. In larger doses it blocks transmission through all the autonomic ganglia and in still larger doses it has a curare-like effect. It has been used clinically for the past few years with good results in the treatment of peptic ulcer. One of its side effects is bladder wall relaxation causing urinary retention which has been quite marked in cases of obstruction of the bladder neck. The occurrence of urinary retention has led the author to the use of banthine in cases associated with urgency and increased frequency of micturition. The detrusor muscle of the bladder is innervated by the parasympathetic fibers arising from the first to the fourth sacral spinal segments. These fibers are conveyed to the bladder in the pelvic nerves and connect with the ganglion cells lying in close relation to the bladder wall. Centers for micturition lie in the midbrain, hind brain and spinal cord. There is also a center in the premotor cortex and local reflex arcs occur in the bladder wall. Conceivably banthine will exert its anticholinergic effect on the bladder as it does elsewhere in the body. This would result in the opposite effect of doryl, urecholine and mecholyl. In a urologic practice many patients are seen, especially women, who complain bitterly of frequency and urgency associated with a small capacity of the bladder. Examination of these patients may reveal chronic trigonitis the cause of which cannot be determined, or frequently nothing is found in the bladder. Despite the use of all known medications the symptoms continue unabated. Frequently these cases are due to severe emotional states which lead to the vicious cycle of frequency, urgency and decreased capacity of the bladder. If, in these cases, the efferent stimuli to the bladder could be blocked or depressed the vicious cycle would be broken and the symptoms would decrease or disappear. Because of the above reasons and the relative safety of banthine, the author decided to use it in the types of cases described below. RUNNER'S ULCER
Case 1. F., aged 50, gross hematuria 1947, cystotomy and fulguration of a bleeding ulcer without relief. Runner's ulcer diagnosed 1947. No healing with any form of medication, frequent attacks of pyelonephritis necessitating prolonged hospitalization. Morphine addiction occurred because of severe pain. While preparations were being made for a bilateral ureteral transplant, banthine was given September 1950, 100 mg. q.i.d. In a few days, symptoms considerably relieved and patient was able to get out of bed. In 1 month patient able to work and continued to take banthine for 6 more months without any other type of therapy. Five months ago patient discontinued banthine and has taken no medication. Cystoscopy September 10, 1951: bladder capacity 300 cc., bladder wall normal 636
BANTHINE IN UROLOGIC DISORDERS
637
in appearance with avascular area at site of previous ulcer. Patient believes she is cured and does not require treatment. A detailed discussion of this case will be published later. Case 2. F., aged 62, Runner's ulcer 3 years duration. Previous treatment of no avail; banthine started February 1951, marked relief of symptoms. Symptoms aggravated with discontinuance of banthine; emotional strain requires increased dose of banthine. Case 3. F., aged 32, Runner's ulcer 6 weeks' duration, chronic cystitis 2 years. Banthine started with almost complete relief of symptoms. Cystoscopy 1 month after therapy revealed ulcer still present but smaller in area. TRIGONAL CYSTITIS
This is an inflammation of the trigone of the bladder characterized by a greatly increased vascularization of the trigone or edema of the trigone which usually decreases towards the ureteral orifices; the edematous area may be dull red but more often of a greyish hue. This condition is more frequent in women than men and is usually associated with severe emotional states. Seven cases, five women and two men, have been treated with banthine with great alleviation of symptoms. Other drugs had very little effect. One man, aged 43, had frequency day and night of 18 years duration, urinating 24 to 30 times per day. After taking banthine for 1 week the frequency has been decreased 50 per cent and his bladder capacity doubled. PROSTATECTOMY
Occasionally in very nervous patients after prostatectomy, suprapubic or transurethral, urgency with a decreased capacity of the bladder is a serious problem. It is true that in most of these cases the symptoms disappear with healing of the posterior urethra. However, in two such cases banthine was of considerable benefit during the period of healing. CONCLUSION
Banthine has been used with benefit in 12 cases of disturbed micturition associated with frequency, urgency and decreased capacity of the bladder. Twelve cases are insufficient to warrant any definite conclusion. However, it is hoped that others will use banthine in urological conditions to evaluate its effectiveness, and further investigative work is in progress. 405 N. Bedford Drive, Beverly Hdls, Calif.
Vol. 68, No. 3, September 1952 Printed in U.S.A.
BANTHINE IN UROLOGIC DISORDERS LESTER A. RISKIND
AND
HARRY A. ZIDE
Banthine is a quaternary ammonium salt with an anticholinergic effect acting in clinical doses on the parasympathetic autonomic ganglia and blocking the action of acetylcholine at the postganglionic nerve endings. In larger doses it blocks transmission through all the autonomic ganglia and in still larger doses it has a curare-like effect. It has been used clinically for the past few years with good results in the treatment of peptic ulcer. One of its side effects is bladder wall relaxation causing urinary retention which has been quite marked in cases of obstruction of the bladder neck. The occurrence of urinary retention has led the author to the use of banthine in cases associated with urgency and increased frequency of micturition. The detrusor muscle of the bladder is innervated by the parasympathetic fibers arising from the first to the fourth sacral spinal segments. These fibers are conveyed to the bladder in the pelvic nerves and connect with the ganglion cells lying in close relation to the bladder wall. Centers for micturition lie in the midbrain, hind brain and spinal cord. There is also a center in the premotor cortex and local reflex arcs occur in the bladder wall. Conceivably banthine will exert its anticholinergic effect on the bladder as it does elsewhere in the body. This would result in the opposite effect of doryl, urecholine and mecholyl. In a urologic practice many patients are seen, especially women, who complain bitterly of frequency and urgency associated with a small capacity of the bladder. Examination of these patients may reveal chronic trigonitis the cause of which cannot be determined, or frequently nothing is found in the bladder. Despite the use of all known medications the symptoms continue unabated. Frequently these cases are due to severe emotional states which lead to the vicious cycle of frequency, urgency and decreased capacity of the bladder. If, in these cases, the efferent stimuli to the bladder could be blocked or depressed the vicious cycle would be broken and the symptoms would decrease or disappear. Because of the above reasons and the relative safety of banthine, the author decided to use it in the types of cases described below. RUNNER'S ULCER
Case 1. F., aged 50, gross hematuria 1947, cystotomy and fulguration of a bleeding ulcer without relief. Runner's ulcer diagnosed 1947. No healing with any form of medication, frequent attacks of pyelonephritis necessitating prolonged hospitalization. Morphine addiction occurred because of severe pain. While preparations were being made for a bilateral ureteral transplant, banthine was given September 1950, 100 mg. q.i.d. In a few days, symptoms considerably relieved and patient was able to get out of bed. In 1 month patient able to work and continued to take banthine for 6 more months without any other type of therapy. Five months ago patient discontinued banthine and has taken no medication. Cystoscopy September 10, 1951: bladder capacity 300 cc., bladder wall normal 636
BANTHINE IN UROLOGIC DISORDERS
637
in appearance with avascular area at site of previous ulcer. Patient believes she is cured and does not require treatment. A detailed discussion of this case will be published later. Case 2. F., aged 62, Runner's ulcer 3 years duration. Previous treatment of no avail; banthine started February 1951, marked relief of symptoms. Symptoms aggravated with discontinuance of banthine; emotional strain requires increased dose of banthine. Case 3. F., aged 32, Runner's ulcer 6 weeks' duration, chronic cystitis 2 years. Banthine started with almost complete relief of symptoms. Cystoscopy 1 month after therapy revealed ulcer still present but smaller in area. TRIGONAL CYSTITIS
This is an inflammation of the trigone of the bladder characterized by a greatly increased vascularization of the trigone or edema of the trigone which usually decreases towards the ureteral orifices; the edematous area may be dull red but more often of a greyish hue. This condition is more frequent in women than men and is usually associated with severe emotional states. Seven cases, five women and two men, have been treated with banthine with great alleviation of symptoms. Other drugs had very little effect. One man, aged 43, had frequency day and night of 18 years duration, urinating 24 to 30 times per day. After taking banthine for 1 week the frequency has been decreased 50 per cent and his bladder capacity doubled. PROSTATECTOMY
Occasionally in very nervous patients after prostatectomy, suprapubic or transurethral, urgency with a decreased capacity of the bladder is a serious problem. It is true that in most of these cases the symptoms disappear with healing of the posterior urethra. However, in two such cases banthine was of considerable benefit during the period of healing. CONCLUSION
Banthine has been used with benefit in 12 cases of disturbed micturition associated with frequency, urgency and decreased capacity of the bladder. Twelve cases are insufficient to warrant any definite conclusion. However, it is hoped that others will use banthine in urological conditions to evaluate its effectiveness, and further investigative work is in progress. 405 N. Bedford Drive, Beverly Hdls, Calif.