Interstitial Cystitis / Painful Bladder Syndrome

What is IC/BPS?

Over the course of the last century, the diagnosis of interstitial cystitis (IC) has been identified, defined, and redefined a number of times.  The variability in the definition of this condition has contributed to a certain level of confusion in the medical world and in turn, patients have been improperly diagnosed and management strategies have been poorly outlined.   This is why the American Urologic Association decided it was time to properly map out a standard management protocol for those with the interstitial cystitis/bladder pain syndrome diagnosis (IC/BPS).

Symptoms

The common symptoms for those with an IC/PBS diagnosis include:

  • Urinary frequency, urinating more than 8 times per day or at night
  • Persistent urge to urinate, sometimes immediately after urinating
  • Suprapubic pain or discomfort that worsens as the bladder fills or is improved after emptying the bladder
  • Pelvic pain or pelvic pressure
  • Pain with sexual intercourse   

 

The American Urologic Association defines IC/PBS as  “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes’.

According to an article outlining the current best practices for the management of IC/BPS in 2018, patients are to be separated into 2 main categories before deciding a treatment pathway.  These categories are the following:

  1.  Hunner’s lesions IC (HL IC) – This is considered the “classic” case of IC.  One in which, there are positive findings during cystoscopy of lesions of reddened mucosal areas with small vessels radiating towards a central scar.  HL IC is relatively rare with a prevalence of 5-20% and is found to be more common in an older, male population.
  2. Non Hunner’s lesions IC (N-HL IC/BPS) – These patients do not show positive findings of Hunner’s lesions on cystoscopy but often present with the frequency, urgency, and bladder pain found in those with HL IC.  


It is important to note, that as of 1997, a cystoscope investigating the presence of Hunner’s lesions was not deemed necessary to receive an IC diagnosis.  

Patients with N-HL IC/BPS commonly present with coexisting systemic comorbidities such as fibromyalgia, depression, temporomandibular joint disorder, inflammatory bowel disease, chronic fatigue syndrome, Sjögren’s syndrome, endometriosis, and migraines.  N-HL IC/BPS patients commonly report sexual dysfunction including dyspareunia, persistent genital pain, and bowel symptoms including constipation and straining.  

What does the Research Say?

According to the American Urological Association (AUA), there is Grade A level evidence supporting pelvic health physiotherapy to address pelvic floor muscle dysfunction in IC/PBS patients.  It has been found that pelvic floor dysfunction and myofascial pain have been found in as many as 85% of patients with the diagnosis of IC/PBS. Several studies have shown the benefit of integrating pelvic health physiotherapy strategies into IC/BPS management.    

Bassaly et al. conducted a review of 186 IC/BPS patients and found that 78.3% had at least one myofascial trigger point and 67.9% had multiple myofascial trigger points during internal palpation of the pelvic floor muscles.  An increasing number of trigger points correlated with more significant symptoms of pelvic pain, urgency, and frequency.

A National Institute of Health trial randomized a group of IC/BPS patients into one of two treatment  streams: internal pelvic muscle physiotherapy and general therapeutic massage and compared symptom outcomes.  It was found that 59% of patients in the internal pelvic muscle physiotherapy group reported symptom improvement compared to 26% in the general therapeutic massage group. 

How can Pelvic Physiotherapy Help?

Along with understanding the IC/BPS patient’s bladder focused symptoms, a thorough subjective history gathered on an initial assessment identifies any concurrent symptoms that the patient may be experiencing related to bowel function, sexual function, and/or persistent low back/hip/genital pain. 

IC/BPS patients commonly present with multiple areas of tension/tightness and weakness within the internal pelvic floor muscles as well as throughout the external structures surrounding the pelvis.  Prolonged periods of tension in these areas can irritate/sensitize nerves and lead to the development of symptoms such as urinary urgency/frequency, pelvic or bladder pain sensations, dysuria (painful urination), dyspareunia (painful sexual intercourse), and difficulty evacuating bowels.  

A pelvic physiotherapy assessment identifies any limitations in mobility throughout the spine and pelvic bones, as well as excessive muscle and connective tissue tension and/or weakness  throughout the legs, hips, groin, and trunk area. An internal vaginal and/or rectal examination is considered the ‘gold standard’ approach to therapy in order to reliably assess pelvic floor muscle tension, flexibility, and/or weakness.

Pelvic health physiotherapists guide clients on developing an exercise program that focuses on optimizing the mobility, flexibility, elasticity of restricted and tense structures throughout the body.  Muscles that are weak and put stress on other muscles or joints within the body are strengthened. Manual therapy techniques encourage normalizing muscle tension, thereby optimizing blood flow and oxygenation to the nerves that supply the pelvic floor, bladder, uterus, rectum, and muscles throughout the pelvis. 

A bowel and bladder diary allows the patient and pelvic health physiotherapist to identify and gain insight on daily dietary or fluid habits that may be exacerbating bladder symptoms.  Treatment incorporates education on bladder irritants, hydration goals and awareness of dietary triggers. At times, an experienced dietician/naturopathic doctor is recommended for certain IC/BPS patients with a more complex history.

As IC/BPS symptoms persist over an extended period of time, this can greatly affect a patient’s quality of life thereby leading to increased levels of anxiety, stress, fear revolving around symptom flares and triggers, and an array of negative emotions.  It is now becoming more understood that these factors contribute to upregulation of the body’s central nervous system, and more specifically, the sympathetic nervous system (fight-or-flight response).  When this heightened activity of the nervous system persists, it amplifies and augments the signals that lead to a pain response.  Understandably, the symptoms of IC/BPS can greatly affect a patient’s quality of life. Pelvic health physiotherapists understand the complex interrelationship between IC/BPS patients and the psychological and social factors that are able to influence pelvic pain.  Therefore, there is strong support and encouragement for the integration of an experienced psychotherapist in an IC/BPS patient’s community of health care practitioners in order to provide tools and and stress management strategies during the recovery process.

The care of IC/BPS patients is expansive and current best practice guidelines recommend pelvic floor physiotherapy as a primary method of treatment in collaboration with a variety of multi disciplinary professionals to properly and holistically address rehabilitation and recovery.  

References:

  1.  https://jamanetwork.com/journals/jama/fullarticle/1167318
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048622/
  3. https://www.auanet.org/guidelines/interstitial-cystitis-(ic/bps)-guideline
  4. https://www.ncbi.nlm.nih.gov/pubmed/20976441
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