An Update to Interstitial Cystitis / Bladder Pain Syndrome Treatment Guidelines

November is Bladder Health awareness month and we would like to discuss with our readers a significant update to the research regarding Interstitial Cystitis / Bladder Pain Syndrome  (IC/BPS). In May 2022, the American Urological Association (AUA) released updated clinical guidelines for the diagnosis and treatment of IC/BPS. The purpose of the bladder pain syndrome treatment guideline is to provide a “clinical framework” for best practice regarding the management of patients who experience this. That includes what should and shouldn’t be done for patients, and how to avoid unnecessary or harmful interventions. The previous bladder pain syndrome treatment guidelines were released 8 years ago, in 2014. 

What is Interstitial Cystitis / Bladder Pain Syndrome anyways?

Check out some of our previous articles for definitions and how pelvic floor physical therapy can help. In this year’s update, the authors--who are made up of experts in the field--continued to include the role of pelvic floor physical therapy in treatment of patients experiencing Interstitial Cystitis or Painful Bladder Syndrome. The AUA has placed pelvic floor physical therapy under the Behavioral / Non-pharmacologic Treatments category, as we are an evidenced-based (research-approved) profession providing treatments that have proven successes for Interstitial Cystitis / Painful Bladder Syndrome. 

The guidelines suggest that Urologists (doctors that specialize in the bladder) and all medical professionals involved in the care of these patients, should include manual physical therapy techniques to patients who present with pelvic floor tenderness. The techniques that pelvic floor physical therapists use, address the common pelvic, abdominal and hip muscle trigger points, and lengthen muscle contractures. Pelvic floor physical therapy also decreases any connective tissue restriction present, such as scar tissue.

The IC/ bladder pain syndrome treatment guidelines also make an important point about the Kegel: pelvic floor strengthening exercises should be avoided. 

The above suggestions on what should and shouldn't be done for these patients were given a level of evidence strength: grade A. This means the suggestion is based on a systematic review of many high quality randomized control trials, which is considered to be the best form of clinical research design.

An important point made under this category is that “no one treatment has been effective for the majority of patients” and “acceptable symptom control may require trials of multiple therapeutic options”. The guidelines also state under this category that self-care practices and behavioral modifications should be implemented. Additionally, a nod to the role of stress in exacerbation of symptoms in this patient population, the guidelines suggest to practitioners that patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. Pelvic floor physical therapy also involves  pain management, education on pain neuroscience and a multimodal approach using varying modalities to further decrease bladder pain. At Femina Physical Therapy, we have Doctors of Physical Therapy specialized in Orthopedic and Pelvic Health diagnoses as we take the full body into consideration. We are not just focusing on the ‘problem area’, but how concurrent orthopedic conditions frequently overlap with pelvic health conditions, including Interstitial Cystitis / Painful Bladder Syndrome.

Recap on Updates to the IC / Bladder Pain Syndrome Treatment Guidelines: 

• Treatment should include manual physical therapy techniques
• Kegels: avoid pelvic floor strengthening exercises 
• no one treatment has been effective for the majority of patients; a multimodal approach is important
• the role of stress is important in exacerbating symptoms 
• pain management should be included 

Additional Benefits of Pelvic Floor Physical Therapy for IC / BPS Patients

This is another area where pelvic floor physical therapy can help patients. Physical therapists, of all specialties, have the unique opportunity to see patients every week--and for long periods of time. This allows us the opportunity to work on important treatments like nervous system modulation, stress management strategies and to review bowel and bladder diaries to determine irritants or anything that contributes to symptoms, in addition to the manual and other  therapies provided in office. Pelvic floor physical therapy should treat patients from head to toe, and accounts for all surrounding segments of the body and brain that may be playing a role. Underlying bladder habits that may be contributing to the bladder pain, such as alcohol consumption, going “just in case” or hovering over public toilets to urinate and training the brain-bladder connection with urge suppression techniques are just some of the ways to manage the symptoms and are taught in pelvic floor physical therapy.

There is new research constantly being published, and unfortunately not all providers (pelvic health doctors and physical therapists alike) will be practicing in alignment with the new AUA recommendations. This is certainly not always the case, so make sure that if you believe this is something affecting you or someone you know, you can ask your provider if pelvic floor physical therapy is an option for you. Connect with us to get on the path to recovery.

References:

1. Clemens JQ, Erickson DR, Varela NP et al: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2022; https://doi.org/10.1097/JU.0000000000002756.
2. Lukban JC, Parkin JV, Holzberg AS, Caraballo R, Kellogg-Spadt S, Whitmore KE. Interstitial cystitis and pelvic floor dysfunction: a comprehensive review. Pain Med. 2001 Mar;2(1):60-71. doi: 10.1046/j.1526-4637.2001.002001060.x. PMID: 15102319.
3. Lilius HG, Oravisto KJ, Valtonen EJ. Origin of pain in interstitial cystitis: effect of ultrasound treatment on the concomitant levator ani spasm syndrome. Scandinavian Journal of Urology and Nephrology. 1973;7(2-3):150-152. doi:10.3109/00365597309133690.