The American Urological Association (AUA) updated their guidelines in 2014 after reviewing the literature relevant to the diagnosis and treatment of interstitial cystitis (IC) and painful bladder syndrome (BPS) from 1983 to 2009. This work was a result of two years of devoted study to instruct clinicians and patients on how to recognize, diagnose and treat IC/PBS.
Specialized manual physical therapy was the only treatment guideline to receive a grade A for evidence strength.
IC/PBS can be confusing. Recently, researchers and scientists have encouraged the use of the term PBS over IC. But because there isn’t any definitive diagnostic criteria, the Interstitial Cystitis Association has decided to continue to use IC. You’ll likely see it referenced both ways.
What Are the Symptoms of IC/PBS?
The symptoms vary widely between individuals, ranging from mild irritation to severe debilitation. The most definitive symptom is pain — defined by the AUA as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder in the absence of infection or other identifiable causes.”
Other symptoms can include:
- Urinary urgency and frequency
- Nocturia (frequent urination at night)
- Pelvic pain
- Females: lower abdominal, vaginal pain
- Males: lower abdominal, testicular or penile pain
- Pain with intercourse
- Dysuria (pain with urination) this can range from mild stinging to severe burning or stabbing
How Is IC/PBS Diagnosed?
There is no definitive test that will diagnose IC/PBS. The AUA recommends initial basic assessment and testing and only using more-invasive diagnostic procedures if there is a complicated situation.
The AUA’s diagnosis criteria is a basic assessment:
- Careful history and physical examination
- Urinalysis (to rule out urinary tract infection)
Only if there is an indication that there may be ulcerations called Hunner’s ulcers or severe inflammation on the bladder wall would a cystocopy be performed.
How Is IC/PBS Treated?
The AUA developed a six-stage IC/PBS treatment algorithm. The general principle is to start with safer and less invasive treatments.
The AUA’s first two lines of treatment are the most important:
First line of treatment
- Patient education and lifestyle modifications
- Education regarding normal bladder function, dietary influences on the bladder, urge suppression techniques, constipation management
- Stress management principles: breathing, meditation, mindfulness
- Flare management strategies
Note: All therapists at N2 Physical Therapy are trained in the recommended first line of treatment.
Second line of treatment:
Physical therapy: The AUA describes what the recommended therapy should be:
Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Clinical Principle Standard (Evidence Strength Grade A)
The guidelines are flexible, because every patient is unique and different. It’s still important to start with conservative interventions, especially pelvic floor physical therapy.
Our therapists are specially trained to treat PBS/IC and use a hands-on and whole-body approach, tailored to each individual:
- Manual myofascial release (abdomen, pelvic, back and hips)
- Joint mobilization
- Fascial release around skin, nerves and ligaments
- Trigger point release
- Functional dry needling
Other tools or techniques in pelvic physical therapy include:
- Biofeedback: special sensors can help you learn to retrain the pelvic muscles in both relaxation and coordination with other muscle groups
- Electrical stimulation: electrical stimulation desensitizes the nerves and calms pain and spasms
Physical therapy does more than just work with your muscles. It can also help assess your posture and gait. Faulty movement patterns can affect the pelvic and hip muscles that could contribute or be a cause of IC/PBS symptoms.
A home program and self-treatment may also include:
- Flexibility and stability exercises designed for the individual
- Self-treatment or educating a partner in the manual treatment
- Sleep hygiene
- Urinary and bowel function
- Sexual function
- Relaxation (breathing, mindfulness, guided imagery)
- Neuroscience of pain
IC/PBS is truly a multifactorial dysfunction, and a multi-disciplinary approach is best. Research supports the important role that specially trained physical therapists play in this rehabilitation process.
Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001:166(6): 2226-2231
Fitzgerald MP, Anderson Ru et al. Urological Pain Collaborative Research Network. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. JUrol. 2009;182(2): 570-580