By Claudia N. Benavides, PT

In 2011 the American Urology Association (AUA) published its Clinical Practice Guidelines (CPG) on Diagnosis and Treatment of Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS). This was later amended in 2014, and most recently updated in early 2022.

But first… CPG: What are they, and why are they so important?

CPG are evidence-based resources that help physiotherapists (and other practitioners) provide the best practice, and help patients make the appropriate decisions for their specific clinical circumstances. These guidelines and recommendations are subject to periodic revision, allowing your pelvic floor physiotherapist to stay up to date with current evidence.

The current CPG Clinical Practice Guidelines (CPG) on Diagnosis and Treatment IC/BPS recommends Pelvic Floor Physiotherapy with the highest level of evidence for treating pelvic floor tenderness (pain).

New Interstitial Cystitis/Bladder Pain Syndrome classifications

Defined by the AUA, Bladder Pain Syndrome is “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.” With a diverse group of patients, categorized by treatment approach:

1- Bladder-centric phenotypes (e.g., Hunner lesions, small bladder capacity, pain improved with intravesical local anesthetics).

2- Pelvic-floor phenotype (e.g., pelvic floor tenderness on an internal assessment). These patients respond better to pelvic floor manual physiotherapy.

3- Systematic or widespread symptoms (“widespread pain”). This includes: “significant non-urologic pain outside the pelvis”, fibromyalgia, IBS, anxiety, depression, higher levels of current and lifetime stress, early life and adult traumatic events, negative affect, poor illness coping, with widespread somatic symptoms across multiple organ systems.

Male pelvis and Interstitial Cystitis/Bladder Pain Syndrome

BPS/IC affects 10:1 female vs male assigned at birth. But it may be under-diagnosed, as it overlaps with chronic prostatitis/ chronic pelvic pain syndrome in those with a male pelvis (pain in the perineum, suprapubic region, testicles, or tip of the penis) “The pain is often exacerbated by urination or ejaculation. Voiding symptoms such as a sense of incomplete bladder emptying and urinary frequency are also commonly reported, but the pain is the primary defining characteristic of chronic prostatitis” 

Pelvic Floor Physiotherapy in Interstitial Cystitis/Bladder Pain Syndrome

Pelvic floor physiotherapy is the STANDARD treatment for pelvic floor tenderness (pelvic pain). What does this mean? If you are presenting with bladder pain and muscle tenderness you should be referred to a pelvic floor physiotherapist for a consultation. There’s no “wait and see”, there’s evidence that we have the tools to help you with your pelvic floor pain.

The guideline provides a list of the current evidence regarding non-pharmacological treatment:

• Patient education is something that is a must in every physiotherapy consultation. Providing treatment options and referrals (multidisciplinary approach with other health care practitioners), focus on pain neuroscience education, bladder retraining, strategies to control urinary urge and frequency, and lifestyle modification, among other things that are tailored for your specific concerns and clinical findings.

• “Self-care practices and behavioural modifications that can improve symptoms should be discussed and implemented as feasible.”

Pelvic floor physiotherapy provides the tools to assess and treat your bladder and bowel function, behavioural modification strategies, referral to other practitioners to help to improve your bladder function, strategies to manage IC/BPS flare-ups (e.g. meditation, imagery), pelvic floor muscle relaxation (Stop doing Kegels!).

• “Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations.”

Pelvic floor physiotherapy is a trauma-informed practice, that can help to control certain pain triggers. Still, clients benefit from a multidisciplinary approach (if needed and you would like to know more about it, we can also connect you with a Holistic Occupational Therapist or a Registered Psychotherapist).

As mentioned in the IC/BPS Guidelines, this condition can be flared-up or exacerbated by other conditions treated by Pelvic Floor Physiotherapy:  “IBS, endometriosis, recurrent vaginitis/vestibulitis, severe predictable flares occurring with a phase of the menstrual cycle.”

• Stop doing Kegels!

If experiencing pelvic pain it is recommended to use tender point therapy, muscle lengthening strategies, and scar/connective tissue release. There’s evidence showing that myofascial techniques are essential  tools to control pelvic pain and help with bladder function (urinary urgency and frequency)

Pelvic floor strengthening (Kegel exercises) should be AVOIDED. There is no evidence they can improve symptoms, and in fact, this type of pelvic floor therapy may worsen the condition. 

The American Urological Association highly recommends:

In the absence of appropriate expertise, routine forms of pelvic physiotherapy that are primarily aimed at strengthening the pelvic floor are not recommended

In summary, Interstitial Cystitis/Bladder Pain Syndrome is not a bladder-centric condition. There are multiple non-pharmacological options for treatment, with pelvic floor physiotherapy having a high level of evidence for the treatment of IC/BPS. It’s recommended to have a pelvic assessment that includes an internal assessment of the pelvic floor muscles to help identify tenderness and tone. Pelvic floor assessment also helps us rule in/out pelvic floor dysfunction, pelvic health disorders, weak/tight pelvic floor, sexual pain, sexual dysfunction, stress incontinence, and pelvic organ prolapse, among other conditions.

If you would like to know more about the IC/BPS guideline please follow the link in the references.

If you want to restore physical health and improve your quality of life and overall wellness book a pelvic floor physiotherapy assessment
click here.

References:

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.

Course notes, Pelvic Health Solutions- Level 2: The Role of Physiotherapy in the Treatment of Anyone Experiencing Pelvic Pain Through a Trauma-Informed Lens

Course notes, Pelvic Health Solutions-  Level 3: Biopsychosocial Reframed