Role of physiotherapy in Interstitial Cystitis

ole of physiotherapy in Interstitial Cystitis

Physiotherapy can play a valuable role in the management of interstitial cystitis (IC). Interstitial cystitis or Bladder Pain Syndrome (BPS) is a chronic condition characterized by bladder pain, urinary urgency, and frequency. While the primary treatment approach for IC involves a multidisciplinary approach, including medications, dietary modifications, and behavioural therapies, physiotherapy can complement these strategies and provide additional benefits.

Research has demonstrated that at least 85% of patients with interstitial cystitis also have pelvic floor dysfunction.  In fact, many of the symptoms of IC can only be explained by the pelvic floor.  The majority of patients report painful intercourse, low back pain, hip pain, or constipation accompanying the condition; symptoms that have nothing to do with the bladder.

Pelvic floor physical therapy is one of the most proven treatments for interstitial cystitis.  It’s recommended by the American Urological Association (AUA) as a first-line medical treatment in their IC Guidelines, and is the only treatment given an evidence grade of ‘A’.

Role of Pelvic Floor in Interstitial cystitis and bladder pain syndrome:

Proper function of the pelvic floor muscles is important for normal bladder, bowel and sexual function. Unfortunately, evaluation of the pelvic floor is not routinely taught in medical school or graduate medical training. In normal voiding, one must be able to relax the pelvic floor, sending a signal to the brain for the bladder to contract. Pelvic floor muscle spasm can result in pseudo-dysynergia and obstructed voiding, leading to urinary urgency, frequency, hesitancy and pelvic pain. A tense and tight pelvic floor can result in referred pain to the vulva, rectum and perineum and is one of the most common causes of dyspareunia.

The European Society for the Study of Interstitial Cystitis (ESSIC) published guidelines to help diagnose IC/BPS and a key criterion for diagnosis is to rule out “confusable states” . One of the most common confusable states is pelvic floor dysfunction (PFD). Myofascial pain and PFD are present in as many as 85% of patients with the diagnosis of IC/BPS. In a study of 186 patients with IC/BPS, 78.3% were found to have at least one myofascial trigger point on pelvic examination and 67.9% had six or more trigger points.

A noxious stimulus may trigger the release of nerve growth factor and substance P in the periphery causing the mast cells in the bladder to release proinflammatory substances, resulting in neurogenic inflammation of the bladder wall. This can result in painful bladder symptoms, vulvar or vaginal pain. There may be a viscero-muscular reflex resulting in the pelvic floor muscles being in a hypertonic contracted state. This hypertonic state results in decreased muscle function, increased myofascial pain, and myofascial trigger points. The pelvic floor muscles then become a source of pain even if the bladder is treated.

Here are some ways in which physiotherapy can be helpful in managing IC :

1. Manual therapy:

Patients with IC/BPS often have tenderness and/or pain in the pelvic floor area, where manual techniques like sweet spot release, Thiele’s and Wise-Andersons techniques can reduce symptoms. There is evidence that physical therapy exercises to strengthen the pelvic floor muscles do not improve symptoms and often make them worse, so activities such as Kegel exercises are not recommended for patients with IC/BPS. However, physical therapists trained to help with pelvic floor

Rehabilitation are best to decide the treatment protocol after a thorough assessment of muscle tone and symptoms.

2. Bladder training:

Physiotherapists can guide patients in bladder training techniques to help increase bladder capacity and reduce urinary urgency. This involves gradually increasing the time intervals between urination and learning strategies to manage the urge to urinate.

3. Education and self-management strategies:

Physiotherapists can educate patients about IC, its causes, and how to manage symptoms effectively. They can provide guidance on self-release techniques, relaxation exercises, posture correction, lifestyle modifications, such as dietary changes, fluid management, and stress reduction techniques, which can help alleviate symptoms.

4. Pain management:

Various pain management modalities, including heat or cold therapy, transcutaneous electrical nerve stimulation (TENS), and relaxation exercises, to help reduce pain and discomfort associated with IC. Ice packs also works as a useful tool for home-management of pain.

“More than 20 years of research supported by the National Institutes of Health and industry have failed to show that bladder-directed therapy is superior to placebo [for IC].  This fact suggests that the bladder may be an innocent bystander in a larger pelvic process.  As clinicians, we must be willing to look beyond the bladder and examine for pelvic floor issues and other causes of patient’s symptoms and not be too quick to begin bladder-focused treatments.” – Dr. Kenneth Peters.

References :

Gupta P, Gaines N, Sirls LT, Peters KM. A multidisciplinary approach to the evaluation and management of interstitial cystitis/bladder pain syndrome: an ideal model of care. Transl Androl Urol. 2015 Dec;4(6):611-9. doi: 10.3978/j.issn.2223-4683.2015.10.10. PMID: 26816861; PMCID: PMC4708537.