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Tags >> Interstitial Cystitis
May 18, 2015

If you area clinic owner, are in a management or leadership position, one of your jobs is making sure your therapists are using best practices. This can be a challenge when best practices are continually being researched and discussed, and when systematic reviews continue to tell us that pelvic rehabilitation research lacks homogeneity and enough high-level evidence to make convincing arguments about interventions. In the absence of this, we can still integrate recommendations from clinical practice guidelines and from best practice statements. The American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) is participating in the APTA's initiative to develop clinical practice guidelines. For current guidelines, check out their page here. To see which guidelines are in development at the APTA, click here.

 

The American Urological Association (AUA) has also developed practice guidelines, including the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/PBS). Within this guideline, the first line treatments are listed as general relaxation/stress management, pain management, patient education, and self-care/behavioral modification. Second-line treatments include "appropriate manual physical therapy techniques", oral medications, bladder medications (administered inside the bladder), and pain management. What is very interesting about this guideline is that the authors define what types of manual therapy approaches are appropriate, and these include techniques that resolve muscle tenderness, lengthen shortened muscles, release painful scars or other connective tissue restrictions. The guidelines also define who should be working with patients who have IC/PBS and pelvic muscle tenderness: "appropriately trained clinicians". Very importantly, the authors state that pelvic floor strengthening exercises should be avoided.

 

How can these guidelines be used to assess best practices? Find out if your therapists who work with patients who have IC/PBS are indeed instructing in relaxation strategies, using pain education and pain management techniques (for pain-brain education specific to pelvic pain, check out the book "Why Pelvic Pain Hurts". Find out if your therapist is instructing in pelvic muscle strengthening as a first-line of treatment, since this would not be in line with the AUA guidelines. (Having said this, teaching pelvic muscle strengthening can be very appropriate when done with consideration of pelvic muscle pain.) Lastly, ask your therapist if she feels that her skill set and training is sufficient to treat the condition. Even in our comprehensive pelvic floor series, there is so much to learn at the initial course that IC/PBS is not discussed in great detail until PF2B. Maybe a little more knowledge and training would help your therapist feel that she is providing the "appropriate manual physical therapy techniques" recommended in the guidelines.

 


May 15, 2015

Many diagnoses that live under the umbrella of "chronic pelvic pain" have similar symptoms, confounding the differential diagnosis and development of a treatment pathway. Dr. Charles Butrick, in an article published in 2007, suggested that gynecologists "…be alert to…interstitial cystitis in patients who present with chronic pelvic pain typical of endometriosis." The concurrent conditions of bladder pain syndrome (BPS) and endometriosis have been described as "evil twins syndrome" in the realm of chronic pelvic pain. Bladder pain syndrome. also known as Interstitial Cystitis (IC), is a condition commonly associated with pelvic pain, bladder pressure, and urinary dysfunction such as urgency and frequency. Endometriosis can also cause or contribute to pelvic pain, and a variety of pelvic dysfunctions including bowel, bladder, or sexual dysfunction.

 

A study published in the International Journal of Surgery reported on the prevalence of these two conditions. Utilizing a systematic review approach, the authors located articles reporting on the prevalence of bladder pain syndrome and endometriosis in women with chronic pelvic pain. Nine observational studies were included, and the range of endometriosis diagnosis ranged from 11%-97%, with a mean prevalence of 61%. The prevalence of endometriosis ranged from 28%-93% with a mean prevalence of 70%. The large variation in these rates were explained as potentially being due to the variations in study quality and sample selection. (The authors point out that the highest rates of prevalence for BPS and endometriosis were noted in the patient groups recruited from specialist clinics and from lists of patients from operating lists.) The study concludes that in women who present with chronic pelvic pain (CPP), screening for bladder pain syndrome is important so that appropriate treatment can be directed to all issues.

 

If another chronic pelvic pain condition, pudendal neuralgia, is added to the diagnoses of endometriosis and painful bladder syndrome, "evil triplet syndrome" can be experienced by a patient. The various symptoms of each of these conditions can add to the total level of pain and dysfunction experienced by a woman with chronic pelvic pain. Having the tools to evaluate and treat symptomatology and address the chronic aspect of tissue, joint, neural, myofascial, and the processing of pain is a skill that most pelvic rehabilitation therapists continue to work on throughout their careers. Michelle Lyons, faculty member from Ireland, brings her "Special Topics in Women's Health" course to Chicago in a couple of weeks. Within the course, Michelle will be discussing each of these conditions from the standpoint of a multidisciplinary approach, and with the role of the pelvic rehabilitation provider in mind. She will also be sharing up-to-date and practical information about infertility and hysterectomy. If you are interested in joining Michelle and colleagues in Chicago, you still have time to sign up! And if you would like to host Michelle's course in your facility, give us a call or send us a note!


Dec 12, 2012

If you have been following research in pelvic pain, you may be aware of the diagnostic terms interstitial cystitis (IC) as well as painful bladder syndrome (PBS). And there's always bladder pain syndrome (BPS), or hypersensitive bladder syndrome. While you may have heard at some point that health care providers should use PBS preferentially over IC, that recommendation does not seem to have stuck, and the Interstitial Cystitis Association (ICA) has decided to utilize "IC" until a more definitive diagnostic criteria and test are developed. Much of the literature you will continue to see published will choose to include both IC and PBS together in the title, and recent research has attempted to further define the diagnosis as having a relationship to ulcers versus no ulcers. 

 

Recognized subtypes of IC include ulcerative (5-10% of those with IC) and non-ulcerative (90% of those with IC). According to the ICA, patients who have non-ulcerative IC have tiny glomerulations or hemorrhages on the bladder wall, indicative of inflammation, but not specific to IC. In patients who have ulcerative IC, Hunner's ulcer's or patches of red, bleeding areas are noted on cystoscopy. Recent research aimed to find out if female patients with ulcerative versus non-ulcerative IC have different symptoms or characteristics. 214 women (36 with ulcerative IC, 178 with non-ulcerative IC) were included in this research. While both groups reported triggers such as certain foods, exercise, and stress, more patients who had non-ulcerative IC reported pain with intercourse. 

 

On the Brief Pain Inventory, one of the outcomes tools used in this study, both groups reported similar numbers of painful areas, with lower abdominal and pelvic pain followed by low back pain. Words used to describe the pain were, however, different among the two subtypes of IC: patients with non-ulcerative IC reported aching, cramping, and tenderness, while patients in the ulcerative group reported sharp, stabbing, and hot burning pain. Aside from these differences, the patients in the two groups did not share significant differences in the outcomes measured. The authors suggest that further research is needed to provide more information about the different presentations of patients who have IC/PBS. 

 

For those of us in pelvic rehabilitation, the most important aspect of our care is to treat what is found, and that can only be accomplished through excellent examination and evaluation techniques. If you are interested in learning more about IC, the ICA website provides a wide array of tools for patients and providers. Until then, we will continue to see IC, PBS, BPS, and other abbreviations that point out that there is much yet to learn about this disabling condition. 


Oct 13, 2012

Have you ever wished that you could impart all that you have learned about pelvic pain to your female patients? Starting from simple concepts such as how one insult or injury to the tissues can start a cascade of events over time, and progressing to the amazing knowledge that keeps pouring in about the brain's involvement in chronic pain states? And don't we always hear from patients how difficult it can be to establish a team of professionals who are all on the same page related to treatment options discussed in a compassionate manner? 

 

The Institute recently heard from  such a team of experts who have joined together to offer a weekend program for women who have chronic pelvic, sexual and genital pain. Diagnoses included in the above categories can include Interstitial Cystitis (IC), vulvodynia, vestibulitis, Irritable Bowel Syndrome (IBS), pelvic floor dysfunction, pudendal neuralgia, lichen sclerosis, endometriosis, and other pelvic and genital pain disorders. The experts who will provide an entire weekend of education for patients (and interested partners) consists of two physicians, Dr. Robert Echenberg, Dr. Deborah Coady, a physical therapist, Amy Stein, and two counselors, Nancy Fish and Alexandra Milspaw. 

 

The weekend goals are to provide a safe environment in which a person can learn skills that can be immediately applied for self-care. You can be assured that with the group of practitioners involved your patients will be addressed in a holistic manner, and that the knowledge gained can be used in conjunction with a patient's current home program or concurrent therapies. The workshop is scheduled for April 27-28 of 2013, and located in Bethlehem, Pennsylvania. Participants can register at the website www.allianceforpelvicpain.com. 


The cost of the retreat itself including several meals is only $450 if registered prior to December 1st of this year (price increases to $475 after December 1st.) What a reasonable price for a patient who can travel (or perhaps lives nearby) and who is interested in expanding her knowledge of how to live with and heal her chronic pelvic pain.


Nov 28, 2011

Vaginal diazepam has been used by patients who have pelvic pain as an "off-label" drug option yet there has been little research to support its use. Recognizing that conditions such as painful bladder syndrome (PBS)/interstitial cystitis (IC) may be complicated by pelvic muscle dysfunction, the use of diazepam (brand names include Valium) aims to target the muscle overactivity. 

 

In the September/October issue of Urologic Nursing, Donna Carrico, MS, WHNP, and Kenneth Peters, MD, report on the effects of vaginal diazepam on 21 women (mean age of 40) who were diagnosed with urogenital pain. Women completed assessment scores at baseline and at one month after being treated with vaginal diazepam. 2-10 mg ("...as needed for symptom relief...") was prescribed to be used up to every 8 hours. Most women started at 5 mg unless they reported high sensitivity to most medications. Although patients had the option to have the medication compounded into a cream or suppository, all patients chose to utilize the oral tablet inserted vaginally. (It was either inserted whole or crushed and mixed with vaginal lubricant to be inserted into the vagina.) The women recorded weekly their dose, usage, and pain score on 0-10 Visual Analog Scale (VAS) as well as any adverse effects that occurred over the month. A serum diazepam level was recorded at the end of the 4 weeks for the 15 women who were using vaginal diazepam at least daily, and these levels were found to be in the normal range.

 

VAS scores decreased on average from 4.8 to 3.4, average vulvar Q-Tip level decreased from 3.3 to 1.2, and vulvar pain levels decreased at one month follow-up as well. Only 1/3 of the women reported a side effect of drowsiness, otherwise no side effects were reported. Interestingly, some patients found it helpful to insert the medication vaginally 1 hour prior to engaging in intercourse so that pain was reduced.

 

The authors are quick to point out that this research was not conducted as a controlled trial, and there is no proposed protocol for the use of vaginal diazepam. What this research does assist with is establishing that the off-label use of diazepam vaginally in those suffering with urogenital pain may have few side effects and may offer benefits. Because pelvic pain often does not have a target organ as a cause, and because pelvic muscles are involved in most urogenital pain cases, it makes sense to address the involved muscles. Of course, pelvic rehab practitioners are well-trained to address the muscles via direct releases as well as through the use of other modes, yet having assistance of pharmacology may be a useful tool for the patient.


Sep 22, 2011

Physical therapy is listed as a "second line" treatment for interstitial cystitis/bladder pain syndrome (IC/BPS) in the updated guidelines from the American Urological Association (AUA). These guidelines aim to "provide a clinical framework for the diagnosis and treatment of..." IC/BPS. Under diagnosis, tests such as urodynamics and cystoscopy (once considered the gold standard for diagnosis) are listed as tests that are not necessary yet they can be used as an aid for diagnosis.

 

First-line treatments include education about normal bladder function as well as about the condition, behavioral modifications, and  stress management. Recommended physical therapy components of treatment include manual therapy techniques and the avoidance of pelvic muscle strengthening exercises. Also listed under second-line treatments are medications, both intravesical (inside the bladder) and oral. 

 

The treatment of IC/BPS continues to change as researchers and clinicians continue to collaborate to understand the condition. This paper is 41 pages in length and the authors utilize 192 references on which they based these guidelines. It is worth reading if you currently have patients that you are treating for bladder pain. It is also a useful tool for understanding the basis of changes in recommended medications for IC/BPS.


Aug 17, 2011

In Therapeutic Advances in Urology, researchers report on the role of inflammation, acute or chronic, and its effect on bladder function. Although the etiology of painful bladder syndrome/interstitial cystitis (PBS/IC) is still unknown, it is agreed upon that inflammation plays a central role in the bladder dysfunction that accompanies the condition. It has been proposed that the inflammation may come from a chronic or subclinical infection, a genetic susceptibility, or an autoimmune response.

 

Although the naming of the condition has gone through proposed changes (from interstitial cystitis to painful bladder syndrome to bladder pain syndrome) you will see the terms used interchangeably in the literature. A more recent attempt at refining the definition of IC  was completed by the European Society for the Study of Interstitial Cystitis. IC is described as "...chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder and accompanied by at least one other urinary system such as persistent urge to void or urinary frequency." Many physicians have based diagnosis on symptoms primarily, as more recent research has demonstrated that use of stringent diagnostic criteria or laboratory tests often excluded patients from being diagnosed appropriately. 

 

This article is useful in assimilating research about IC/PBS.  The authors briefly list the pharmacology of several different oral medications that have been studied for use with patients with bladder pain. Some of the medications target the mucosal lining of the bladder, act as antihistamines, target the pro-inflammatatory agents found in patients with bladder pain, or help the patient manage the pain (narcotics.) Other medications cited include anticonvulsants, antidepressants, anticholinergics, or hormones modulators. 

 

As for a nonpharmacological treatment approach for IC, physical therapy is recommended and modalities such as manual therapy, bladder training, biofeedback, and pelvic floor rehab are recommended. The authors conclude that in terms of management guidelines, because patients with bladder pain syndrome have such varied clinical presentations, it is necessary to individualize treatment approaches.


Aug 04, 2011

Painful bladder/interstitial cystitis (IC) may be undiagnosed in many women according to the Harvard Health Blog and according to research published in the Journal of Urology. The research results were based on phone interviews (60 minute interviews!) of nearly 13,000 household females. Results of the surveys estimate that the prevalence of painful bladder symptoms range from 2.70% to 6.53%. Only 9.7% of these women reported that they had been diagnosed with painful bladder/IC conditions. 

 

The research community has also tried to create improved definitions of painful bladder/IC. One such study hypothesized that the pain of painful bladder could be utilized as criteria for diagnosis. The authors found the following information specific diagnostically for the condition: pain related to certain food and/or drink, or pain related to bladder filling and/or emptying. Physicians continue to base the diagnosis in large part on symptoms of urinary urgency, frequency, bladder pain and nocturia, and it remains elusive to find a medical test that can consistently determine the diagnosis.

 

As a population estimate, this translates to 3-8 million women over age 18 who are affected by this condition. Pelvic rehabilitation therapists can help women in part by dealing with the painful muscle tension that accompanies this debilitating pain. The treatment of painful bladder is covered in the Institute's intermediate "2B" course. Click here to see when this course is coming to a location near you, or near a warm, sunny beach (hint: San Diego, September.)

 


Apr 25, 2011

The Institute is sponsoring a radio show hosted by Dr. Melanie Barton and featuing Amy Stein, MPT, BCB-PMD. Amy will talk about Interstitial Cystitis and Pelvic Pain and the role of physical therapy in treating these problems

Tune in on April 28th or visit Dr. Melanie's site to download the podcast.


Upcoming Continuing Education Courses

Special Topics in Women's Health - Maywood, IL
May 30, 2015 - May 31, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Middletown, CT
May 30, 2015 - May 31, 2015
Location: Middlesex Hospital

Pelvic Floor Level 2B - Seattle, WA (Sold Out!)
Jun 05, 2015 - Jun 07, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Pelvic Floor Level 3 - Atlanta, GA
Jun 05, 2015 - Jun 07, 2015
Location: One on One Physical Therapy

Visceral Mobilization of the Urologic System - Madison, WI
Jun 05, 2015 - Jun 07, 2015
Location: Meriter Hospital

Nutritional Perspectives for the Pelvic Rehab Therapist - Seattle, WA
Jun 06, 2015 - Jun 07, 2015
Location: Pacific Medical Center

Rehabilitative Ultra Sound Imaging: Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 13, 2015
Location: Johns Hopkins Bayview Medical Center

Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 14, 2015
Location: Johns Hopkins Bayview Medical Center

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Jun 12, 2015 - Jun 14, 2015
Location: Marathon Physical Therapy

Pelvic Floor Level 2B - Derby, CT (SOLD OUT)
Jun 26, 2015 - Jun 28, 2015
Location: Griffin Hospital

Breast Oncology - Maywood, IL
Jun 27, 2015 - Jun 28, 2015
Location: Loyola University Stritch School of Medicine

Chronic Pelvic Pain - Arlington, VA
Jul 10, 2015 - Jul 12, 2015
Location: Virginia Hospital Center

Myofascial Release for Pelvic Dysfunction - Winfield, IL
Jul 17, 2015 - Jul 19, 2015
Location: Central DuPage Hospital Conference Room

Pediatric Incontinence - Houston, TX
Jul 18, 2015 - Jul 19, 2015
Location: Texas Children’s Hospital

Yoga for Pelvic Pain - Cleveland, OH
Jul 18, 2015 - Jul 19, 2015
Location: UH Case Medical Center - University Hospitals