Physical Therapy Treatment for Interstitial Cystitis and Chronic Pelvic Pain Syndrome

In Interstitial Cystitis by Stephanie Prendergast2 Comments

 

By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles

 

Urinary tract infections hurt. It hurts as your bladder fills, you constantly feel the need to pee and when you do it feels like knives are coming out of your body. You do not experience post-void relief and immediately feel like you need to pee again. Your doctor asks you to urinate urinate in a cup, you are (thankfully!) told you have a UTI, you are given medication and in a few days you are back to normal.

What happens when you have those horrendous symptoms and there is no infection?

November is Bladder Health Awareness Month and November 27th – 30th has been designated Interstitial Cystitis Awareness Week. We are dedicating this week’s blog post to Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS), Chronic Pelvic Pain Syndrome/Nonbacterial Chronic Prostatitis (CPPS) and the role physical therapy plays in treating these disorders.

These syndromes can cause debilitating pain, the type of pain that leaves patients actually HOPING to have an infection, because that means there is a fast treatment. Unfortunately in most cases of IC/PBS/CPPS cultures return negative and patients and their doctors are left wondering what is going on and what to do about it.

 

Did you know…..

 

  1. Hypertonic pelvic floor muscles cause symptoms that feel like a urinary tract infection?
  2. Hypertonis and/or myofascial trigger points in pelvic girdle muscles, such as the rectus abdominus muscles and adductors, can also cause urinary urgency, frequency, and burning with urination?
  3. Hormonal changes during menopause, breastfeeding, and oral contraceptive use can compromise the peri-urethral tissues and contribute to symptoms of urgency and frequency, dysuria, and urethral pain?
  4. The majority of men diagnosed with ‘Prostatitis’ never had an actual prostate infection?
  5. Skilled pelvic floor physical therapy can reduce these impairments and lead to a reduction in symptoms?

 

The Evidence

 

Multiple studies have been published on the association between pelvic floor/girdle muscle dysfunction and Interstitial Cystitis/Painful Bladder Syndrome and Chronic Pelvic Pain Syndrome. These studies show that dysfunction in the musculoskeletal system can mimic urologic dysfunction (1,2). This means patients with symptoms of urinary urgency, frequency, and burning in the absence of infection can benefit from a pelvic floor physical therapy evaluation to determine if pelvic floor dysfunction is a contributing factor to their symptoms. To read more about what this type of evaluation entails please click here.

 

But how effective is physical therapy treatment for these symptoms? In 2009 a prospective, randomized, blinded, prospective multi-center study was initiated by Rhonda Kotarinos and Marypat Fitzgerald.3 This high-powered study was the first of its kind to be published on the role of myofascial physical therapy for the treatment of urologic chronic pelvic pain syndrome. The investigators compared two methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urologic pelvic pain symptoms.

 

In the study, 49 men and women enrolled and were divided into two groups. One group received skilled myofascial pelvic floor physical therapy and the control group received general massage, one hour per week, for 10 weeks. 94% of the participants completed the study, demonstrating that it is feasible to conduct a larger study on myofascial physical therapy treatment. Importantly, this trial also showed that 57% of the group that received skilled pelvic floor physical therapy demonstrated improvement, and this group showed statistically significant improvement over the group receiving massage.

 

These studies are important because they demonstrated the role the musculoskeletal system can play in what seems to be solely a bladder or prostate problem. Furthermore, they demonstrate that manual pelvic floor physical therapy treatment can play an important part of someone’s treatment plan. The role of a pelvic floor physical therapist does not stop manual therapy alone, however.

 

Recent studies have also shown that pain physiology education improves the health status of  people recovering from persisting pain syndromes. In a study initiated by J Van Ossterwick in a double-blind randomized controlled trial, 30 patients with fibromyalgia were assigned to receive pain physiology education or pacing self-management education.4 The results showed that the group receiving pain physiology education worried less about their pain, had long-term improvements in physical function, vitality, mental health, and general health perceptions. In addition and importantly, this group reported lower pain scores and showed improved endogenous pain inhibition compared with the control group.4

 

These quality studies show that physical therapy can help reduce or eliminate the symptoms of Interstitial Cystitis/Painful Bladder Syndrome and Chronic Pelvic Pain Syndrome as well as have a positive effect on pain, disability, and catastrophization in patients with these debilitating pain disorders. But the role of physical still does not end with manual therapy and pain physiology education.

 

Assessment, case management, goal setting and quality of life restoration

 

Physical therapists are often afforded the most one-on-one time with patients. Therefore, we are well-positioned to help the patient figure out how they developed their symptoms and link their history to their physical findings. This is called an assessment and it often includes components such as the differential diagnosis and development of an interdisciplinary treatment plan.

 

Specialists working with patients with IC/PBS/CPPS will tell you that no two patients are alike and therefore standard one-size-fits-all protocols are not effective. Each individual will have different levels and combinations of musculoskeletal, central and peripheral nervous system, and urologic impairments. Physical therapists can help patients identify why certain treatments have worked and why others have failed, and can use critical reasoning skills to help them set reasonable goals. Patients with these disorders often have multiple doctors and other healthcare providers involved in their care. Physical therapists can help them organize the treatment plan to make sure their goals are being met and they are improving. Individualized treatment plans may include various combinations of medications, medical interventions, physical therapy, cognitive behavioral therapy, hypnosis, diet management, yoga, etc. It is a lot to understand and manage, however, functional improvement and complete symptom resolution is totally possible. You can read more about this in our previous post “Why a ‘diagnosis’ is not the key to recovery”, and in our book, Pelvic Pain Explained.

 

As a physical therapist myself, I value the role we can play in helping patients organize their treatment plans, use education to reduce the understandable anxiety that comes from being diagnosed with IC/PBS/CPPS, reduce or eliminate the terrible symptoms with skilled manual techniques and home exercises, and help people put these problems behind them and move on with their lives. They can stop hoping for positive urine cultures because they understand the true causes of their symptoms and are equipped with the tools to treat them. 

 

In honor of Bladder Awareness Month and Interstitial Cystitis Awareness Week, we ask that everyone reading this share this post with at least one person who may not know about the role pelvic floor physical therapy can play to help people with IC/PBS/CPPS!

 

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

References

 

  1. Male pelvic pain: beyond urology and chronic prostatitis https://www.ncbi.nlm.nih.gov/m/pubmed/26717951/?i=4&from=pelvic%20floor%20dysfunction%20and%20chronic%20prostatitis#fft  
  2. MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome. https://www.ncbi.nlm.nih.gov/m/pubmed/26231233/?i=5&from=interstitial%20Cystitis%20and%20Pelvic%20Floor%20Dysfunction)
  3. Multicenter feasibility trial of myofascial physical therapy for the treatment of urologic chronic pelvic pain syndromes: https://www.ncbi.nlm.nih.gov/pubmed/23234638Randomized
  4. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial: https://www.ncbi.nlm.nih.gov/pubmed/23370076

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

Comments

  1. Reply

    Do you know of a PT for pelvic pain/IC near the Frederick, MD; Gettysburg, PA area?

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