By Guest Blogger Jessica Drummond MPT, CCN, CHC
One of the reasons that relieving pelvic pain is so challenging is that pain in different systems within the pelvis can overlap. For example, in rats where experimental colitis (colon irritation) was induced, many of the rats also experienced bladder and urethral pain (Yoshikawa et al., 2015). Thus, there is clear overlap between bladder pain and gastrointestinal symptoms. Root cause relief for Small Intestinal Bacterial Overgowth (SIBO) and Interstitial Cystitis-related bladder pain requires optimizing the functioning of the digestive system and health of the gut microbiome.
Women with interstitial cystitis (IC) often have overlapping gastrointestinal symptoms.
Let’s focus today on one common GI issue called Small Intestinal Bacterial Overgrowth (SIBO) and how that can relate to pelvic pain of the bladder. More and more research is coming out about the microbiome in the digestive system. As it turns out, humans have far more bacterial cells than human cells living in our bodies. The vast majority of those bacteria live in the large intestine. If we take care of our gut bacteria (otherwise known as the gut microbiota), then the beneficial bacteria within the colon serve multiple purposes to keep us healthy.
For example, supportive (commensal) gut microbes, probiotics, displace pathogens, synthesize some vitamins, and support the functioning of the immune system. But, when too many microbes (supportive or pathogenic) leak back from the large intestine into the small intestines… problems will occur.
How is SIBO diagnosed?
The most common test for SIBO is called a lactulose breath test. A physician can order the lactulose solution, which a patient drinks. The patient will then breathe into collection tubes 2-3 hours later. The transit time of the solution is 3 hours to the large intestine.
Then hydrogen and methane gas are measured. If hydrogen is increased by 20 ppm or more the test is considered positive, if methane is increased by 3 ppm or more, the test is also considered positive. If both hydrogen and methane are increased by 15 ppm or more, the test is also positive.
In terms of actual gastrointestinal symptoms, hydrogen gas is more commonly associated with diarrhea and methane is more commonly associated with constipation.
However, a systemic review published in 2008, found no gold standard test for SIBO based on the lack of quality evidence available at the time of the review (Khoshini, Dai, Lezcano, & Pimentel, 2008).
While more research needs to be done on the validity, sensitivity, and specificity of the testing for SIBO, there is data that shows the relationship between SIBO and IC.
In patients with IC who also had GI symptoms, a majority of them tested positive for SIBO (Weinstock, Klutke, & Lin, 2008). Of those who did and were treated with an antibiotic plus a prokinetic therapy, 47% had sustained global improvement in their IC.
Thus, when we’re working with patients with pelvic floor dysfunction and specifically pelvic pain, we need to be mindful of their symptoms across systems. In the case of many of the women with IC in this study, it was necessary to address the digestive system in order to more fully relieve the associated bladder pain.
What are clinical symptoms of SIBO?
- Diarrhea
- Constipation
- Abdominal pain
- Bloating
- Changes in bowel habits
*Clinically, I find that bloating symptoms are the key symptom to look for when considering SIBO.
What dietary changes can be effective to relieve SIBO?
Relief for SIBO and interstitial cystitis related bladder pain using a root cause approach requires assessing digestive function, and gut microbial health.
Various antibiotic therapies are recommended for medical treatment of SIBO, but unfortunately these can lead to side effects affecting the overall health of the symbiotic healthy bacteria in the digestive system (Malik, Xie, Wine, & Huynh, 2011; Weinstock et al., 2008)
A functional nutrition approach to relief for SIBO and interstitial cystitis related bladder pain…
Instead of antibiotics, using antibacterial herbs to rid the small intestines of the pathogens and to concurrently make dietary changes to relieve symptoms and restore depleted nutrients is gentler and effective in most of the patients that I work with that have comorbid pelvic pain and SIBO.
I recommend collaborating with a skilled functional nutrition professional or herbalist to provide antibacterial herbs such as oregano oil, wild garlic and berberine. A specific herbal antimicrobial protocol has been studied by researchers at John’s Hopkins University, and found to be equally as effective as using antibiotics to resolve SIBO symptoms (Chedid et al., 2014).
Nutrition changes that can both improve the bacterial balance and restore lost nutrients are to avoid sugars (even fruit sugars), fructans, lactose (dairy sugar), and legumes. I recommend starting with a basic elimination diet avoiding sugars, dairy, wheat and gluten containing grains, and a few other common irritants based on our Nourish, Pelvic Pain Relief Programs.
Pelvic floor physical therapists are specifically trained to help patients deal with overlapping pain conditions and help guide patients through an interdisciplinary treatment plan.
Dr. Jessica Drummond, DCN, CCN, PT, Founder of the Integrative Women’s Health Institute, is passionate about empowering women who struggle with chronic conditions, and supporting women’s health and wellness professionals globally. She has 2 decades of experience working with women with chronic health conditions, including chronic pelvic pain, from an integrative, conservative perspective.
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References:
- Abbasi, M. H., Zahedi, M., Darvish Moghadam, S., Shafieipour, S., & HayatBakhsh Abbasi, M. (2015). Small bowel bacterial overgrowth in patients with irritable bowel syndrome: the first study in iran. Middle East J Dig Dis, 7(1), 36-40.
- Chedid V, Dhalla S, Clarke JO, Roland BC, Dunbar KB, Koh J, Justino E, Tomakin E, Mullin GE. (2014) Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014 May;3(3):16-24. doi: 10.7453/gahmj.2014.019.
- Khoshini, R., Dai, S. C., Lezcano, S., & Pimentel, M. (2008). A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci, 53(6), 1443-1454. doi: 10.1007/s10620-007-0065-1
- Malik, B. A., Xie, Y. Y., Wine, E., & Huynh, H. Q. (2011). Diagnosis and pharmacological management of small intestinal bacterial overgrowth in children with intestinal failure. Can J Gastroenterol, 25(1), 41-45.
- Weinstock, L. B., Klutke, C. G., & Lin, H. C. (2008). Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms. Dig Dis Sci, 53(5), 1246-1251. doi: 10.1007/s10620-007-0022-z
- Yoshikawa, S., Kawamorita, N., Oguchi, T., Funahashi, Y., Tyagi, P., Chancellor, M. B., & Yoshimura, N. (2015). Pelvic organ cross-sensitization to enhance bladder and urethral pain behaviors in rats with experimental colitis. Neuroscience, 284, 422-429. doi: 10.1016/j.neuroscience.2014.08.064
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
This makes total sense!! I have had IC since 2000.
It’s in fact very complicated in this active life to listen news on Television,
thus I simply use internet for that purpose, and take the latest news.
This helped me understand why when I mentioned IC to my GI dr he immediately wanted to do a SIBO. You also helped me Inform my general doctor. And made me look smart
Haleigh- This is exactly why we continue to publish our blogs, in hopes of educating others and helping in their path to treatment.