Urinary Tract Infection Protocol
What is Interstitial Cystitis/BPS?

What is Interstitial Cystitis/Bladder Pain Syndrome?

Interstitial Cystitis(IC)/Bladder Pain Syndrome (BPS) is a chronic pain and bladder condition with painful urinary symptoms that lasts over 6 weeks in the absence of urinary tract infection or any other clear cause.

IC/BPS was once seen as a rare condition but the amount of individuals with the condition is surprisingly high. It is said that over 12 million people in the United States alone have the condition – which means it is almost as common as heart disease and depression (Cozean, 2016).

Symptoms

  • Urinary frequency (needing to urinate often)
  • Urinary urgency (needing to urinate suddenly because of pain)
  • Pain in urethra, lower abdomen, lower back
  • Urethral burning with voiding
  • Pressure and/or pain can be felt in pelvic/perineal area, groin, vulva/vagina and scrotum/testicles
The Interstitial Cystitis Pain Cycle

Causes

There is no recent progress in truly understanding the causes of IC/BPS but in 2015, Dr. Christopher Payne led several efforts at classifying the different types of IC/BPS patients observed clinically.

He argued that the diagnosis of IC/BPS should be much more specific so that a clear treatment pathway can be identified for patients. He suggested five subtypes of IC that assess the whole patient and produces a customized treatment plan.

Dr. Payne has run the IC/BPS research initiative at the University of Stanford for the last two decades.

Interstitial Cystitis/Bladder Pain Syndrome Subtypes:

Subtype 1 – Hunner’s Lesions –  5% to 10% of patients present with inflammatory lesions in the bladder wall: Hunner’s lesions. These are wounds on the bladder that, when biopsied, show severe inflammation. These lesions can be very painful, require a strict diet and specific treatments.

Pain is described as sharp, burning or pressure and it’s normally experienced in the suprapubic region (above pubic bone).

Hunner’s lesions are diagnosed by Cystoscopy with or without hydrodistention and may require local lesion-directed therapy (laser or steroid injections) and do not generally respond to oral medications and bladder instillations (combination of medicines put directly into the bladder). 

Ic Bladder
© IC Network

Subtype 2 – Bladder Wall Injury These patients symptoms start after a bladder assault like multiple UTI’s, chemotherapy, bad diet, chemical exposure. Because the bladder wall has been injured in some way, urine penetrates deeply into the tissues where it can cause irritation.

Symptoms normally worsen with bladder filling and are reduced with urination. Treatment normally focuses on bladder behavioural training, diet modification, supplements and oral medications. These patients may be also receptive to bladder instillations with lidocaine. 

Subtype 3 – Pelvic Floor Injury – These patients can present with muscular trigger points in pelvic floor, abdominal, low back or hip muscles which recreates bladder pain and sensations. Having a child, abuse/trauma, a car accident or a bad fall may cause the pelvic floor muscles to spasm and tighten around the bladder and pelvic nerves where it can cause bladder symptoms and pelvic pain.

Pelvic floor muscle physical therapy is now considered a gold standard therapy for IC/BPS patients and research studies have found it to be more effective than oral medications and/or bladder treatments for many patients.

Subtype 4 – Pudendal Neuralgia – These patients often have tight muscles that they are squeezing or pressing on the pudendal nerves. Pain with sitting can become quite unbearable. 

Treatment should start by identifying the cause of the nerve irritation. The first line of conservative treatment would be pelvic floor physical therapy to identify if there are any myofascial reasons for nerve compression. If conservative treatment does not help, nerve blocks can be used both diagnostically and therapeutically to reduce symptoms. 

Sometimes medications such as gabapentinoids can help relieve this neuropathic pain.

Subtype 5 – Multiple Pain Disorders/Central Sensitization – These patients struggle with more multiple conditions, other than just Interstitial Cystitis. Patients often suffer from Endometriosis, IBS, Vulvodynia, Prostatodynia, Fibromyalgia, and more. These patients may have had symptoms from a young age and/or could have other relatives who struggle with bladder and other pain syndromes. In some cases, it’s genetic and in other cases, it can be result of injury or trauma.

Diagnosis

Many Interstitial Cystitis/BPS patients are not officially diagnosed until their forties (Cozean, 2016), due to many physicians believing it can onluy happen after the age of 35 or child birth. This unfortunately leads to years of misdiagnosis and incorrect treatment for so many.

Together, with your medical team (Urologist, Urogynaecologist, OBGyn, or Pelvic PT), you should:

Go over medical history

Your healthcare team should take a look at your medical history, including your symptoms, triggers, surgeries, pregnancies, falls or accidents, history of abuse, history of sports etc. They will need to know if you have other chronic pain conditions such as: IBS, Fibromyalgia, Endometriosis, etc. They may also ask if anyone else in your family struggles with IC like symptoms.

Pelvic Floor Muscle Examination

The pelvic floor muscles should be assessed (by a Pelvic Floor educated Practitioner) to look for tenderness and/or painful trigger points. If there are trigger points present, a referral to Pelvic Floor Physical Therapy is necessary.

*The pelvic floor supports the bladder, rectum, sexual organs and urethra. IC/BPS is deeply intertwined with pelvic floor dysfunction. Having tight, hypertonic muscles can sometimes be a root cause to many IC/BPS symptoms, like pain, irritation and frequency.*

Learn how Pelvic Floor Physical Therapy can help Interstitial Cystitis here.

After the evaluation, your doctor may request more testing:

Cystoscopy – This is a test where a camera looks in your bladder to rule out bladder cancer or stones + to look for IC Hunner’s Lesions.

Urodynamics – This tests how well the bladder, sphincters, and urethra are storing and releasing urine. The bladder is filled with water through a catheter to measure bladder pressures as it fills and empties.

Voiding Diary: Take home printable to evaluate your voiding patterns

Interstitial Cystitis Treatment + Alternative Therapies

Interstitial Cystitis/Bladder Pain Syndrome symptoms range widely from patient to patient and it takes a wholistic, Biopsychosocial approach to improve your symptoms and quality of life.

Interstitial Cystitis Biopsychosocial ApproachThe Biopsychosocial approach suggests that our biology, thoughts, emotions, behaviours and social/cultural factors play an important role in healing overall human function when someone is living with chronic pain or illness. Using this approach in addressing and managing bladder symptoms shows promise in the treatment of IC/BPS.

Unfortunately, no one medication or therapy will cure or eliminate your Interstitial Cystitis pain and symptoms. You and your medical team should look at your case holistically and produce a customized treatment plan. 

According to the AUA and CUA (American and Canadian Urological Associations) IC/BPS treatment should always start with conservative, least invasive therapies and if symptom relief is not reached, treatment should try less conservative therapies.

This six step treatment protocol was created with respect to patient safety.
Not one single treatment has been found effective for the vast majority
of IC/BPS patients; which means multiple trials and a combination of therapies
may be required to receive symptom relief.

First line of Treatment:

Education, behavioural modifications and stress management:

  • Water intake
  • Diet modification
  • Hot + Cold therapy
  • Meditation/Mindfulness
  • OTC Supplements
  • Yoga
hot cold therapy
Second line of Treatment:
  • Pelvic Floor Physical Therapy
  • Pain Management 
  • Bladder Instillations: Lidocaine, Heparin, DMSO, or a combination 
  • Oral Medications: Amitriptyline, Hydroxyzine, Elmiron
Pelvic Floor Physical Therapy and Interstitial Cystitis
© Michelle Milheiras 2020
Third line of Treatment:
  • Short duration, low pressure hydrodistension under anesthesia 
  • If Hunner’s lesions are present, fulguration with laser or electrocautery
Fourth line of Treatment:
  • Neuromodulation/ Neurostimulator
  • Intra-bladder Botox injections
Neurostimulator for Interstitial Cystitis
Creator: Dr Levent Efe CMI
Copyright: © 2013 Levent Efe P/L – All rights reserved
Fifth line of Treatment:
  • Oral Medication: Cyclosporine A
Sixth line of Treatment:
  • Major bladder surgery

A key takeaway when looking at IC/BPS treatment, is that almost always, a holistic approach is needed to improve symptoms and get you on the right path to healing. 

Healthcare team

Forming your healthcare team

Your Interstitial Cystitis/BPS healthcare team can consist of many medical doctors in various specialties such as Gynaecology, Urology, and Pain Management. But it can also consist of a variety of other practitioners such as:

  • Physical Therapists
  • Naturopaths
  • Psychologist/Therapist
  • Gastroenterologists
  • Acupuncturists
  • Chiropractors
  • Pharmacists
  • Nutritionists

You’ll likely want to research practitioners by going on online forums and communities and searching for the top IC Urologists in your area.

Then use Google, join Facebook groups, read peer-reviewed scientific studies, read the blogs of practitioners and others experiencing the same symptoms as you are. 

Knowledge is power.

Check out The Happy Pelvis Resource page for helpful links, studies and blogs. 

Now, once you have narrowed down your list, you can start by finding the one doctor who understands your conditions and pain most (the one you will see the most – does NOT have to be your “primary care physician”) and build your team starting there.

This is because like-minded doctors tend to network and know other like-minded doctors and practitioners. Their referrals can (sometimesstreamline your healthcare dream-team, saving you time and money.

Once you start working with a doctor you like and trust, they will be able to give you better guidance as to what other practitioners you may benefit from on your healing journey. 

Blog Post: How to Become Your Own Medical Advocate

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References:

Hanno, Philip & Burks, David & Clemens, J Quentin & Dmochowski, Roger & Erickson, Deborah & Fitzgerald, Mary & Forrest, John & Gordon, Barbara & Gray, Mikel & Mayer, Robert & Newman, Diane & Nyberg, Leroy & Payne, Christopher & Wesselmann, Ursula & Faraday, Martha. (2011). AUA Guideline for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. The Journal of urology. 185. 2162-70. 10.1016/j.juro.2011.03.064.

Can Urol Assoc J 2016;10(5-6):E136-55. http://dx.doi.org/10.5489/cuaj.3786 Published online May 12, 2016.

Cozean, N. (2016). Interstitial Cystitis Solution: A Holistic Plan for Healing Painful Symptoms, Resolving Bladder and Pelvic Floor Dysfunction, and Taking Back Your Life (1st ed.). Fair Winds Press.

Osborne, J. (2020, July 16). Interstitial Cystitis – IC Symptoms Treatments, Pain And Causes. Interstitial Cystitis Network. https://www.ic-network.com/

Nickel JC: Interstitial cystitis: a chronic pelvic pain syndrome. Med Clin North Am 2004; 88: 467.

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