Pelvic floor treatments
Work by Wise and Anderson has shown that urologic pelvic pain syndromes, such as BPS/IC and CP/CPPS, may have no initial trigger other than anxiety, often with an element of Obsessive Compulsive Disorder or other anxiety-spectrum problem.
This is theorized to leave the pelvic area in a sensitized condition resulting in a loop of muscle tension and heightened neurological feedback (neural wind-up).
This is a form of myofascial pain syndrome. Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress.
Most major BPS/IC clinics now evaluate the pelvic floor and/or refer patients directly to a physical therapist for a prompt treatment of pelvic floor muscle tension or weakness.
Chronic pelvic floor tension can cause pain in the bladder and/or pelvis, which is often described by women as a burning sensation, particularly in the vagina. Men with pelvic floor tension experience referred pain, particularly at the tip of their penis.
In 9 out 10 BPS/IC patients struggling with painful sexual relations, muscle tension is the primary cause of that pain and discomfort. Tender trigger points —small, tight, hyperirritable bundles of muscle— may also be found in the pelvic floor.
Pelvic floor dysfunction is a fairly new area of specialty for physical therapists world wide.
The goal of therapy is to relax and lengthen the pelvic floor muscles, rather than to tighten and/or strengthen them as is the goal of therapy for patients with incontinence. Thus, traditional exercises such as Kegels, can be helpful as they strengthen the muscles, however they can provoke pain and additional muscle tension.
A specially trained physical therapist can provide direct, hands on, evaluation of the muscles, both externally and internally.
While weekly therapy is certainly valuable, most providers also suggest an aggressive self-care regimen at home to help combat muscle tension, such as daily muscle relaxation audiotapes, stress reduction and anxiety management on a daily basis.
Anxiety is often found in patients with painful conditions and can subconsciously trigger muscle tension.
Transvaginal manual therapy of the pelvic floor musculature (Thiele massage) has shown promise in relieving the pain associated with Interstitial cystitis in at least one open, clinical pilot study.
As recently as a decade ago, treatments available were limited to the use of astringent instillations, such as chlorpactin (oxychlorosene) or silver nitrate, designed to kill "infection" and/or strip off the bladder lining.
In 2005, our understanding of BPS/IC has improved dramatically and these therapies are now no longer done. Rather, BPS/IC therapy is typically multi-modal, including the use of a bladder coating, an antihistamine to help control mast cell activity and a low dose antidepressant to fight neurogenic inflammation.
However, some studies have found that a minority of patients do respond to pentosan polysulfate.
Amitriptyline can reduce symptoms in patients with BPS/IC. Patient overall satisfaction with the therapeutic result of amitriptyline was excellent or good in 46%.
DMSO, a wood pulp extract, is the only approved bladder instillation for BPS/IC yet it is much less frequently used in urology clinics.
Research studies presented at recent conferences of the American Urological Association by C. Subah Packer have demonstrated that the FDA approved dosage of a 50% solution of DMSO had the potential of creating irreversible muscle contraction.
However, a lesser solution of 25% was found to be reversible. Long term use is questionable, at best, particularly given the fact that the method of action of DMSO is not fully understood.
More recently, the use of a "rescue instillation" composed of Elmiron or heparin, Cystistat, lidocaine and sodium bicarbonate, has generated considerable excitement in the BPS/IC community because it is the first therapeutic intervention that can be used to reduce a flare of symptoms. Published studies report a 90% effectiveness in reducing symptoms.
Other bladder coating therapies include Cystistat (sodium hyaluronate) and Uracyst (chondroitin). They are believed to replace the deficient GAG layer on the bladder wall.
Like most other intravesical bladder treatments, this treatment may require the patient to lie for 20 – 40 minutes, turning over every ten minutes, to allow the chemical to 'soak in' and give a good coating, before it is passed out with the urine.
The foundation of therapy is a modification of diet to help patients avoid those foods which can further irritate the damaged bladder wall.
Common offenders are highly spiced or acidic foods and include alcohol, coffees, teas, herbal teas, green teas, all sodas (particularly diet), concentrated fruit juices, tomatoes, citrus fruit, cranberries, the B vitamins, vitamin C, monosodium glutamate, chocolate, and potassium-rich foods such as bananas.
Most BPS/IC support groups and many urology clinics have diet lists available.
The problem with diet triggers is that they vary from person to person: the best way for a person to discover his or her own triggers is to use an elimination diet.
Anecdotal evidence has linked gluten intolerance to UCPPS symptoms.
Studies are lacking in this area.
Bladder distension (a procedure which stretches the bladder capacity, done under general anaesthesia) has shown some success in reducing urinary frequency and giving pain relief to patients.
However, many experts still cannot understand precisely ''how'' this can cause pain relief.
Recent studies showing that pressure on pelvic trigger points can relieve symptoms may be connected.
Unfortunately, the relief achieved by bladder distensions is only temporary (weeks or months) and consequently, it is not really viable as a long-term treatment for BPS/IC.
Surgical interventions are rarely used for BPS/IC. Surgical intervention is very unpredictable for BPS/IC, and is considered a treatment of last resort when all other treatment modalities have failed and pain is severe.
Some patients who opt for surgical intervention continue to experience pain after surgery.
Surgical interventions for BPS/IC include transurethral fulguration and resection of ulcers, using electricity/laser; bladder denervation, where some of the nerves to the bladder are cut (Modified Ingelman-Sundberg Procedure); bladder augmentation; bladder removal (cystectomy); electrical nerve stimulation, similar to TENS, where an electrical unit is implanted in the body and provides continuous or intermittent electrical pulses to the affected areas (Interstim); spinal cord stimulation (SCS), where an electrical unit is implanted that provides electrical stimulation to the spinal cord, interfering with pain reception to the brain (ANS/Advanced Neuromodulation Systems spinal Cord Stimulator); and the implantation of the intrathecal pain pump, where very small amounts of medication, like morphine sulfate, dilaudid, or baclophen are released into the cerebrospinal fluid via a catheter stemming from the small electrical pump, requiring only about 1/100 to 1/300 the amount of medication needed orally for the same therapeutic benefit, but with significantly fewer side effects.
Pain control is usually necessary in the BPS/IC treatment plan.
The pain of BPS/IC has been rated equivalent to cancer pain and may lead to central sensitization if untreated.
The use of a variety of traditional pain medications, including opiates and synthetic opioids like tramadol, is often necessary to treat the varying degrees of pain.
Even children with BPS/IC should be appropriately addressed regarding pelvic pain, and receive necessary treatment to manage it.
Electronic pain-killing options include TENS.
PTNS stimulators have also been used, with varying degrees of success.
Percutaneous sacral nerve root stimulation (PNS) was able to produce statistically significant improvements in several parameters, including pain.
A 2002 review study reported that acupuncture alleviates pain associated with BPS/IC as part of multimodal treatment.
While a 1987 study showed that 11 of 14 (78%) patients had a >50% reduction in pain, another study (published in 1993) found no beneficial effect.
A 2008 review found that although there are hardly any controlled studies on alternative medicine and BPS/IC, "rather good results have been obtained" when acupuncture is combined with other treatments.
Biofeedback, a relaxation technique aimed at helping people control functions of the autonomous nervous system, has shown some benefit in controlling pain associated with BPS/IC as part of a multimodal approach that may also include medication or hydrodistention of the bladder.
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