Why do I need to urinate frequently?

• Is there pain as your bladder fills?
• Are you rushing to get to the toilet to urinate?
• Do you go to the toilet frequently?
• Is there pain in skin around your vaginal opening?
• Does your pelvic floor feel too switched on?

If you answered yes to one or more of these questions, you may have interstitial cystitis.

What is Interstitial Cystitis?

What we used to know as bladder pain syndrome (BPS) has changed over the years. 

Our understanding of bladder mechanics, pelvic floor dysfunction, endometriosis, gut bacteria, lifestyle and stress have made the history of naming this condition complicated.  

The American Urological Association (AUA) published guidelines in 2011 defining interstitial cystitis / bladder pain syndrome (IC / BPS) as 

“an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.” 

A revision of these guidelines in 2014, however, refined the definition as

“a collection of symptoms, including but not limited to bladder pain, after other causes such as infections have been ruled out.” 

Confusing? 

You bet!  Fortunately, these guidelines have ruled “in” non bladder related symptoms, such as vulvodynia (pain, burning and discomfort in the vulva) and pelvic floor dysfunction.  

Is Interstitial Cystitis a common condition?

• The average age of onset for Interstitial Cystitis is 40 years.
• 25% of patients are under the age of 30.
• 50% of patients experience spontaneous remissions with a duration ranging from 1 to 80 months.
• Patients with Interstitial Cystitis are 10 times more likely than controls to report childhood bladder problems.
• 50% of Interstitial Cystitis patients have pain while riding in a car.
• 63% of Interstitial Cystitis patients are unable to work full time.
• 52% of women with Interstitial Cystitis reported panic attacks and over 30% reported depression.

Symptoms of Interstitial Cystitis:

• Bladder pain.
• Urinary Urgency.
• Urinary Frequency.
• Pain worsened with bladder filling.
• Nocturia (excessive urination at night).
• Dysuria (pain with urination).

How is Interstitial Cystitis diagnosed?

There are no definitive tests to diagnose IC / PBS. It is important to rule out other infections and conditions using the following assessment process.  I like to think of this in three main sections – subjective assessment, physical assessment and laboratory testing.  

• The initial assessment should include a careful history of your bladder and bowel health, menstrual health, gut disorders, lifestyle, stress and dietary intake.  
• The physical examination will also rule in / out vulvar conditions or pelvic floor dysfunction.  Up to 80% of women with IC have vulvodynia (pain of the vulva), and 90% have pelvic floor dysfunction!
• The AUA guidelines recommend the following laboratory examinations to rule in symptoms that characterise IC / BPS and rule out other similar (but confusing) conditions:
  • Blood test.  
  • Urinalysis.
  • Prostate excretions.
  • Cystoscopy* see below.
  • Bladder wall biopsy.

Is a cystoscopy useful to diagnose my Interstitial Cystitis?

As of 2020, the guidelines no longer recommend cystoscopies. 

To understand why, we need to dive into bladder anatomy and function.  Interstitial CystitisInterstitial Cystitiswas initially thought of as a disease of the bladder lining in which case doing a cystoscopy to look at the bladder lining makes sense. However, recent studies show that some people with abnormal looking bladders did not have urinary symptoms, and others with urinary symptoms had normal looking bladders. 

Furthermore, only 10% of people diagnosed with Interstitial Cystitis have Hunner Lesions and bladder symptoms.

Although not full Hunner lesions, some people do have glomerulations (small defects in the bladder lining that will bleed during bladder stretching). 

Add to this the 80% of women with vulvodynia, and 90% with pelvic floor dysfunction. 

Therefore, a cystoscopy is not needed since Interstitial Cystitis is no longer considered a disease of the bladder lining, yet many patients who present to me have already had one.
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 How is Interstitial Cystitis treated?

“No single treatment has been found effective for the majority of patients, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved.” (AUA IC Guidelines, 2014). 

The best approach is an holistic approach in combination of different therapies as has been recommended by the Interstitial Cystitis Association (ICA), the American Urological Association (AUA), and American College of Obstetrics and Gynaecology (ACOG).

• Patient education.
• Pelvic Floor Physiotherapy – this includes fluid and dietary intake, down training the overactive pelvic floor muscles, eliminating bladder irritants (e.g. coffee), bladder scheduling.
• Manage associated conditions – i.e. irritable bowel syndrome, vulvodynia, depression, endometriosis, anxiety disorder, fibromyalgia and TMJ.
• Self-care behaviour modification and avoidance of activities that may make symptoms worse i.e. wearing tight clothing, stopping pelvic floor strengthening, hygiene during and after sexual intercourse.
• General relaxation / stress management – guided imagery, meditation, yoga, mindfulness.
• Pain management – hands on treatment, urinary analgesics, oral medications (second line treatment).
• Bladder instillations – a small tube is placed in the urethra to fill the bladder with medicine.  Note that this is only when the first two lines of treatment have provided no relief, but is not recommended lightly.
• Bladder stretching / hydrodistension – the bladder is filled with sterile water in order to distend the bladder and increase the amount of urine you can hold ((low-pressure (60-80 cm H2O), short duration (less than 10 minutes) procedures).   This procedure is performed under anaesthesia in a theatre.  Note that this is only when the first three lines of treatment have provided no relief, but is not recommended lightly.
• Nerve stimulation – this may be helpful in reducing urgency and urinary frequency but sometimes can help with the bladder/suprapubic pain.  The non-surgical, more affordable method (Urgent PC®) is often attempted before the more invasive, costly surgical method (Interstim®).  Note that this is only when the first three lines of treatment have provided no relief, but is not recommended lightly.  
• Surgery – this is the last recommended line of treatment.  Urinary diversions, substitution cystoplasties or cystectomies come with complications, as the pain can be persistent even after cystectomy, especially in non-ulcer IC.  

Is there a cure for Interstitial Cystitis?

Interstitial Cystitis is a tricky condition to diagnose, however the symptoms and flare ups can be managed with the above treatment strategies under the guidance of a Pelvic Floor Physiotherapist.  

Researchers in Japan asserted that there are two subsets of Interstitial Cystitis, which will dictate which line of treatment to follow:

• The first group – Hunner lesions and histological and cellular level caused changes to the bladder lining (5-10% of patients with IC).  This is known as “classic IC” and it is very clear that they have a bleeding, damaged bladder wall. Treatment protocol therefore should include therapies that directly address this cellular level dysfunction. 
• The second group – without lesions, are more likely to have their symptoms caused by pelvic floor dysfunction (not cellular and pathological findings in the bladder lining).  This is the remaining 90% of Interstitial Cystitis patients.  Treatment protocol should therefore address overactivity of the pelvic floor muscles, bladder wall injury, nerve trauma. 

Click here to find out how a Pelvic Floor Physiotherapist can diagnose and reduce your pain.

Where can you find us?

Performance Plus Women’s Physiotherapy provides the Women’s Health Service at Waverley Private Hospital. Consulting nearby at 40 Lemana Crescent Mount Waverley for outpatients means that all your Women’s Health Services are covered. Conveniently located it means that it services the suburbs of Glen Waverley, Burwood, Chadstone, Oakleigh and Clayton.

Additionally, our clinics close proximity to the Monash Freeway also means that suburbs such as Dandenong, Cranbourne and Springvale are close by.

Contact us on 03 9815 2555 or book online