What is it?
Bladder pain syndrome (BPS) is ‘the occurrence of persistent or recurrent pain perceived in the urinary bladder region, accompanied by at least one other symptom, such as pain worsening with bladder filling and day-time and/or night-time frequency. There is no proven infection or other obvious local pathology’ (Engeler et al, 2020).
It is considered a complex pain condition of the bladder, nervous system and pelvic floor.
How common is it?
1.2 million people in Australia are living with BPS, that’s approximately 5% of the population.
What are the symptoms?
The ‘classic’ BPS symptoms include:
- Pain above the pubic bone
- Burning sensation while passing urine
- Bladder urgency
- Bladder frequency
- ‘Phantom UTI’s’
- Specific types of inflammation can be present in certain patients
Other common symptoms have no relation to the bladder:
- Generalised pelvic pain
- Hip/SIJ/Lower back pain
- Pain with intercourse/tampon use
BPS is often associated with negative cognitive, behavioural, sexual or emotional consequences and may be linked with reduced quality of life (Engeler et al, 2020).
What causes it?
Many people believe BPS is caused by dysfunction in the bladder lining. It is, however, more complicated than that. Only 10% of BPS cases have defects in the bladder (presence of ‘Hunner’s lesions’ on cystoscopy) while 87% have pelvic floor dysfunction (Peters et al., 2007).
In patients with BPS, muscles of the pelvic floor have been found to be overactive, tight and may be referring pain inside the pelvis. This occurs through ‘pelvic organ crosstalk’, a real phenomenon whereby changes in muscle tension can directly influence the behaviour of organs and vice versa. (Ustinova et al, 2010)
How is BPS diagnosed?
Bladder cystoscopies, hydrodistension and biopsies may be performed to rule out the presence of cancer, lesions within the bladder itself or define different phenotypes/subgroups within the BPS spectrum. However, no conclusive testing exists and BPS remains a diagnosis of exclusion and clinical symptoms.
Can men experience BPS?
Although previously believed to affect only women, BPS has been shown to be almost as common in men. It is thought that BPS is identical or closely related to chronic prostatitis. There is little difference between the anatomy of male and female pelvic floors and as a result, similar dysfunction can occur.
How is BPS treated?
Pelvic floor physiotherapy is the best treatment for BPS, and the only option given grade ‘A’ evidence by the American Urological Association. It is recommended as the first line of treatment for BPS and has been proven to offer significant pain relief in over 63% of patients (Weiss, 2001; Bedaiwy et al, 2013)
Other treatments such as medications, bladder instillations, nerve stimulation, botox or even bladder removal surgeries should not be considered until a trial of pelvic physiotherapy has been completed.
Pelvic floor physiotherapy & BPS
As mentioned, over 80% of people with BPS have associated pelvic floor dysfunction.
A common feedback loop exists in patients with BPS: urinary urgency causes strain/irritation to the pelvic floor which sends messages of pain to the bladder signalling it to empty again in an attempt to relieve these symptoms.
Physiotherapists who are specialised in pelvic floor dysfunction will be able to identify the muscular and fascial restrictions within the pelvic floor that may be related to your symptoms, bring this into your conscious awareness and facilitate change. Patients are often surprised when gentle pressure placed on a muscle within their pelvic floor reproduces a particular sensation (eg. bladder urgency)!
Once all underlying causes have been identified, the road to healing begins. Treatment with your physiotherapist will include education, hands on treatment both internally and externally as required, in addition to self-management strategies.
The overall goal of pelvic physiotherapy for this population is to optimise mind-body connections and empower patients to re-gain full function, whatever that may be.
What are ‘Self-Management’ strategies for BPS?
Self-management is a critical part of the BPS healing journey. Depending on your symptoms, your physiotherapist can offer advice on what can be done outside of the clinic to enhance the effect of treatments and help you to re-gain control over your body. Some of these strategies include:
- Deep breathing exercises
- Baths (+/- epsom salts)
- Targeted hip and pelvic stretches (+/- nerve flossing)
- External release exercises: foam roller, lacrosse balls, Franklin balls…
- Internal release exercises: Therawand (vaginal/rectal), self-release, partner-facilitated
- Gentle core strengthening: functional exercises that incorporate the entire core
- Self-care / self-compassion – doing things that you love!
- Enhancing sleep quality
By adopting a multi-dimensional approach, all factors are considered which ensures the best possible outcome for the patient.
Your body, brain and nervous system are bioplastic with potential to change no matter how long you have been experiencing dysfunction. Many people with BPS live healthy, pain-free lives…you can too!
Take home messages
- BPS is not well-known, but very treatable with the right practitioner.
- BPS can occur in both sexes.
- Pelvic floor physiotherapy is first line, ‘Grade A’ treatment for patients with BPS.
- BPS is not purely a condition of the bladder. The symptoms can be due to the bladder, the pelvic floor or most likely, both.
- Some tight muscles within the pelvic floor refer pain to the bladder. By releasing these, the bladder will be given an opportunity to function optimally.
- Self-management is vital in optimising patient outcomes.
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