Painful Bladder Syndrome/Bladder Pain Syndrome (PBS/BPS) / Overactive Bladder Syndrome (OBS)
Painful bladder syndrome is a complex, difficult to treat and poorly understood, yet benign, condition affecting the bladder and the functioning operations of the bladder. At Core Body Clinic (our physiotherapy and pelvic pain clinics in Reading and Swansea) we aim to offer hope to patients by educating, providing pain relief and ensuring patients are confident in a long term management strategy to get their lives back.
Bladder pain syndrome is characterised by:
- Increased frequency of needing to pass urine
- and/or urgency when toileting.
These symptoms would be differentiated from more sinister conditions and any changes should be reported to your GP and a referral for examination by a urologist should be made. Only then, once all necessary tests have been carried out by the urology team can PBS / OBS be assigned as a diagnosis. Bladder pain syndrome or overactive bladder syndrome can fit under the umbrella term of chronic pelvic pain because it may occur without any identifiable diagnostic markers. This means a battery of tests may be performed and not provide a diagnosis. Therefore, patients with Painful Bladder syndrome or overactive bladder syndrome experience a long and drawn out process of hospital visits and tests.
PBS can involve a wide variety of pain locations including: Bladder, urethra, vagina, groin, and, prostate in men. Hence, it is sometimes difficult to differentiate the syndrome from chronic pelvic pain. In addition, the duration of symptoms may eventually lead to a more chronic pain manifestation. OBS may be the only symptom with incresased urgency and thus may eventually be a more specific diagnosis.
Patients sometimes present with the diagnosis of ‘Interstitial cystitis (IC)’. This is a difficult to treat and diagnose condition and is sometimes grouped along with bladder pain syndrome. It is a debilitating condition and again, it is poorly understood because of the paucity in diagnostic markers which differentiate it from other benign conditions. This will often lead to a delay in diagnosis and a more chronic pain pattern for the patient. IC is thought to primarily begin as a chronic inflammatory condition that affects the bladder wall. There is sometimes evidence of inflammation, yet in other patients there is nothing. Pain may also persist after the inflammation has reduced. This condition mostly affects women.
- PBS/IC can share common symptoms with pelvic pain:
- Frequency, urgency and pain in the bladder
- Pain over the abdomen, bladder region, genital region
- Increased nocturnal micturition (ie, needing to get up at night)
- A feeling that the bladder does not empty after toileting
- Needing to go to the toilet more during the day, more chronic manifestations may experience this due to lot bladder capacity.
- Pain after sexual intercourse (ejaculation in men) where the bladder feels irritated and a sense of needing to go to the toilet, despite an empty bladder
- Pain is worse when there is stress
The diagnosis of bladder pain syndrome or overactive bladder syndrome are typically by process of elimination of other disorders. Patients often present having undergone several tests with no diagnosis, often leaving them very low in mood. It is always important to emphasise the necessity of doing this to exclude other conditions of a sinister nature such as bladder, prostate, urethral or other pelvic / gynaecological cancers.
Typical examination procedures include: ultrasound, MRI, cystoscopy, cytology and biopsy. There may be urine flow test which measures how quickly we urinate or a bladder ultrasound to measure residual urine after toileting. Again, most of these tests exclude other causes and once completed a diagnosis of bladder pain syndrome/PBS is made.
Patients presenting at the clinic have often gone through a number of different treatments including:
- Pain management,
- Bladder distension,
- Bladder installation
- Botox injections
- Surgery can sometimes be offered in extreme cases
- An in-depth assessment about the condition - when did it start and what has happened up to now?
- What are the drivers of the patient’s pain.
- We look at behaviour; what they do, what coping strategies they have and whether they work or not.
- How long it takes to work and does it last?
- We want to know how long pain spikes or lasts for.
- What tests or treatment has already been done.
- How does the pain make the person feel?
This is called the history and it is a story unique to the patient and helps us understand how they feel about the condition. It is perhaps one of the most important components of pain management.
We look at:
- breathing patterns,
- spinal and hip ranges of movement,
- muscle strength
- nerve length.
We are assessing the patient to determine if they have any drivers for their pain. More chronic presentations will be easily aggravated by movements of joints and muscles close to the bladder/pelvic floor. While these are not necessarily the cause, they become part of the problem. Sometimes, the initial cause remains a mystery. However, we aim to work through the assessment to understand your condition and the potential drivers. Looking at the general condition of the individual is essential with evidence supporting that a better conditioned body favours recovery from chronic syndromes.
- Dynamic ultrasound (DUS) of the bladder and pelvic floor
DUS is an important and unique assessment procedure that we use at Core Body Clinic. It is important because it provides a functional understanding of how the muscles switch on and more importantly, switch off. Quite often in bladder pain syndrome the muscles are chronically sensitised and the patient has difficulty turning the muscles off. This level of sensitivity constantly drives up the pain and with this the muscles fail to disengage. Through a training process the muscles become too good at staying in a contracted state. We know that over time chronically tensed and active muscles over sensitise muscles and nerves leading to a chronic pain state and with it, a painful bladder syndrome. Dynamic ultrasound helps to examine and re-train a painful and chronically irritated area while avoiding physical examination which may further aggravate pain. Many patients have had unsuccessful internal massage which can leave them further irritated and damage confidence in therapy. We term the use of ultrasound: ‘looking inside while staying outside’. It is a very dignified way of assessment because the ultrasound transducer if placed on the lower abdomen allowing the patient to remain dressed. The ultrasound provides a real-time understanding of pelvic movement and relaxation and gives the patient a visual understanding of how muscles in the pelvis function. We have found this procedure in examination and treatment provides the patient with a real sense of control and helps to manage their pain in a much better way.
Physiotherapy Treatment for Painful Bladder Syndrome:
We formulate a treatment plan based on the assessment findings and this is unique to the individual. Treatments may look familiar but they will not be identical between patients.
Treatment may include:
- Ultrasound muscle retraining
- Relaxation and breathing techniques
- Stretches and active release techniques
- Weight training
- Cardiovascular conditioning
- Diet and drink advice
- Manual therapy to the abdomen and spine
- Coaching techniques on pain management
- Electrical nerve stimulation (percutaneous tibial electrical nerve stimulation) using TENS or Acupuncture - PTNS
- Rarely we use internal massage or instruct the patient in the use of a Therawand.
At Core Body Clinic we aim to build confidence in our patients by helping them to understand the chronic nature of pain. We offer physical therapies to assist with pain relief and exercise rehab to provide patients with a sense of control to manage their condition long term. We emphasise that chronic pain is a state in which long term changes have taken place in the soft tissue and, more importantly, in the central nervous system (Nerves and brain). We stress that pain is “an unpleasant experience” (as described by the NISP) where beliefs, previous experiences and learned behaviour all have an impact on how we tolerate and feel pain, which in turn determines how our body and muscles or bladder reacts. With this, we aim to educate patients stressing that, because pain develops over time there is an opportunity to unlearn and rewire the nervous system to a point where pain is more manageable and even cured.