It depends on what is causing the pelvic pain.
1. Pelvic pain that has nothing to do with the bladder. For example, pelvic pain can come from endometriosis, tumors or infection, of the pelvis, uterus, prostate, rectum, etc. We have to exclude these major problems in the beginning.
2. Neuropathic pain. In this instance, the nerves themselves are malfunctioning. They send inappropriate pain messages to the brain, which incorrectly tells the patient that there's a problem in the bladder. The nerve problem can exist anywhere from the nerves of the pelvis to the spinal cord to the brain. This problem could be due to factors such as previous surgery, trauma, lower back disc disease, or tumors of the spine. In most instances, medical evaluation fails to demonstrate a cause. As you can imagine, any treatment that you apply directly to the bladder, such as DMSO, may have no effect on those patients. I find that patients having this type of pain are the most difficult to treat.
3. Bladder hypersensitivity/Interstitial Cystitis. A good history and physical examination will often help the physician hone in on the bladder as a central problem. For example, most patients with bladder specific pain will have one or more of the following problems:
4. Pelvic floor dysfunction (PFD). The fourth site of pain is often the pelvic floor muscles. As you probably already know, the bladder and the rest of the pelvic organs rest upon these muscles. The muscles of the pelvic floor are very complex and serve very important roles for us on a moment-to-moment basis. For example, they need to relax when one urinates, has a bowel movement or, in the case of females, has sexual intercourse. I often see patients who complain of a very poor urinary stream. The urine flow may even start and stop. Many of these patients feel that they need to "push" in order to completely empty themselves. These patients are having a normal bladder contraction, however, instead of pelvic floor muscle relaxation occurring, they are actually tightening up and preventing urine from being released. The act of pushing urine out may be counterproductive since it often worsens the muscle "spasticity." On physical examination, pushing into this muscle group often elicits significant pain. The muscles are frequently "bulky" and in some instances very taught, having the characteristics of a violin string (as opposed to being soft and non-tender). Muscle problems such as this often give rise to vague complaints of pelvic discomfort. PFD is often associated with painful sexual intercourse (the pain is usually most severe "the day after"), irritable bowel syndrome and/or chronic constipation. Stress seems to be a very important factor in symptom worsening.
Overall, those are the broad reasons that patients will develop a pelvic pain syndrome. The big question is how to deal with it. This can be particularly complicated since patients often have several associated problems. For example, many of IC patients will have accompanying PFD. If both problems aren't addressed, patients generally have a suboptimal response to treatment.
If the patient's main problem is the bladder, then we will treat the bladder. As you know, dietary changes, oral medications, will often improve symptoms. These medications have specific qualities that target the bladder. Sometimes medications instilled directly into the bladder may help. If the pain and discomfort appear to be coming from the muscles of the pelvic floor, then the therapy is not going to be the same. We want therapy aimed at relaxing the muscles. Teach patients how to deal with those pelvic floor muscles appropriately.
2. Patients cannot be constipated. If you are constipated, you will never get better unless that problem is dealt with aggressively. You may have to go to a gastroenterologist to make sure there is no other associated problem.
3. The third thing patients should do is to get into the bathtub twice a day. It should be a warm bath which facilitates muscle relaxation. You can use two moist heating pads, sitting on one and placing the other on the lower abdomen if you don't have access to a bathtub. Keep in mind that baths usually work better.
4. Put patients on a muscle relaxant. Patients are usually weaned down on their dosage as symptoms improve. This is not given as a medication for stress, (although stress can play a role in PFD), but to get the muscles relaxed. It tends not to make patients sleepy as opposed to other muscle relaxants.
There are other things that can be done for PFD. For example, biofeedback can be helpful. If in-office therapy is helpful, small, portable home units are often prescribed.
More and more physical therapists are now being trained to manage these problems. Some physical therapists are experienced in pelvic floor biofeedback, but be careful. Biofeedback is a method that is also used to treat urinary leakage. The therapist may be trained to deal with leakage but has no experience when dealing with pain derived from the muscles of the pelvic floor. Physical therapists who specialize in this area are able to perform "internal massage" to identify the trigger points to smooth this area out. Again, PFD can be a problem associated with IC, or it can be a separate entity.
You first need to know how is classified pelvic pain:
1. Pelvic pain that has nothing to do with the bladder. For example, pelvic pain can come from endometriosis, tumors or infection, of the pelvis, uterus, prostate, rectum, etc. We have to exclude these major problems in the beginning.
2. Neuropathic pain. In this instance, the nerves themselves are malfunctioning. They send inappropriate pain messages to the brain, which incorrectly tells the patient that there's a problem in the bladder. The nerve problem can exist anywhere from the nerves of the pelvis to the spinal cord to the brain. This problem could be due to factors such as previous surgery, trauma, lower back disc disease, or tumors of the spine. In most instances, medical evaluation fails to demonstrate a cause. As you can imagine, any treatment that you apply directly to the bladder, such as DMSO, may have no effect on those patients. I find that patients having this type of pain are the most difficult to treat.
3. Bladder hypersensitivity/Interstitial Cystitis. A good history and physical examination will often help the physician hone in on the bladder as a central problem. For example, most patients with bladder specific pain will have one or more of the following problems:
- Urinary frequency and urgency
- Pain relieved somewhat by bladder emptying
- Discomfort on physical examination when the bladder is pressed
4. Pelvic floor dysfunction (PFD). The fourth site of pain is often the pelvic floor muscles. As you probably already know, the bladder and the rest of the pelvic organs rest upon these muscles. The muscles of the pelvic floor are very complex and serve very important roles for us on a moment-to-moment basis. For example, they need to relax when one urinates, has a bowel movement or, in the case of females, has sexual intercourse. I often see patients who complain of a very poor urinary stream. The urine flow may even start and stop. Many of these patients feel that they need to "push" in order to completely empty themselves. These patients are having a normal bladder contraction, however, instead of pelvic floor muscle relaxation occurring, they are actually tightening up and preventing urine from being released. The act of pushing urine out may be counterproductive since it often worsens the muscle "spasticity." On physical examination, pushing into this muscle group often elicits significant pain. The muscles are frequently "bulky" and in some instances very taught, having the characteristics of a violin string (as opposed to being soft and non-tender). Muscle problems such as this often give rise to vague complaints of pelvic discomfort. PFD is often associated with painful sexual intercourse (the pain is usually most severe "the day after"), irritable bowel syndrome and/or chronic constipation. Stress seems to be a very important factor in symptom worsening.
Overall, those are the broad reasons that patients will develop a pelvic pain syndrome. The big question is how to deal with it. This can be particularly complicated since patients often have several associated problems. For example, many of IC patients will have accompanying PFD. If both problems aren't addressed, patients generally have a suboptimal response to treatment.
If the patient's main problem is the bladder, then we will treat the bladder. As you know, dietary changes, oral medications, will often improve symptoms. These medications have specific qualities that target the bladder. Sometimes medications instilled directly into the bladder may help. If the pain and discomfort appear to be coming from the muscles of the pelvic floor, then the therapy is not going to be the same. We want therapy aimed at relaxing the muscles. Teach patients how to deal with those pelvic floor muscles appropriately.
The basic principles are as follows:
1. Every patient has to stop pushing. Some patients don't feel like they are emptying their bladders, so they try to empty out the bladder completely by trying to get every drop out. That type of behavior can potentiate even more muscle spasticity. It becomes a vicious cycle. It is better that a patient go back to the bathroom 10-20 minutes later (called double voiding) than to try to push it out at one time.2. Patients cannot be constipated. If you are constipated, you will never get better unless that problem is dealt with aggressively. You may have to go to a gastroenterologist to make sure there is no other associated problem.
3. The third thing patients should do is to get into the bathtub twice a day. It should be a warm bath which facilitates muscle relaxation. You can use two moist heating pads, sitting on one and placing the other on the lower abdomen if you don't have access to a bathtub. Keep in mind that baths usually work better.
4. Put patients on a muscle relaxant. Patients are usually weaned down on their dosage as symptoms improve. This is not given as a medication for stress, (although stress can play a role in PFD), but to get the muscles relaxed. It tends not to make patients sleepy as opposed to other muscle relaxants.
There are other things that can be done for PFD. For example, biofeedback can be helpful. If in-office therapy is helpful, small, portable home units are often prescribed.
More and more physical therapists are now being trained to manage these problems. Some physical therapists are experienced in pelvic floor biofeedback, but be careful. Biofeedback is a method that is also used to treat urinary leakage. The therapist may be trained to deal with leakage but has no experience when dealing with pain derived from the muscles of the pelvic floor. Physical therapists who specialize in this area are able to perform "internal massage" to identify the trigger points to smooth this area out. Again, PFD can be a problem associated with IC, or it can be a separate entity.
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