IBS – Irritable Bowel Syndrome
“IBS is a group of symptoms that occur together, not a disease. In the past, IBS was called colitis, mucous colitis, spastic colon, nervous colon, and spastic bowel. The name was changed to reflect the understanding that the disorder has both physical and mental causes.
IBS is diagnosed when a person has had abdominal pain or discomfort at least three times a month for the last 3 months without other disease or injury that could explain the pain. The pain or discomfort of IBS may occur with a change in stool frequency or consistency or be relieved by a bowel movement.
IBS is often classified into four subtypes based on a person’s usual stool consistency. These subtypes are important because they affect the types of treatment that are most likely to improve the person’s symptoms. The four subtypes of IBS are:
- IBS with constipation (IBS-C) ◦hard or lumpy stools at least 25 percent of the time.
◦loose or watery stools less than 25 percent of the time - IBS with diarrhea (IBS-D) ◦loose or watery stools at least 25 percent of the time
◦hard or lumpy stools less than 25 percent of the time - Mixed IBS (IBS-M) ◦hard or lumpy stools at least 25 percent of the time
◦loose or watery stools at least 25 percent of the time - Unsub typed IBS (IBS-U) ◦hard or lumpy stools less than 25 percent of the time
◦loose or watery stools less than 25 percent of the time”
Physiotherapists don’t treat a lot of these conditions that I have listed, but the effect of these problems may cause associated muscle tensions within the pelvic floor. Sometimes the condition can be mild and only cause occasional pain, slowly becoming more of a problem as you try and become sexually active. Sports Focus women’s health Physiotherapists trained in the treatment of pelvic pain can help to reduce the muscle tensions, address the pain and work with your doctors to establish the underlying cause. We can offer advice and refer on to appropriate health practitioner.
Pudendal Neuralgia
Pudendal Neuralgia can affect men and women. It is defined as burning, stabbing, and/or throbbing pain in the distribution of the pudendal nerve. The pain typically increases with sitting and exercise and decreases with standing and rest. The pudendal nerve supplies most of the skin, labia and superficial pelvic floor muscles. Pain can be felt around or inside the vagina. Patients with pudendal neuralgia commonly have pelvic floor dysfunction as well as pain. Patients may report urinary dysfunction such as dysuria, (difficulty or pain on urination) urinary hesitancy, urgency, and frequency, and/or bowel problems such as constipation and difficulty evacuating. Some patients may also experience sexual dysfunction such as dyspareunia, (pain on penetration of the vagina) anorgasmia, (inability to reach orgasm) and post-ejaculatory pain. Common causes of pudendal neuralgia include chronic constipation, chronic urological or gynaecological infections, and repetitive sporting activities such as bicycling and strong abdominal and ‘core’ type exercises.
- Interstitial Cystitis IC: Bladder Pain Syndrome
What is IC? The following information is reproduced from the Melbourne bladder clinic website. A great link for a more in depth understanding of this difficult conditionBPS/IC is a chronic, debilitating disease of the bladder that is characterised an unpleasant bladder sensation, of more than 6 weeks’ duration and in the absence of infection or other identifiable causes.How common is it ?
The incidence of BPS/IC is estimated at 8 to 1600 per 100 000. It affects men and women of all ages, cultures and socioeconomic backgrounds. It is more common in women and the male-to-female ratio is estimated to be about 1:10.What are the causes?
Despite extensive research, the exact causes of BPS/IC are still unclear. - What are the symptoms?Patients complain of frequent urination, sensation of constant urge to void and bladder pain. Chronic pain is an essential component of the syndrome and is described as worsening with bladder filling and is relieved by voiding. This pain is not only localised to the bladder, but can be felt throughout the pelvis (vagina, rectum, urethra, vulva).
- How is it diagnosed?IC is a diagnosis of exclusion; meaning that other causes of these symptoms such as infection, overactive bladder (OAB), cancer, radiation or other forms of cystitis must be ruled out first.Assessment should include a careful history, physical examination and investigations. In the history, BPS/IC patients void to avoid or relieve pain, whereas OAB patients void to avoid incontinence. The number of voids per day, sensation of urge to void and characteristics (location, severity, character) of the pain should be documented. A bladder diary may be useful here.A urine test is done to exclude a urinary tract infection. It can also be done to look for cancer cells, especially in those with increased risks (over 50 years old, smoking history).Cystoscopy and Urodynamics are considered as an aid to diagnosis and are not necessary in uncomplicated cases.
- Cystoscopy:
- A cystoscopy (inspection of the inside of the bladder with a tubelike camera) can be done to look for features of IC, such as bladder ulcers or small bleeding points seen after distension of the bladder with sterile fluid. These findings are helpful but not necessary when making a diagnosis of IC.
- During the cystoscopy, a bladder biopsy can also be done to look for inflammatory cells in parts of the bladder wall.
- This can also rule out other bladder pathology like a bladder tumour, stone, or a urethral diverticulum (small out-pouching in the tube that drains the bladder).
- Urodynamics:
- Rule out other diagnoses like an overactive bladder (OAB) or a poorly compliant (stiff) bladder.
- Can look for bladder outlet obstruction from failure to relax the pelvic floor during voiding.
- Treatments for IC:First of all, it must be clear that at the moment are no curative treatments; the treatments are aimed at alleviating the symptoms such that a patient can continue to have a reasonable quality of life. The patient should be counselled with regards to reasonable expectations for treatment outcomes. Treatment strategies should proceed from conservative ones to more invasive therapies. Some patients may benefit from a combination of treatments. Acceptable symptom control may also require trials of multiple therapeutic options. This
- Conservative approaches:
- Diet changes: avoid food that triggers symptoms (e.g. spicy foods, alcohol, caffeine).
- Altering the concentration or volume of urine, wither by fluid restriction or additional hydration.
- Application of local heat or cold over the bladder, trigger points and areas of hypersensitivity
- Strategies to manage flare-ups.
- Pelvic floor muscle relaxation / avoid pelvic floor strengthening exercises.
- Bladder retraining with urge suppression.
- Manual physical therapy (trigger point release by physiotherapist).
- Multimodal management:
- May involve medications, stress management or manual therapy.
- A pain specialist is usually involved.
- It is difficult to predict which pain medication is most effective; this may require a trial of different medications.
- Oral medications:
- Tricyclics antidepressants
- Some examples are amitriptyline, imipramine.
- Side effects are fatigue, drowsiness, weight gain, dry mouth (a third of patients cannot tolerate this).
- Sodium pentosan polysulfate (Elmiron)
- Acts by repairing defects in the bladder mucosa.
- A 3 to 6-month course is needed to demonstrate an effect.
- At a dose of 100mg three times a day, it is well tolerated and has few side effects.
- Cimetidine
- Dose of 400mg twice a day.
- Potential interaction with other medications.
- Vitamin D
Antibiotics have no role in the management of BPS/IC in the absence of a proven urinary tract infection.
- Bladder instillation therapy:
A catheter is first inserted, and the medication is then infused into the bladder for a period of about 15 – 20 minutes (depending on the drug). Multiple therapies are usually required. This route of administration provides high drug concentrations in the bladder and avoids systemic side effects. Long term remission is achievable in some patients, but most will relapse eventually and need more treatments. Some examples of these medications are dimethyl sulfoxide (DMSO) and Clorpactin.
- Surgical therapy:
- Cystoscopy with bladder distension and electrical cautery of bladder ulcers if present.
- Some patients get relief of symptoms from this procedure, but most of the time, the effects will wear off.
- Trial of sacral neuromodulation (bladder pacemaker)
- A temporary stimulator is first inserted during the trial period; a permanent implant is then inserted if the patient demonstrates positive response.
- Anti – spasm bladder injection – Botox
- Urinary diversion with or without surgical removal of the bladder
- The ureters (tubes draining the kidneys to the bladder) are reimplanted into a segment of bowel which is diverted to the abdominal skin surface as a stoma (opening). A bag is then placed over the stoma to catch the urine.
- This option is often the last resort and can sometimes be very effective.
- Patients must understand that pain relief is not guaranteed even if the bladder is removed.
Please, if you have pelvic pain, see your GP and let’s try and get to the cause of your problem. Sports Focus Physiotherapy can help you deal with overactive pelvic floor muscles, then this may go a long way in reducing and controlling your problem. Remember you don’t need a referral to come and see us. If we think you need other referral/investigations, we will discuss these with you.
