Bladder pain syndrome (BPS) is a condition that is estimated to affect up to 3% of women, but can also affect some men. It is defined by the International Continence Society as a “persistent or recurrent chronic pelvic pain, pressure or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptom such as an urgent need to void or urinary frequency.” Nevertheless, a variety of different definitions and treatment algorithms exist [1].

Physiotherapy is one of the very few treatment strategies that is recommended by all advisory bodies, such as the European Association of Urology, the American Urological Association, and the Royal College of Obstetricians and Gynaecologists [1]. Furthermore, a Cochrane meta-analysis of 81 studies found that physical therapy and behavioural therapy were the only interventions that wholly favoured treatment versus control in BPS patients, and that only physical therapy met their primary outcome for improving pain (moderate level of certainty) [2].

Despite the above rating, few studies examine the effectiveness of physical therapy in BPS, and most studies are hampered by small sample sizes [2]. Hence, we are excited to share our findings as our retrospective audit has one of the largest sample sizes examining the effectiveness of pelvic floor physiotherapy for patients with BPS.

Our primary aim was to determine the proportion of patients with BPS who benefit from pelvic floor physiotherapy in our unit, assessed by symptoms and quality of life.

Our secondary aim was to determine patient engagement with the treatment. Initially, not all our BPS patients were offered pelvic floor physiotherapy, but it has become standard care in our institution. Some patients decline the offer. Of those patients referred to physiotherapy, we measured the proportion who attended; and of those that attended, we determined how many engaged with their treatment and completed their physiotherapy course.

Our institution uses an online clinical system that allows watchlists to be set up as information governance-compliant databases. Our senior author established a watchlist of patients seen by themselves or their team who have either been diagnosed with or are suspected of having BPS. All patients on this watchlist were included, capturing patients from June 2019 up to and including November 2023. This method provided 198 BPS patients for our retrospective audit. 

Data was gathered through the same clinical system. We reviewed clinic letters, referral letters, outpatient appointments booked (including in the future), physiotherapy reports, and pathway outcomes for physiotherapy referrals.

The physiotherapy reports are written individually for each patient and detail in free text what was undertaken in the sessions, the benefits achieved if any, and any plans beyond discharge from physiotherapy. Patients still undergoing physiotherapy do not have a formal report yet, but we have taken ongoing care to imply engagement with the treatment. Patients are routinely discharged after one failure to attend, and a report is then written.

There were 198 patients with BPS, aged between 19 and 85, with an average age of 44.

179 (90%) of the patients were female.

140 (70.7%) of the 198 patients were offered physiotherapy. The remaining 58 (29.3%) patients were already established on and doing well with other treatments, such as instillations, or had already trialled physiotherapy previously.

Of the 140 patients who were offered physiotherapy, 93 (66.4%) patients attended their first appointment. 42 (30%) did not attend, 4 (2.9%) were awaiting their first appointment, and 1 (0.7%) had moved out of the area after having been offered physiotherapy.

Of the 93 patients who attended their initial physiotherapy appointment, 57 (61%) completed their course. 31 (33%) patients did not engage with physiotherapy after having attended their first appointment, and 5 (5%) had ongoing physiotherapy.

With regards to our primary aim, we identified 57 patients with BPS who completed a course of physiotherapy. From this group, 51 (89%) patients reported a notable benefit to their symptoms or quality of life, 3 (5%) patients experienced little or no benefit, and 3 (5%) patients’ physiotherapy report did not comment on the outcome.

The greatest strength of our retrospective audit is the sample size. As mentioned earlier, not only has there been a limited number of studies into the treatment of patients with BPS, but they are also often restricted by small numbers of patients [2]. Our audit presents one of the largest cohorts assessed, and our demographics mirror another study which had an age range of 18 to 77 and average age of 43 [3].

We had anticipated that the majority of patients who engage would experience a benefit following completion of physiotherapy, but we were impressed with improvement in at least 89%. Undoubtedly, this justifies and encourages the use of pelvic floor physiotherapy as a treatment for patients with BPS. Upon reviewing the physiotherapy reports, we were able to collate what the recorded benefits were specifically, and some of these are listed in Figure 2. Some patients had more than one positive outcome comment.

We believe that physiotherapy is such an effective treatment strategy because our physiotherapists have more time allocated per appointment, versus a doctor-led clinic, to explore the patient’s worries and symptoms to a fuller degree. They provide holistic care, including psychological concerns, and are not limited to physical therapy alone.

Whilst having patient-specific reports written by our physiotherapists provides us with detailed, individualised summaries, it does not provide qualitative data. Currently, we ask patients to complete validated symptom questionnaires from their first interaction with us, which can vary in terms of treatment stage. Our plan moving forward is to have patients complete validated questionnaires upon completion of physiotherapy specifically, which will better allow us to compare physiotherapy-related outcomes.

Whilst variation exists in diagnosing BPS and in its management, all guidelines advise treatment in a stepwise fashion, beginning with conservative measures [1]. We did not explore any adverse side-effects to physiotherapy within our audit, but the Cochrane meta-analysis found no serious adverse event with physiotherapy [2]. Although another study reports that 62% of participants reported one adverse event, most commonly pain, they add that it may in part be due to the fluctuating nature of their disorder [3]. Physiotherapy can be viewed as a safe, well-tolerated, effective treatment.

Physiotherapy is a well-tolerated and safe treatment for BPS. In our institution, at least 89% of those patients who engage with the process are seen to benefit. Therefore, our team is going to introduce upfront referral to physiotherapy alongside seeing a urologist. We will also use the data from this audit to encourage future patients in clinic to attend and persist with physiotherapy, to improve attendance and engagement.

Malde, S., Palmisani, S., Al-Kaisy, A. and Sahai, A., 2018. Guideline of guidelines: bladder pain syndrome. BJU international, 122(5), pp.729-743.
Imamura, M., Scott, N.W., Wallace, S.A., Ogah, J.A., Ford, A.A., Dubos, Y.A. and Brazzelli, M., 2020. Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis. Cochrane Database of Systematic Reviews, (7).
FitzGerald, M.P., Payne, C.K., Lukacz, E.S., Yang, C.C., Peters, K.M., Chai, T.C., Nickel, J.C., Hanno, P.M., Kreder, K.J., Burks, D.A. and Mayer, R., 2012. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. The Journal of urology, 187(6), pp.2113-2118.