Treating patients diagnosed with IC is always a challenge. They often have a complicated history. They usually have a lot of misconceptions about the condition. We get dragged in to discussing medical management. But there are also areas of our evaluation I often see overlooked in patients with IC.
So when doing your evaluation, make sure you don't miss this five areas:
Evaluate vulvar and urethral tissues for estrogenization
Check sciatic nerve tension
Evaluate the Urachus and bladder mobility
Check the pudendal nerve
Evaluate the inner thigh and ischiorectal fossa
Check out the full 'sode for why this is so important, what percentage of patients with IC have dysfunction in these areas, and more!
IC Course - Cohort #2
If you want to level up your treatment of patients with IC, make sure to join us for Cohort #2 of the IC Course (opening in one week, on Feb 19th). We go through everything you need to know about the condition to provide the best care for your patients.
We also get really practical. There's hands-on demonstrations on both a model and live patient showing the specific techniques we recommend.
And for this cohort, you'll get $50 off the course and a LIVE Q&A to get any questions answered! Find more details and get on the wait list at www.pelvicptrising.com/ic
About Us
Nicole and Jesse Cozean founded Pelvic PT Rising to provide clinical and business resources to physical therapists to change the way we treat pelvic health. PelvicSanity Physical Therapy (www.pelvicsanity.com) together in 2016. It grew quickly into one of the largest cash-based physical therapy practices in the country.
Learn more at www.pelvicptrising.com, follow Nicole @nicolecozeandpt (www.instagram.com/nicolecozeandpt) or reach out via email (nicole@pelvicsanity.com).
Treating patients diagnosed with IC is always a challenge. They often have a complicated history. They usually have a lot of misconceptions about the condition. We get dragged in to discussing medical management. But there are also areas of our evaluation I often see overlooked in patients with IC.
So when doing your evaluation, make sure you don't miss this five areas:
Evaluate vulvar and urethral tissues for estrogenization
Check sciatic nerve tension
Evaluate the Urachus and bladder mobility
Check the pudendal nerve
Evaluate the inner thigh and ischiorectal fossa
Check out the full 'sode for why this is so important, what percentage of patients with IC have dysfunction in these areas, and more!
IC Course - Cohort #2
If you want to level up your treatment of patients with IC, make sure to join us for Cohort #2 of the IC Course (opening in one week, on Feb 19th). We go through everything you need to know about the condition to provide the best care for your patients.
We also get really practical. There's hands-on demonstrations on both a model and live patient showing the specific techniques we recommend.
And for this cohort, you'll get $50 off the course and a LIVE Q&A to get any questions answered! Find more details and get on the wait list at www.pelvicptrising.com/ic
About Us
Nicole and Jesse Cozean founded Pelvic PT Rising to provide clinical and business resources to physical therapists to change the way we treat pelvic health. PelvicSanity Physical Therapy (www.pelvicsanity.com) together in 2016. It grew quickly into one of the largest cash-based physical therapy practices in the country.
Learn more at www.pelvicptrising.com, follow Nicole @nicolecozeandpt (www.instagram.com/nicolecozeandpt) or reach out via email (nicole@pelvicsanity.com).
In the last 10 years, our field has gone from an unknown specialty to a household name. This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve. In order to help others get better, we need to be better. This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way. Join us as we rise together. We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.
Speaker 2:
Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine. Hello, excited to be talking about IC.
Speaker 1:
I am always excited to be talking about interstitial cystitis bladder pain syndrome. Man this is my jam, you guys. I seriously get so excited when we're talking about it. Also, leading up to this podcast, and this week I'm speaking at CSM and with Jessica Rial of Southern Pelic Health on interstitial cystitis and it's just been on my mind and I'm really excited to be revamping the IC course and I'm excited to speak at CSM about it and all of the things.
Speaker 2:
Yeah, so if you want to be a part of that cohort number two of Nicole's IC course is going to open a week from today for listening to this on the day it drops. To be honest with you, if you just listen and implement the stuff in this podcast, you're probably going to be in the top 80% of people treating the condition. If you want to be in the top 99th percentile of that, then make sure that you are taking that course. So that's going to be the second group going through it. You'll get $50 off. You get to do a live Q&A with Nicole. That's all online. Go at your own pace. It's got a bunch of didactic stuff, but it also has stuff on models and on live humans and lab stuff. I mean, it's the real deal when it comes to this.
Speaker 1:
I know I was reviewing it for the talk with CSM and I'm like this shit's so good. It's really good. It's super comprehensive. I think one of the things that I love about it is that it's a start to finish guide on how to treat anybody with interstitial cystitis. Anybody that walks into your office, you will know all of the medical management stuff, all the supplement stuff, all the nutrition stuff, everything and all of the PT stuff related to it. I'm just really stoked about it. It's gold.
Speaker 2:
So get on the wait list for that. You can do that at pelvicptrisingcom. Nicole also has some new stuff in there because the AUA released some new guidelines since it came out initially. There's new research, there's some new insights. Those of you guys who have already gone through the course will get access to all of that. We'll make sure to send you guys an email too. Almost 300 of you guys have already been through that but you'll have access to all of those updates as it goes as well. You could actually jump onto that live Q&A if you want to sneak on there. Also, we will prioritize questions from those who are starting in this second cohort, so that happens a week from today. Make sure to get on the wait list. That's pelvicptrisingcom.
Speaker 2:
So, nicole, let's dive in Five areas, not to miss in your ISE E-Vow, and the first one is to evaluate for de-estrogenation of vulva and urethra. That is a phrase the me of 20 years ago did not think the me of today would ever say. That just came out of my mouth.
Speaker 1:
Yeah, man, good job Jess, and you said it pretty great, right? I did, we think.
Speaker 2:
I think. Well, it's like I always get confused because Michelle Lyons this is a total tangent but talks about this all the time and she spells it yostrogen but still pronounces it estrogen, but does it in an accent. I just can't get that out of my head. Every time I see the word estrogen, I'm adding that extra O in and then trying not to pronounce it, and it's just really a problem.
Speaker 1:
Yeah, totally. Maybe you listen to Michelle, that's so nice yeah.
Speaker 2:
And Nicole evaluating for de-estrogenation of vulva and urethral tissues. Why do we care and why is this a big deal?
Speaker 1:
Okay. So we care about this for a bunch of different reasons, and I think it's one of the most overlooked things about interstitial cystitis. Also, if you look back at the history of interstitial cystitis, we used to think that only women in their 40s got interstitial cystitis, and what's very interesting about that is that, if you really think about it, women in their 40s are probably in that perimenopause menopausal state. And were we just describing things of people going into this lack of estrogen mode, pathologizing that and instead of just treating that and then having it become interstitial cystitis? I'm not saying that that's like the whole evolution of the condition, but I am saying it's very interesting that this was first noticed and recognized in people that were probably in that perimenopausal range.
Speaker 2:
Because the symptom overlap. Basically, if you put the Venn diagram together like it's just like a circle.
Speaker 1:
The Venn diagram is probably. It's actually, I think it probably is a circle. If not a circle, then the it's real, it's a real close and there would be only be a skinny sliver in the middle of things that are, or it would be a huge thing in the middle. That's different. Just a sliver on the outside. That would be different. So basically, you guys, the symptom overlap of the lack of estrogen at the tissue of the vulvar area is the symptom overlap is like exactly the same with symptoms of interstitial cystitis. All of the symptoms of the genitourinary, symptoms of menopause and the lack of estrogen at the tissue is literally almost exactly the same of that of people with interstitial cystitis and, of most importance, people that have deestrogenization of that tissue also are susceptible to UTIs. Guess what a lot of folks with interstitial cystitis report recurrent UTIs, utis that maybe are positive, they clear and then they recur.
Speaker 1:
They maybe be initially have an UTI, then it goes away and then you have symptoms of it, even though they continue to test negative. So irritation of that tissue. So it really is something that needs to be looked at. And remember that the vestibular tissue of female anatomy is literally almost exactly the same histologically to the lining of the urethra and bladder. It's actually more closely related to the bladder than it is of the vagina, so instead of it the vestibule being the opening of the vagina, it's actually the external ur. It's like the urinary tract is external there, not the opening of the vagina actually. So histologically it makes sense. Embryologically that's what's happening, and so we really need to make sure that we're looking at that area for signs that there is a lack of local estrogen at the place Now it can be because you're in perimenopause and, by the way, perimenopause symptoms can start as early as like in the mid 30s.
Speaker 1:
all right, and there is some evidence to show that people that have been on the hormonal birth control for a long time can also be affected in that region with lack of estrogen as well, and so actually, I had a really good comment from one of my staff members. She's like hey, I don't understand. Like people, aren't you taking estrogen and progesterone with a hormonal birth control pill? Why does it actually create lack of estrogen at that area? I was like that's a great question, and what we don't sometimes realize is that taking estrogen orally in the hormonal birth control pill actually shuts down our own bodies making of estrogen right, so it's supplementing and it keeps it even keeled because you're getting the same amount every time, so it's not fluctuating as much and it essentially stops your body's process of making it and supplements it from a different area, so it can significantly affect the tissues that have estrogen receptors, of which it's been studied to show that pelvic floor does, your rethral area does and the vulva vestibule does as well.
Speaker 1:
So, those are the areas that are estrogen receptor rich and therefore, if there's not enough estrogen, are some of the areas where it those symptoms manifest first.
Speaker 2:
You just blew my mind that the vulvar tissue is like bladder tissue. Yeah, vestibule tissue is like, the opening of the vagina is like the bladder, so like you're almost walking around with like a grade four prolapse all the time, jesse don't say wrong shit, wrong shit on here, but kind of just kidding Anyways.
Speaker 1:
but you get just that's wild.
Speaker 1:
Yeah it's wild. It is wild, right, it's wild. And so the thing is is like, when you understand that it's not weird that something like clothes, like people that with interstitial cystitis or really honestly, vestibulodinia, vulvodinia, they say, clothes bothers them, it makes them feel like they have to pee, it's like, yeah, it's like that tissue is getting irritated and your brain is kind of like, oh, that's closest to the bladder. So I'm just gonna the bladder only knows two things, right, I hurt and I have to pee. So which one am I gonna give it? And then for people that are just with the dyno, since both like, I'm just gonna tell them both right, and that's how I explain it to patients.
Speaker 1:
So it's really important to look at that and we have the ability to actually look. We have the time to look at that tissue to really assess for its estrogen values there right.
Speaker 1:
So, and we might be the only ones that are actually looking at that, because if you think about the way that somebody with interstitial cystitis is getting into your office sometimes it's the urologist well, they're not always looking. Doing a full-blown vulvar exam now they should be. And some of the great urologist song, instagram and stuff right, jorubin and stuff like that those and Dr Ashley Winter those people are talking about doing that, but a lot of urologists aren't, and even if they would take a little peek, they're not going to be like doing an actual tissue examination of the clitoral hood and all the things that we need to be doing. So all that is to say is that is a huge area that's missed.
Speaker 1:
With people with interstitial cystitis and the symptom overlap of deestrogenized tissue and interstitial cystitis is crazy, so we can't forget it.
Speaker 2:
So if you find this deestrogenation, then you get someone to treat it.
Speaker 1:
That's one of the things that we can't directly treat. We can identify it. We can encourage people to go back to their physicians. We can help them advocate for themselves. We can show the patient. This is what I'm talking about. This does not look like a healthy deestrogenized area. I need you to go and show your doctor this exact thing and get some estrogen cream, not necessarily just this depository form, but the cream where you can put it all over and that's what you tell your patients. So we can't treat it, but you can sure help your patient to get to the place where they can get somebody to help them treat it and this is something you talk about in the course in a lot more depth.
Speaker 2:
Yes, so moving on. Next thing you say is evaluate for sciatic nerve tension.
Speaker 1:
Yes.
Speaker 2:
No, I have heard of this sciatic nerve. That's the thing that sends like zingers down the back of your leg right.
Speaker 1:
Yes, that's not bladder.
Speaker 2:
So why are we evaluating it?
Speaker 1:
Jesse, what a good question. We are evaluating it because, as all of you know, the sciatic nerve branches at the knee or their bouts into the tibial nerve and the common peroneal nerve. The tibial nerve is the nerve that has direct links to bladder function. Right, it's one of the reasons why we do tibial nerve stimulation. The nerve roots that contribute to the tibial nerve also have some bladder afferents and functioning and, again, it's one of the reasons why TTNS or PTNS works for number one, overactive bladder, but also interstitial cystitis and a bunch of other things. By the way, it's almost like the gateway into the sacral nerve roots that also innervate the bladder. And the cool thing about the tibial nerve stuff and the sciatic nerve is that you can treat that area and it's far away from the bladder. So if someone like super hypersensitive and they're like freaked out around the area, they don't want you to do an internal exam, all that stuff.
Speaker 1:
You can really affect quite a few things by working down the entire posterior chain and assessing for sciatic nerve tension. Now, however you want to do that, bust out your ortho skills. You can do that. I do it by a straight leg raise test passive straight leg raise test for sciatic nerve tension and sensitize at the ankle and the hip. You can do it however you want. Some people like to do dural tension testing here. It's not as specific for sciatic nerve, but it is something that you can totally do. Still, it's huge and it's an area that is quite commonly overlooked by us in folks that have an interstitial status.
Speaker 2:
So, if you find it, what do you do?
Speaker 1:
You treat it, treat the area, treat the sciatic nerve tension, especially if they also have overlapping things that also are affected by the sciatic nerve, right Performous issues, hip mobility problems, glute activation issues, posterior chain stuff. It's really important.
Speaker 2:
Okay, so number three on your list is evaluate for the Urakis and for bladder mobility.
Speaker 1:
Yes, Looking at me like wait. What does that mean?
Speaker 2:
and the Euracus is around your belly button. I know this. Oh, yes, okay.
Speaker 1:
So you guys, the Euracus for people who don't know. I've also heard it pronounced Eurekis.
Speaker 2:
And I. This is like the Uranus, or Uranus yeah debate.
Speaker 1:
I apparently I'm not sure. Anyways I call it the Euracus and we're going with it. But it is a tissue remnant of the Median umbilical ligament. It Actually, if you look at an anatomy book and we have some really cool pictures in the IC course about this but it's it like totally like envelopes the bladder and if and it's very connected to the abdominal wall.
Speaker 1:
So somebody that has abdominal wall restrictions, breathing restrictions, core activation pattern issues and this tissue is hypomobile, then it can affect the Euracus and the umbilicus and that has a direct link to the bladder. It's actually interesting sometimes some people either are really adverse to having their belly button touched or Touching in and around their belly button actually creates bladder symptoms, especially with folks that have urinary urgency frequency and interstitial cystitis like symptoms. It's also like right at where the area of the super pubic region is right. Which is one of the most common pain reports of people with interstitial cystitis is pain in the super pubic area. So we need to assess this, both bladder mobility and the Euracus and, by extension, the lower abdominal wall.
Speaker 2:
I feel like that's a. Is that a technique that's commonly taught? I feel like every time I just know all the training that we do at pelvic sanity for our folks I don't feel like anyone's ever come in and you haven't had to teach this correct.
Speaker 1:
I totally need to teach us all the time and, honestly, like in the course, we talk about the ways that we do that in combination. So it's not a straight visceral Mobilization but it's a combination of visceral and connective tissue mobilization. Most visceral courses that involve the urinary tract Will go over some of this stuff. I know remote and Horton's courses do, and I believe Baral does as well. So it's taught. But sometimes you're not taking those courses as a newer pelvic floor therapist Because they're a little bit more advanced and so. But in the course, in the IC course, I teach some really pretty, really great techniques that are easy to learn that are basically combinations of bladder mobility and connective tissue mobility in and around the Euracus and abdominal wall. That can really be helpful with folks with interstitial cystitis.
Speaker 2:
So so and that If you find problems in the Euracus and with bladder mobility, what do you do?
Speaker 1:
You treat it.
Speaker 2:
Sensing, sensing a pattern here.
Speaker 1:
Sensing a pattern. Treat what you find. I know that we learn that in PT school quite a bit, and it really is Treat what you find. The interesting thing about what we're doing here with this podcast is helping you to Find the things that are most likely related to patient's interstitial cystitis symptoms that you might not be looking for, and so you're not just blindly treating everything you find, but you're finding things to treat that are specifically related to these patients.
Speaker 2:
Okay, next you've got evaluate for inner thigh and ratio rectal fossa, or the IRF.
Speaker 1:
Yes, good job, jesse. Do people actually call it the IRF? I just I don't know. I usually write the IRF, I don't usually say the IRF.
Speaker 2:
I think we'd call it the IRF. Okay, it'll be a time saver, or what are you talking about? Plus it doesn't? It doesn't sound very smart, it doesn't sound very smart. It sounds like yeah, like you're kind of dumb, we're gonna work on your earth.
Speaker 1:
Okay, so inner thigh Connective tissue is your rectal fossa connected tissue. Essentially, you are assessing for subcutaneous Pneculosis in this area, and why? And that's because of Of the power of the visceral somatic reflex, and remember that the visceral somatic reflex is Visceral, somatic, somato, visceral and somato somato, and so what that means is that People that have bladder symptoms can have something in the connective tissue of the somatic structures that it refers to, people that have tissue dysfunction in the somato areas that refer to the organ can also have issues right and so we can treat, let's say, the inner thigh and that can affect the bladder.
Speaker 1:
We can work on the bladder and that can work on the inner thigh. We can also think about things like ischiorectal fossa and how that relates really commonly to inner thighs and superficial, transverse, perineal and all the tissue around that region.
Speaker 1:
It is really important to look for that stuff. There is an older study, but a really great one, on the urogynecologic. So 49 people with urogynecological symptoms and irritate avoiding symptoms were shown to have a characteristic pattern of this visceral somatic reflex and it is really important to understand that that reflex is can go both ways and we need to treat both areas.
Speaker 2:
And if that lost you because I've been gone now for a little bit here this is why you need the IC course, right? Because you go into a ton of depth on all of that and how to actually use that visceral somatic reflex to help people.
Speaker 1:
Yes, and how it gets there right. How does it actually affect the connective tissue? We go through all of that. We go through what subcutaneous paniculosis is and how to treat it. We go through the correct way to skin roll, which most folks do not, great. And if you find dysfunction in this area, jesse, what do we do?
Speaker 2:
Well, I always say just leave it alone and hope it goes away.
Speaker 1:
That is wrong. No, we treat it.
Speaker 2:
Got it Okay. So the final thing you have on here the thing is evaluate for issues along the path of the pedendal Nerve.
Speaker 1:
Yes.
Speaker 2:
Okay, why that? Because that's also not your bladder.
Speaker 1:
True, that is not your bladder. But one of the things that most people forget is a straight-up anatomy of the pedental nerve. The pedental nerve has apharins to the bladder that are usually silent, right? So it's kind of like we can't feel the tag on our shirt, right? Most people can't, we just learn to ignore it. So most of the time those apharins to the bladder from the pedental nerve are silent. With interstitial cystitis, and especially with people that have a centralized nervous system on top of that, which is most folks with IC, those silent apharins get turned on. And when they get turned on, guess what the bladder starts to say to the brain hey, I heard, or I have to pee, or, most frequently, both.
Speaker 1:
So assessing along the path of the pedental nerve and thinking about pedental nerve health overall is really important. How can it? Is it gliding well, is it? Does it have great blood flow, all of those things? So we also need to make sure that we understand that the pedental nerve also innervates the majority of the pelvic floor, including the urethral sphincters, and so if there is an irritation to that nerve, that can be irritation to the urethral sphincters and that can create the feeling of urinary urgency frequency that has nothing to do with the actual bladder itself, right?
Speaker 1:
And so what we need to do is we need to make sure the health of the pedental nerve is achieved. We do that by blood flow, we do it by making sure that the muscles in and around the path of that nerve are functioning well, and we are uniquely equipped, y'all, to do this with our internal examination and treatment. So don't forget about the path of the pedental nerve. I would suggest not freaking your patient out and telling them that their pedental nerve is involved, because, guess what? They're going to go home, they're going to Google and they're going to be like, oh my god, she told me that I have pedental neuralgia and now we're in.
Speaker 2:
Now they're on a plane to go get a decompression surgery in France.
Speaker 1:
Right, right, no thanks.
Speaker 2:
So obviously then if you find something, you treat it there. So I mean, it sounds like with all of this stuff, no, nicole, you should probably be able to wrap this stuff up in like four to six visits.
Speaker 2:
Jesse, you know you're trying to get me pissed off, so let me just ask this question, though, nicole If I was going to go through these five things and totally put you on the spot in a very non-scientific way, but just saying as a percentage of people who come in, because we see a ton of people with IC from all over the country if I was going to say what's the percentage of people you evaluate who have an issue with each of these? If I walk through and say de-estrogenation of tissue, what percentage of your IC patients would have that?
Speaker 1:
Ooh, good question. I'd say at least half.
Speaker 2:
Okay, same question for sciatic nerve tension.
Speaker 1:
Almost all.
Speaker 2:
Okay, euracus and bladder mobility 100. Yes, seriously, stay away from my belly button. Every time you do it to me, I have to pee. It's the worst. Inner thigh and isorectophosa issues.
Speaker 1:
I mean, I don't, I can't even think of a patient that I've treated with IC that has not had significant issues here.
Speaker 2:
And something along the path of the pedental nerve.
Speaker 1:
Like 70%, so this is why I'm telling you not to miss this shit. You guys, it's like most people have all this. That's why.
Speaker 2:
Right. So which is why it drives you absolutely bananas when somebody goes to a pelvic floor physical therapist and they're told that they've got IC and that their pelvic floor is kind of fine.
Speaker 1:
Yeah, oh God, that, yeah, that fries me because it's like clearly they're not looking at these things it's fine.
Speaker 1:
You guys, like I know that somebody out there is sitting there being like I remember this one patient that shaped their pelvic floor kind of was sort of fine and it's like, but kind of was sorta fine, is not fine, is not good, certainly isn't good. And so I don't know. I just feel like if you take your patient and they're sitting in front of you and they're saying like I have this massive bladder problem and I have this map or symptoms and I have this massive pain and I've had basically dysregulated like urination for most of the time when these folks are coming in, it's at least six months, usually years, of these symptoms. They have a pelvic health history for days that can lead up to probably pelvic float dysfunction. I have yet to meet a patient that doesn't have at least hip, back or tailbone pain.
Speaker 1:
Also, we didn't even talk about that, we talked about that in the course, but, like, all of those things cause pelvic floor dysfunction. So if all of those things are true and then you're saying like, oh, I think the pelvic floor is fine, I would bet I, if I'm a betting person, I would bet that there's a part of that that's missing, like you. That just like doesn't make sense, right? So you're either missing the periurethral muscles, which is very frequently overlooked, you're missing the superficial muscles, which is also very frequently overlooked, you're not all of the stuff that we just talked about Like there's something that's driving that, and the pelvic floor is usually not fine in folks that are symptomatic.
Speaker 2:
Got it Perfect, guys. So I hope this has given you some ideas of things to make sure that you are checking when you've got people coming in with IC. If you want to learn more about this, if you want to dive into some of these techniques and topics, make sure you are on the wait list for that second cohort of the IC course that comes out on the 19th, one week from today. You can find that at pelvicptrisingcom slash IC. Hope this has been really helpful. If you have questions, please feel free to reach out, ask us. We always want to keep this conversation going.