The Role of Pelvic Floor Dysfunction in Interstitial Cystitis

When it comes to pelvic floor dysfunction and interstitial cystitis, it’s one of those “Which came first, the chicken or the egg?” situations. To better understand what that means, let’s start with what pelvic floor dysfunction is.

The pelvic floor is essentially a hammock of muscles and connective tissue that supports the pelvic organs including the bladder, uterus and rectum. These muscles and connective tissue also help keep the bladder outlet (urethral sphincter) and the rectum (anal sphincter) closed to prevent involuntary loss of urine and stool, respectively.

Pelvic floor dysfunction (PFD) is a term used to describe a variety of symptoms and conditions due to abnormal function of the pelvic floor. The abnormal function includes either increased muscle activity (hypertonicity), decreased activity (hypotonicity), or asynchronous coordination, i.e. muscles relax when they are supposed to tighten or vice-versa. Today we will focus on hypertonic pelvic floor dysfunction (muscles too tight), as this is more common with interstitial cystitis (IC).

Symptoms of a hypertonic pelvic floor (muscles too tight) range from vague pelvic pain to painful sexual activity and even inability to urinate. The hypertonicity can be a primary problem indicating that there is a problem with the muscles themselves, or the hypertonicity can be a secondary problem that implies the muscles are tight due to another reason–and this is the connection between PFD and IC as well as the question, “Which came first?”

Muscles anywhere in our body can be dysfunctional for no obvious reason and potentially cause pain. Another common example of this is jaw pain from temporomandibular joint disorder (TMJ). Similarly, if the pelvic floor muscles are too tight, not only can the chronic muscle contraction and lack of relaxation cause pain, but the nerves that run through these muscles can be compressed by the tight muscles causing more pain and other symptoms. These other symptoms can include urinary frequency, urinary urgency, and bladder discomfort or pain–symptoms typical of interstitial cystitis. This scenario is an example of primary pelvic floor dysfunction.

Secondary pelvic floor dysfunction is when the scenario is reversed. It is the normal reflex of the body to recoil from pain, i.e. tighten muscles. Similarly pelvic pain, whether it’s from IC, endometriosis, or another condition, can cause reflexive tightening of the pelvic muscles. If the pain is chronic, over time, the pelvic floor muscles can become dysfunctional.

Regardless of whether pelvic floor dysfunction is primary or secondary, treatment is aimed at relaxing the pelvic floor muscles. Of course, if there is an underlying cause of the PFD such as IC, this needs to be treated concomitantly. Some of the treatment modalities for PFD include muscle relaxants and pelvic floor physical therapy.

Since hypertonic PFD is the result of abnormal muscle tightness, muscle relaxants can be very effective. Muscle relaxants can be taken orally or inserted vaginally/rectally. A common side effect of muscle relaxants is somnolence, or drowsiness, which is why the vaginal or rectal route is often preferred. Vaginal or rectal muscle relaxants are usually compounded as a cream or suppository, and these can be inserted regularly or just as needed, such as in situations where discomfort during sexual activity is the main issue. The muscle relaxant medication can also be mixed with pain medication.

However, while muscle relaxants can be helpful, pelvic floor physical therapy (PFPT) is really the cornerstone for PFD. For the best results, it’s essential that PFPT be performed by a physical therapist with special training in pelvic floor disorders. Much like back muscle tightness can be improved with massage, PFD can also be improved with massage of the pelvic floor muscles (yes, it’s exactly what you’re thinking). And if internal massage is painful, a compounded muscle relaxant with pain medication can be inserted before the PFPT session. Over time, your pelvic floor muscles and nerves can be reconditioned to be less reflexive and contracted, leading to improved pelvic floor function and comfort.

Dr. Karyn Eilber is a board-certified urologist and fellowship-trained specialist in female pelvic medicine and reconstructive surgery. She is dedicated to empowering women with clear, compassionate information about pelvic floor health and bladder conditions.