Bladder Directed vs. Pelvic Floor Therapy in IC/BPS

Study Overview
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Brief Summary
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Women with interstitial cystitis/bladder pain syndrome (IC/BPS) have debilitating urinary frequency and urgency, and chronic pelvic or bladder pain perceived to be related to the bladder. Although many clinicians think that IC/BPS symptoms result from a bladder problem, tight pelvic floor muscles can cause similar symptoms and might be responsible for ICBPS symptoms instead of the bladder. Inadequate assessment of the problem leads to delays in treatment and often years of suffering. This clinical trial will test a bladder directed therapy (bladder instillations) compared to a course of pelvic floor physical therapy (PFPT) to assess the role of the pelvic floor as a major contributor to pelvic pain and voiding dysfunction in adult women with non-ulcerative IC/BPS. Early assessment of the pelvic floor muscles in patients with IC/BPS symptoms may prevent common delays in proper diagnosis and allow for early, more effective treatment.

Detailed Description
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This will be a prospective randomized trial of pelvic floor therapy vs. bladder directed therapy. The study target population consists of females, aged 18 to 85 years of age with a clinical diagnosis of IC/BPS and symptoms of chronic urinary frequency, pelvic pain/discomfort, and/or urinary urgency. The approximate number of subjects that will be enrolled in the study is 128, 64 women in each treatment group. Women who satisfy all of the eligibility criteria will be enrolled in the study and randomized to receive bladder treatments (instillation of medications into the bladder) or pelvic floor physical therapy. Outcome measures will include validated questionnaires, voiding diaries, and Global Response Assessment (GRA). The investigators also will evaluate changes in pelvic floor muscle tone and discomfort pre and post treatment, and their relationship to symptom changes. Finally, the investigators will utilize their well-established urine and serum biomarkers evaluations pre and post treatment to determine if they correlate with symptom change.

Official Title
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Comparison of Bladder Directed and Pelvic Floor Therapy in Women With Interstitial Cystitis/Bladder Pain Syndrome

Conditions
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Cystitis, Interstitial, Painful Bladder Syndrome

Intervention / Treatment
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* Procedure: Pelvic Floor Physical Therapy
* Drug: Bladder Instillations


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female Age 18 to 85 years History of patient self-reported of IC/BPS symptoms for at least 6 months. Using an approved method of birth control, or surgically sterile, or of non-child bearing age with no menstrual period for the past 12 months Must be willing to not start any new medication known to affect bladder or muscle function, and to ideally remain on a stable dose of all other medications through the secondary endpoint. Exclusion Criteria: Active urethral or ureteral calculi, urethral diverticulum, history of pelvic radiation therapy, tuberculous cystitis, bladder cancer, carcinoma in situ (bladder), urethral cancer Hunner's lesions found on screening cystoscopy Prior investigational or therapeutic bladder instillations for IC/BPS symptoms within the past 3 months Lactation, pregnancy, or refusal of medically approved/reliable birth control in women of child-bearing potential. Pain, frequency, and/or urgency symptoms only present during menses Clinically confirmed urinary tract infection at time of screening Participant unable to tolerate insertion of one or two vaginal examining fingers (e.g. Vulvar allodynia) Participant had prior course of physical therapy (PT) that included internal (vaginal and/or rectal) manual therapy with connective tissue manipulation by physical therapist for the same symptoms within the past 3 months (prior treatment by therapist with biofeedback, electrical stimulation, or pelvic floor exercises is not exclusionary) Participant in the opinion of the investigator has a relevant neurologic disorder that affects bladder and/or neuromuscular function Participant has/reports any severe, debilitating or urgent concurrent, medical condition Participant has a potentially significant pelvic pathology or abnormality on examination or prior imaging, including prolapse beyond the hymenal ring, pelvic mass, etc., that in the investigators' judgment, could cause or contribute to the clinical symptoms, or require treatment Any other condition which, in the investigator's judgment, may increase risk to subject's welfare Participation in an investigational trial that uses a study treatment less than 6 months from the date of the screening visit Note: For the sake of preserving scientific integrity, one or more of the eligibility criteria have been left off the list posted while the trial is ongoing. A full list of eligibility criteria will be posted upon completion of the trial.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Pelvic Floor Physical Therapy<br>One hour of pelvic floor physical therapy twice weekly for 8 weeks | Procedure: Pelvic Floor Physical Therapy<br>* Internal and/or external myofascial release of the pelvic floor muscles<br>* Other names: Myofascial release;|
| Active Comparator: Bladder Instillations<br>Bladder instillation of lidocaine, kenalog, heparin sulphate, and bicarbonate twice weekly for 8 weeks | Drug: Bladder Instillations<br>* A solution of heparin sulphate 40,000 IU (4 cc of 10,000 units/cc), lidocaine 2% 16 ml, Sodium bicarbonate 8.4% 4 ml and Kenalog 40 mg (1cc) to reach a total fluid volume of 25 ml will be instilled into the bladder with a urinary catheter<br>* Other names: xylocaine, triamcinolone;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Markedly/Moderately Improved on Global Response Assessments | Proportion of patients in each treatment arm that report Marked or Moderate improvement in symptoms on Global Response Assessments at Week 9 (one week after last treatment) | Week 9 (one week after last treatment) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in symptoms | Change in pelvic floor examination findings and symptoms as measured by questionnaires at Week 9 (one week after last treatment) | Week 9 (one week after last treatment) |