AUA IC Guidelines

http://tinyurl.com/AUA-IC-guidelines

The American Urological Association released the first version of Clinical Guidelines for Interstitial Cystitis / Painful Bladder Syndrome (IC/PBS) on March 1, 2011.   This landmark document was created by 14 well know and respected professionals including one nurse practitioner (Diane Newman), one PhD, and one dietician.  In addition they solicited input from 84 peer reviews.  I had the honor of submitting input to the draft document in May 2010.  The documents reviews literature and makes recommendations for diagnosis and treatment of IC/PBS including treatments that should not be offered.  Diagnostic procedures suggested are primarily related to history and physical with urodynamics and cystoscope only offered in complex conditions.    Treatment suggestions are divided into 7 groups. 

• Overall management suggested conservative management first, multiple simultaneous treatments, good pain management, and multi-disciplinary approach. 
• First line treatments – education on aggravating and easing self treatments and stress management.
• Second line treatments – cut from the documents

13. Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Clinical Principle

14. Multimodal pain management approaches (e.g., pharmacological, stress management, manual therapy if available) should be initiated. Expert Opinion

15. Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as second-line oral medications (listed in alphabetical order; no hierarchy is implied). Options (Evidence Strength- Grades B, B, C, and B)

16. DMSO, heparin, or lidocaine may be administered as second-line intravesical treatments (listed in alphabetical order; no hierarchy is implied). Option (Evidence Strength- Grades C, C, and B)

• Third-line treatments: Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension, if Hunner‘s lesions are present, then fulguration (with laser or electrocautery) and/or injection of tri-amcinolone should be performed.
• Fourth-line treatment: neurostimulation
• Fifth-line treatments: oral Cyclosporine A, Intradetrusor botulinum toxin A
• Sixth-line treatment:  Major surgery (e.g., substitution cystoplasty, urinary diversion with or without cystectomy)

• Treatments that should not be offered: Long-term oral antibiotic administration  Intravesical instillation of bacillus Calmette-Guerin (BCG) or resiniferatoxin,  High-pressure, long-duration hydrodistension, Systemic (oral) long-term glucocorticoid

These guidelines are very supportive of the role of PT in the care of patient with IC/PBS.  My input (as with the government guidelines on SUI) focused around the appropriate use of the term “Physical Therapy”.  I think it was well written in this way. It does not state that manual therapy must be done by a PT but does point out the difficulty in finding trained and skilled practitioners to do this work.  The guidelines do mention several aspects of manual therapy and discourage the use of PFM exercises for the purpose of strengthening. 

The documents also lists evidence levels for the recommendations given.  Unfortunately the first line and second line treatments PT can offer do not have high level research evidence and are being recommended at “Clinical Principle”.  The PT community needs to continue to produce high level research about the effectiveness of the treatments we know work.

 I see this document as a great success for PT as AUA has very little grassroots PT influence.  I would encourage the Section on Women’s Health to consider reaching out to the AUA in regard to these guidelines and form a working relationship for collaboration in other projects such as this.  AUA is a very strong professional organization with input into almost every country with practicing urologists.  It would be great to see this document used in marketing to urologist (I know I will be).  Share your marketing success with others here.