Yazici İlhan H. et al., 2026: Physiotherapeutic Management of Painful Bladder Syndrome/Interstitial Cystitis: A Systematic Review of the Literature.

Yazici İlhan H, Atabey Gerlegiz EN, Özgül S.
Int Urogynecol J. 2026 May 20. doi: 10.1007/s00192-026-06696-3

Abstract

Introduction and hypothesis: Painful bladder syndrome/interstitial cystitis (PBS/IC) is a chronic pelvic pain condition with unclear etiology that significantly affects quality of life. Although physiotherapeutic interventions are considered low-risk conservative options and may be incorporated into multimodal management in selected patients, evidence regarding their effectiveness remains limited. This review aimed to evaluate the effects of physiotherapy on pain and urinary symptoms in PBS/IC.

Methods: This systematic review followed the PRISMA 2020 guidelines and was registered in the PROSPERO database (CRD42024539744). A comprehensive search was conducted in PubMed and Web of Science up to August 2025 without language restrictions. Titles and abstracts were screened using the Rayyan AI. Risk of bias was assessed with RoB-2 and ROBINS-I tools, and the quality of evidence was rated using GRADE criteria. Given the heterogeneity of the included studies, a narrative synthesis was conducted.

Results: Fourteen studies involving 609 participants were included-eight randomized controlled trials and six prospective single-arm studies. Common interventions included electrotherapy techniques such as extracorporeal shock wave therapy (ESWT), posterior tibial nerve stimulation (PTNS), and transcutaneous electrical nerve stimulation (TENS), along with manual therapies like myofascial release and Thiele massage. Most studies reported short-term improvements in pain and urinary symptoms, though long-term results were inconsistent. Many studies had significant methodological limitations and a high risk of bias. Moderate-quality evidence suggests that ESWT may provide short-term pain relief, while low-quality evidence indicates potential benefits from manual therapies, bladder training, and multimodal approaches.

Conclusions: Physiotherapeutic interventions may provide short-term symptom relief in PBS/IC. However, given the limited quality of existing research, more rigorous, long-term randomized trials are needed.

Comment Jens Rassweiler

Objective

The review aimed to evaluate whether physiotherapeutic interventions improve symptoms in patients with painful bladder syndrome/interstitial cystitis (PBS/IC )particularly:

• Pain
• Urinary urgency/frequency/nocturia
• Bladder-related symptoms
• Quality of life

Study Design

This was a systematic review conducted according to PRISMA 2020 guidelines and registered in PROSPERO searching in PubMed and Web of Science. Searches were updated to August 2025. Because the included studies were highly heterogeneous, the authors did not perform a meta-analysis and instead used a narrative synthesis.

The review included 14 studies with 609 total participants in 8 randomized controlled trials and 6 prospective single-arm studies. Most participants were women, which reflects the higher prevalence of PBS/IC in females, but this limits conclusions for men.

Main Physiotherapy Interventions Studied

The interventions were grouped into several categories:

1. Electrotherapy including:

• Extracorporeal shock wave therapy — ESWT
• Posterior tibial nerve stimulation — PTNS
• Transcutaneous electrical nerve stimulation — TENS
• Microcurrent electrical neuromuscular stimulation — MENS

Main finding: Electrotherapy, especially ESWT, showed the most consistent short-term evidence for pain reduction. However, improvements in objective urinary parameters, such as voiding diary results or urodynamic measures, were less consistent.

2. Manual Therapy including:

• Myofascial physical therapy
• Trigger point release
• Thiele massage
• Intravaginal manual therapy

Main finding: Manual therapy may help selected patients, especially those with:

• Pelvic floor muscle tenderness
• High-tone pelvic floor dysfunction
• Myofascial trigger points

The strongest manual therapy evidence came from the FitzGerald et al. RCT, where myofascial physical therapy was superior to general therapeutic massage. However, evidence for Thiele massage was inconsistent.

3. Biofeedback and Pelvic Floor Muscle Training

Biofeedback combined with pelvic floor muscle training was associated with improved quality of life in one study. However, the evidence remains limited because few studies evaluated this intervention specifically.

4. Bladder Training

Bladder training added to hydrodistention appeared to improve:

• Urgency
• Voided volume
• Daytime and nighttime urinary frequency

But this was based on limited evidence.

Main Results

Overall, the review found that physiotherapeutic interventions may provide short-term improvement in:

• Pain
• Urinary symptoms
• Symptom burden
• Quality of life

But evidence for long-term benefit remains weak. The authors concluded that there is no strong evidence yet to support durable long-term benefit or firm clinical recommendations.

Quality of Evidence

The evidence quality was limited. According to the review:

• Most randomized trials had high risk of bias or at least some methodological concerns.
• All six non-randomized prospective studies had a serious risk of bias.
• Sample sizes were often small.
• Follow-up periods were usually short.
• Intervention protocols varied widely.
• Outcome measures were inconsistent.
• Prior or concomitant treatments were often poorly reported.

Clinical Interpretation

The most clinically relevant conclusion is that physiotherapy may be useful as part of a conservative, individualized, multimodal treatment plan for PBS/IC.

The best candidates may be patients with evidence of pelvic floor involvement, such as:

• Pelvic floor tenderness
• Muscle overactivity
• Trigger points
• Dyspareunia
• Pain worsened by pelvic floor contraction or palpation

For these patients, manual therapy and pelvic floor-focused physiotherapy may be particularly reasonable.

ESWT may also be considered as a short-term pain-relieving modality, although its impact on urinary function is less clear.

Obviously, this review does not include first promising experiences with extracorporeal magnetotransduction therapy (EMTT) for this indication.

Conclusions

Physiotherapy may provide symptom relief in patients with painful bladder syndrome/interstitial cystitis, especially for pain and pelvic floor-related symptoms.

The most promising approaches appear to be:

• ESWT for short-term pain relief
• Myofascial pelvic floor therapy in patients with pelvic floor tenderness
• Multimodal physiotherapy programs including bladder training, biofeedback, manual therapy, and exercises

However, current evidence is not strong enough to confirm long-term effectiveness. More rigorous, larger, placebo-controlled randomized trials with longer follow-up are needed.

Jens Rassweiler