Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a chronic, debilitating pain disorder of the bladder and urinary tract, usually comorbidity with autonomic and pelvic dysfunction. The main symptoms include chronic pelvic pain , and usually associated with symptoms of frequent urination,  and urgency. The literature points out that the application of biofeedback therapy is helpful, and can also effectively reduce stress and anxiety.
      The study is to investigate the effect of autonomic biofeedback combined with pelvic floor biofeedback to the clinical symptom index (ICSI), clinical problem index (ICPI), and the improvement of depression and anxiety in patients with interstitial cystitis (IC/BPS).

In this study, patients with IC/BPS underwent cystodilation, and were given 4 times of pelvic floor muscle relaxation training and 3 times autonomic biofeedback  intervention. Changes in symptoms and emotional symptoms were analyzed by generalized estimating equations (GEE) to compare whether there were significant differences before and after intervention.

(1)	Improvement of ICSI and ICPI 
ICSI scores after two weeks and six weeks of treatment were significantly reduced by 3.70 and 3.74, respectively. Compared with the baseline value, there was an improvement effect but not significant after four weeks and three months of treatment. Regarding the ICPI scores, there were significantly decrease by 1.86 and 4.54 after four weeks and six weeks of treatment respectively. Compared with the baseline value, there was improvement but not significant after two weeks and three months of treatment (Table 1).
 (2) Improvement of urinary tract symptoms
In terms of pelvic pain and urinary urgency/frequency (PUF), the mean distress index scores were reduced by 5.96, 2.94 and 6.59 after two weeks, four weeks and six weeks of treatment respectively. However, the improvement effect was not significant (Table 1).
As assessed by VAS for pain and urgency, the mean score for urgency was significantly reduced by 2.29, 2.75, and 3.46 after two, four, and six weeks of treatment, respectively. The mean score for pain was significantly reduced only after six weeks of intervention (β= -2.18(-3.65, -0.71) , p=0.004). .
The difference between before and after treatment was assessed by GRA (Global Response Rating Scale), and only after six weeks of treatment, there was a significant improvement (β=0.84(0.25, 1.43), p=0.005) (Table 1).

(3) Improvement of anxiety and depression symptoms
In terms of Beck Anxiety Inventory (BAI), the score was only significantly reduced by 4.24 after six weeks of intervention. However, after two weeks, four weeks, and three months of treatment, there were no significant improvements compared with the baseline values (Table 1). In terms of Beck depression Inventory (BDI-II), the scores after two weeks, four weeks and six weeks of treatment intervention were significantly reduced by 1.96, 3.81 and 5.41, respectively. After three months of continuous treatment, there was a significant improvement compared with the baseline value (β= -4.77(- 4.83, -4.71) , p<0.001).
(4) further analysis of the four questions of ICSI, the second question is "Did you need to urinate again within 2 hours after urinating in the past month?" revealed that: after six weeks, a significant reduction of more than 1 point was achieved, but after three months, there was no significant difference (Table 2). In the ICPI, the first question, "urinating frequently during the day", achieved a significant reduction after two, four and six weeks of continuous treatment intervention. The improvement effect was not significantly different after three months (Table 3)

(1)	Improvement of ICSI and ICPI: 
The ICSI, ICPI revealed significant improvement after 6 weeks, but no improvement post 3 months treatment implicit the intervention were effective in the short period, not in long period. Whether the result was due to the autonomic or pelvic biofeedback should be further clarified..
(2)	Improvement of urinary tract symptoms:
The PUF score showed improvement in short time period (6 weeks), but not in the long period (3 months) mean the biofeedback may be only effective in the short term period. 
Both VAS pain and urgency were improved after 6 weeks of continuous intervention, but not after three months, may be the only short time effective.
(3)	Improvement of anxiety and depression symptoms:
The BDI was the only clinical index that could maintain significant improvement for three months in this study showed that combined autonomic and pelvic biofeedback should be the core-strategy of treatment in term of depression.
(4)  The sub-score of ICSI, ICPI revealed only ICSI-2, ICPI-1 have significant improvement. The underlying reason could not be clarified from our study.

After cystodilation for IC/BPS patients, 4 times of pelvic floor muscle relaxation training and 3 times of autonomic biofeedback intervention can be used to improve short-term clinical severity, urinary tract symptoms and emotional symptoms.
The improvement of depressive symptoms can last up to three months after the intervention, and the effect of symptom improvement in the medium and long term (six months) still needs to be further evaluated by increasing the number of cases and continuous follow-up.

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Chui-De Chiu, Ming-Huei Lee, Wei-Chih Chen, Hoi Lam Ho & Huei-Ching Wu. (2017). Alexithymia and anesthetic bladder capacity in interstitial cystitis/bladder pain syndrome. Journal of Psychosomatic Research , 100, 15-21.
Goessl, V. C., Curtiss, J. E., & Hofmann, S. G. (2017). The effect of heart rate variability biofeedback training on stress and anxiety: A meta-analysis. Psychological Medicine, 1-9.