From the Guidelines
Chronic autoimmune cystitis should be managed with a combination of immunosuppressive medications, symptom management, and lifestyle modifications to improve morbidity, mortality, and quality of life. The condition is characterized by the immune system mistakenly attacking the bladder, causing inflammation and symptoms like pelvic pain, frequent urination, and urgency. Treatment typically involves immunosuppressive medications such as hydroxychloroquine (200-400mg daily), prednisone (starting at 20-40mg daily with gradual tapering), or methotrexate (7.5-25mg weekly with folic acid supplementation) 1.
Symptom management includes phenazopyridine (100-200mg three times daily) for pain relief, anticholinergics like oxybutynin (5mg twice daily) for urgency, and amitriptyline (10-75mg at bedtime) for both pain and frequency. Lifestyle modifications are essential, including:
- Increasing water intake to 2-3 liters daily
- Avoiding bladder irritants (caffeine, alcohol, spicy foods, acidic juices)
- Practicing pelvic floor relaxation exercises
- Using heat therapy for pain relief
- Modifying certain behaviors that worsen symptoms, such as altering the concentration and/or volume of urine, avoiding certain foods known to be common bladder irritants, and using an elimination diet to determine which foods or fluids may contribute to symptoms 1.
The condition results from dysregulation of T-cells and B-cells producing autoantibodies that target bladder tissue, creating a cycle of inflammation. Treatment aims to suppress this immune response while managing symptoms. Regular follow-up with a urologist and possibly a rheumatologist is important to monitor disease progression and medication effectiveness. According to the most recent guideline amendment, patients with IC/BPS constitute a previously under-recognized and underserved population in need of adequate medical management 1.
From the FDA Drug Label
In patients with severe interstitial cystitis with very sensitive bladders, the initial treatment, and possibly the second and third (depending on patient response) should be done under anesthesia. CLINICAL TRIALS ELMIRON® was evaluated in two clinical trials for the relief of pain in patients with chronic interstitial cystitis (IC).
The treatment for chronic autoimmune cystitis may involve the use of medications such as dimethyl sulfoxide (DMSO) or pentosan polysulfate.
- Dimethyl sulfoxide (DMSO) is administered via instillation into the bladder, with an initial treatment possibly done under anesthesia for patients with severe interstitial cystitis.
- Pentosan polysulfate has been evaluated in clinical trials for the relief of pain in patients with chronic interstitial cystitis, with results showing improvement in bladder pain in some patients 2 3.
From the Research
Chronic Autoimmune Cystitis
- Chronic autoimmune cystitis is a condition that is related to interstitial cystitis/bladder pain syndrome (IC/BPS), which is defined as persistent or chronic discomfort perceived to be related to the urinary bladder accompanied by urinary urgency or frequency 4.
- The management of noninfectious cystitis, including chronic autoimmune cystitis, continues to evolve as new treatments continue to be developed and investigated 5.
- Treatment strategies for IC/BPS have traditionally focused on the bladder, but the growing body of evidence suggests a multifaceted nature of the disease with systemic components 6.
Treatment Options
- Pharmacotherapies used to treat IC/BPS include oral and intravesical agents, such as amitriptyline, hydroxyzine, cyclosporine A, and pentosan polysulfate sodium (PPS) 4.
- However, recent findings have shown that PPS can have adverse ophthalmologic effects, including pigmented maculopathy with chronic use 4, 5.
- Other treatment options include combination antihistamine therapy, phosphodiesterase 5 inhibitors, alpha lipoic acid supplements, and onabotulinumtoxin A 5.
- Multimodal regimens are often the most effective, and treatment should be started with conservative options and escalated as necessary to oral treatments, intravesical options, or procedural management 5.
Guidelines and Recommendations
- Current guidelines recommend a personalized and progressive approach to treatment, starting with behavioral changes and progressing to more invasive and combined treatments 6, 7.
- The American Urological Association (AUA) guidelines separate IC treatment recommendations into six tiers of increasing invasive therapies, starting with education and lifestyle modifications and progressing through levels of physical, pharmacological, and ultimately surgical therapies 7.