What is the treatment for chronic non-infectious (non-infectious) interstitial cystitis?

From the Guidelines

Treatment for chronic non-infectious cystitis should involve a multimodal approach, including behavioral modifications, oral medications, and potentially bladder instillations, to address the complex symptoms and improve quality of life.

Key Components of Treatment

• Behavioral modifications, such as increased fluid intake (2-3 liters daily), avoiding bladder irritants (caffeine, alcohol, spicy foods), and timed voiding, are essential for managing symptoms 1.
• Oral medications, including amitriptyline 10-25 mg nightly for pain and urgency, and pentosan polysulfate sodium (Elmiron) 100 mg three times daily to repair the bladder lining, are often necessary 1.
• For pain management, phenazopyridine 100-200 mg three times daily can provide temporary relief, but its use should be limited to short courses 1.
• Antihistamines like hydroxyzine 10-25 mg can reduce mast cell activation in the bladder, contributing to symptom relief 1.
• More severe cases may benefit from bladder instillations containing dimethyl sulfoxide (DMSO), heparin, lidocaine, and sodium bicarbonate, administered weekly for 6-8 weeks 1.
• Physical therapy targeting pelvic floor dysfunction often complements medication, addressing the chronic inflammation and pain cycle by reducing bladder irritation, decreasing nerve hypersensitivity, and improving bladder lining integrity 1.

Patient Education and Shared Decision-Making

• Patients should be educated about normal bladder function, the benefits and risks of available treatment alternatives, and the potential need for trials of multiple therapeutic options to achieve acceptable symptom control 1.
• A shared decision-making approach, considering the unique characteristics of each patient, is crucial for developing an effective treatment plan 1.

From the FDA Drug Label

CLINICAL TRIALS ELMIRON® was evaluated in two clinical trials for the relief of pain in patients with chronic interstitial cystitis (IC). In this study, 28/74 (38%) of patients who received ELMIRON® and 13/74 (18%) of patients who received placebo, showed greater than 50% improvement in bladder pain (p=0. 005). At 3 months, 722/2499 (29%) of the patients originally in the study had pain scores that improved by one or two categories. ELMIRON® is used to treat the pain or discomfort of interstitial cystitis (IC). Instillation of 50 mL of RIMSO-50® (dimethyl sulfoxide) directly into the bladder may be accomplished by catheter or asepto syringe and allow to remain for 15 minutes.

Treatment Options for Chronic Non-Infectious Cystitis:

• Pentosan Polysulfate (PO): The medication has shown to improve bladder pain in patients with interstitial cystitis, with 38% of patients experiencing greater than 50% improvement in bladder pain 2.
• Dimethyl Sulfoxide (INH): The medication can be instilled directly into the bladder to provide relief from symptoms of interstitial cystitis 3.

Key Considerations:

• Pentosan polysulfate is a weak anticoagulant and may increase bleeding, especially when taken with other anticoagulant medications 2.
• Dimethyl sulfoxide should be administered under anesthesia in patients with severe interstitial cystitis and very sensitive bladders 3.

From the Research

Treatment Options for Chronic Non-Infectious Cystitis

• Oral medications such as pentosan polysulfate, amitriptyline, hydroxyzine, and cimetidine can be effective in treating chronic non-infectious cystitis 4
• Intravesical therapy with dimethyl sulfoxide, heparin, or anesthetic therapeutic combinations containing lidocaine can be attempted if oral drugs are ineffective 4
• Fulguration is typically performed if Hunner ulcers are found on cystoscopy 4
• Hydrodistention, sacral neuromodulation, and intradetrusor onabotulinumtoxinA are sometimes useful in treating chronic non-infectious cystitis 4

Management Strategies

• The management of non-infectious cystitis should be patient-specific, based on factors such as etiology and symptom profile 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
• Novel treatments such as combination antihistamine therapy, phosphodiesterase 5 inhibitors, alpha lipoic acid supplements, and onabotulinumtoxin A have shown promise as management options for non-infectious cystitis 5

Specific Treatments

• Pentosan polysulfate sodium is the only oral therapy with U.S. Food and Drug Administration approval for the treatment of interstitial cystitis/painful bladder syndrome 6
• Dimethyl sulfoxide is the only intravesical therapy with U.S. Food and Drug Administration approval for the treatment of interstitial cystitis/painful bladder syndrome 6
• Pentosan polysulfate therapy has been shown to be effective in reducing chronic pelvic pain and voiding symptoms in patients with interstitial cystitis and chronic nonbacterial prostatitis/chronic pelvic pain syndrome 7
• Hydrodistension combined with pentosan polysulfate treatment has been shown to be more effective than pentosan polysulfate treatment alone in improving treatment outcomes and compliance in patients with interstitial cystitis/bladder pain syndrome 8