What is the diagnosis and treatment for Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)?

From the Guidelines

Interstitial cystitis/bladder pain syndrome (IC/BPS) treatment should prioritize a multimodal approach, including lifestyle modifications, pharmacological interventions, and behavioral modifications, as recommended by the most recent guidelines 1. The treatment of IC/BPS typically begins with lifestyle modifications, such as avoiding trigger foods and beverages (caffeine, alcohol, spicy foods, citrus), stress management, and pelvic floor physical therapy.

• First-line medications include amitriptyline (10-75 mg daily), which helps reduce pain signals and improve sleep, and pentosan polysulfate sodium (Elmiron, 100 mg three times daily), which may repair the bladder lining but requires 3-6 months for effectiveness 1.
• Antihistamines like hydroxyzine (10-25 mg at bedtime) can help if allergies worsen symptoms.
• For acute flares, phenazopyridine (Pyridium, 100-200 mg three times daily for 2-3 days) provides urinary tract pain relief.
• Bladder instillations with dimethyl sulfoxide (DMSO), heparin, or lidocaine may be performed in-office for direct symptom relief. More invasive options include cystoscopy with hydrodistention under anesthesia or Botox injections for refractory cases. IC/BPS likely results from a damaged bladder epithelium allowing irritants to penetrate the bladder wall, triggering inflammation and pain. A multidisciplinary approach is often necessary as symptoms can significantly impact quality of life and may coexist with other chronic pain conditions, and patients should be encouraged to become aware of and avoid specific behaviors that worsen symptoms, such as certain foods, exercise, or tight-fitting clothing, as suggested by clinical experience and limited literature 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION 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. 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. Administration of oral analgesic medication or suppositories containing belladonna and opium prior to the instillation of RIMSO-50® can reduce bladder spasm CLINICAL TRIALS ELMIRON® was evaluated in two clinical trials for the relief of pain in patients with chronic interstitial cystitis (IC). Clinical improvement in bladder pain was based upon the patient's own assessment. 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).

Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome:

• Dimethyl sulfoxide (RIMSO-50®) can be used to treat interstitial cystitis/bladder pain syndrome, with instillation of 50 mL directly into the bladder, remaining for 15 minutes, and repeated every two weeks until maximum symptomatic relief is obtained 2.
• Pentosan polysulfate (ELMIRON®) has been evaluated in two clinical trials for the relief of pain in patients with chronic interstitial cystitis, with 38% of patients showing greater than 50% improvement in bladder pain compared to 18% of patients who received placebo 3. Key Considerations:
• Patients with severe interstitial cystitis may require treatment under anesthesia.
• Administration of oral analgesic medication or suppositories containing belladonna and opium prior to instillation of RIMSO-50® can reduce bladder spasm.

From the Research

Interstitial Cystitis/Bladder Pain Syndrome Treatment

• Pentosan polysulfate (PPS) is the only oral treatment approved by the World Health Organization for interstitial cystitis/bladder pain syndrome (IC/BPS) 4.
• Studies have shown that PPS can achieve recovery in symptoms, increase Interstitial Cystitis Symptom Index score, and improve quality of life and patient satisfaction 4, 5.
• A multicenter, double-blind, placebo-controlled, randomized study found that PPS therapy is more effective than placebo in treating IC/BPS, with a significant improvement in symptoms and quality of life 5.
• However, another study found no statistically significant difference between PPS and placebo in terms of symptom improvement 6.

Efficacy and Safety of Pentosan Polysulfate

• PPS has been shown to be effective in relieving bladder pain and discomfort in adults with IC, with beneficial effects in a proportion of patients 7.
• A systematic review and meta-analysis found that PPS treatment has a statistically significant effect over placebo on the subjective improvement of patients with BPS/IC 8.
• PPS is generally well tolerated, with a similar percent of patients discontinuing due to adverse events across different treatment groups 6.
• The majority of studies do not report any particular serious side effects associated with PPS treatment 8.

Patient Outcomes and Quality of Life

• Studies have used self-evaluation scales and quality of life scores to assess the effectiveness of PPS treatment in patients with IC/BPS 4, 5.
• PPS treatment has been shown to improve quality of life and patient satisfaction, with significant increases in Interstitial Cystitis Symptom Index scores and quality of life scores 4, 5.
• However, the effectiveness of PPS treatment may vary depending on the individual patient and the severity of their symptoms 6.