From the Guidelines
Treatment for interstitial cystitis (IC) and chronic bladder pain typically involves a multimodal approach tailored to each patient's symptoms, with a focus on lifestyle modifications, oral medications, and bladder instillations, as recommended by the most recent guidelines 1. The treatment approach should prioritize a combination of therapies to manage symptoms, improve quality of life, and reduce morbidity and mortality.
- First-line treatments include:
- Lifestyle modifications such as avoiding trigger foods and beverages (coffee, alcohol, spicy foods, citrus)
- Stress management
- Pelvic floor physical therapy
- Oral medications commonly prescribed include:
- Amitriptyline (10-75mg daily)
- Pentosan polysulfate sodium (Elmiron, 100mg three times daily), although its effectiveness has been contradictory 1
- Antihistamines like hydroxyzine (25-50mg daily)
- Pain medications such as gabapentin (300-900mg daily) or pregabalin (150-300mg daily)
- Bladder instillations may provide relief, typically using dimethyl sulfoxide (DMSO), heparin, lidocaine, or sodium bicarbonate solutions administered weekly for 6-8 weeks. For severe cases, more invasive options include hydrodistention during cystoscopy, Botox injections into the bladder wall, sacral neuromodulation, or rarely, surgical interventions like augmentation cystoplasty, with the initial treatment typically being nonsurgical except for patients with Hunner lesions 1. Most patients benefit from combining several approaches, as IC is a chronic condition requiring ongoing management, and treatment success varies widely, requiring patience and close work with healthcare providers specializing in pelvic pain 1.
From the FDA Drug Label
ELMIRON® (pentosan polysulfate sodium) is indicated for the relief of bladder pain or discomfort associated with interstitial cystitis. 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). 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.
The treatment options for chronic bladder pain, specifically interstitial cystitis, include:
- Pentosan polysulfate (PO): indicated for the relief of bladder pain or discomfort associated with interstitial cystitis, with 38% of patients showing greater than 50% improvement in bladder pain 2.
- Dimethyl sulfoxide (IV): can be instilled directly into the bladder to provide symptomatic relief, with treatment repeated every two weeks until maximum relief is obtained 3.
Key points:
- Pentosan polysulfate (PO) has been shown to be effective in reducing bladder pain in patients with interstitial cystitis.
- Dimethyl sulfoxide (IV) can be used to provide symptomatic relief for interstitial cystitis.
From the Research
Treatment Options for Chronic Bladder Pain
- The treatment options for chronic bladder pain, specifically interstitial cystitis, include oral and intravesical agents 4.
- Pentosan polysulfate sodium (PPS) is a heparin-like, sulfated polysaccharide used to manage bladder pain and discomfort in adults with interstitial cystitis (IC) 5.
- PPS has been shown to repair damaged glycosaminoglycan (GAG) layers lining the urothelium and provide an anti-inflammatory effect in patients with IC 5.
- Oral therapies for IC/BPS also include amitriptyline, hydroxyzine, and cyclosporine A 4.
Efficacy of Pentosan Polysulfate
- PPS has been proven to be efficacious in the treatment of bladder pain, urinary urgency, and frequency of micturition in randomized controlled trials 6.
- A systematic review of randomized controlled trials found that treatment with PPS led to a statistically significant improvement in the patient's overall response assessment, pain, and urgency 6.
- PPS is the only US FDA-approved oral treatment for the relief of bladder pain or discomfort associated with IC 5.
Side Effects and Considerations
- Side effects of PPS include mild haemodilution, nausea, and loss of hair 7.
- There is a potential correlation between prolonged high-dose therapy with PPS and a special kind of maculopathy, although this correlation is still unclear 7.
- An ophthalmologic examination is recommended before and during treatment with PPS due to the potential risk of maculopathy 7.