What are the treatment options for interstitial cystitis?

From the Guidelines

Treatment for interstitial cystitis should be individualized and based on the unique characteristics of each patient, incorporating a range of options from behavioral/non-pharmacologic treatments to oral medicines, bladder instillations, procedures, and major surgery, as recommended by the 2022 updated Guideline 1. When considering treatment options, it's essential to prioritize a stepwise approach, starting with conservative measures and progressing to more invasive options as needed.

• Behavioral and non-pharmacologic treatments are crucial, including lifestyle modifications such as dietary changes, stress management, and bladder training techniques, as these can significantly impact symptom severity and quality of life 1.
• Oral medications like pentosan polysulfate sodium (Elmiron, 100mg three times daily) can help repair the bladder lining, though it may take 3-6 months to show benefit, and antihistamines like hydroxyzine (25-50mg at bedtime) can reduce mast cell activity and inflammation.
• For pain management, amitriptyline (10-75mg at bedtime, starting low and gradually increasing) or other tricyclic antidepressants are often used, and for acute flares, phenazopyridine (Pyridium, 100-200mg three times daily for 2-3 days) provides urinary analgesic effects.
• Bladder instillations with medications like dimethyl sulfoxide (DMSO), heparin, or lidocaine, and physical therapy targeting pelvic floor dysfunction, can provide relief for moderate to severe cases.
• In refractory cases, more invasive options such as hydrodistention during cystoscopy, Botox injections into the bladder wall, sacral neuromodulation, or rarely, surgical interventions, may be considered, with the approach tailored to the patient's specific needs and circumstances, as outlined in the most recent guidelines 1.

From the FDA Drug Label

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. RIMSO-50® is a sterile solution of 50% dimethyl sulfoxide (DMSO) and 50% water that has been approved by the U. S. Food and Drug Administration for use in the symptomatic relief of patients with interstitial cystitis.

The treatment options for interstitial cystitis include:

• Pentosan polysulfate (PO): taken orally, three times a day, to treat the pain or discomfort of interstitial cystitis (IC) 2.
• Dimethyl sulfoxide (IV): instilled directly into the bladder, every two weeks, to provide symptomatic relief of interstitial cystitis 3 3.

From the Research

Treatment Options for Interstitial Cystitis

• The treatment of interstitial cystitis (IC) is tailored to each specific patient, given the varying presentations and severities of the disease 4.
• The American Urological Association (AUA) guidelines separate the 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 4.
• Pharmacotherapies used to treat IC include oral and intravesical agents, such as amitriptyline, hydroxyzine, cyclosporine A, and pentosan polysulfate sodium (PPS) 5.
• Bladder instillation therapy, which refers to the direct introduction of medication into the bladder, is a common treatment modality for patients with IC who have failed conservative and oral therapies 6.
• The AUA recommendations list three medications as options for IC instillation therapy: dimethyl sulfoxide, heparin, and lidocaine 6.
• Pentosan polysulfate sodium (PPS) has been shown to be efficacious in the treatment of IC, with statistically significant improvements in patient's overall response assessment, pain, and urgency 7.
• However, the use of PPS has been associated with a possible correlation with maculopathy, and patients should be informed of this potential risk 5, 8.
• Despite this potential risk, PPS remains a recommended treatment option for IC, and its use should be re-evaluated after a treatment period of six months 8.

Pharmacological Therapies

• Oral therapies for IC include:
  • Amitriptyline
  • Hydroxyzine
  • Cyclosporine A
  • Pentosan polysulfate sodium (PPS)
• Intravesical therapies for IC include:
  • Dimethyl sulfoxide
  • Heparin
  • Lidocaine
• Certolizumab pegol is a pharmacologic therapy that is currently in clinical development for the treatment of IC symptoms 5.

Non-Pharmacological Therapies

• Education and lifestyle modifications are recommended as the first line of treatment for IC 4.
• Physical therapies, such as bladder training and pelvic floor physical therapy, may also be recommended 4.
• Surgical therapies may be considered for patients who have failed less invasive therapies 4.