What are the treatment options for interstitial cystitis (bladder pain syndrome)?

From the Guidelines

Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by recurring pain or discomfort in the bladder and pelvic region, often accompanied by urinary frequency and urgency. The treatment options for interstitial cystitis (IC) include both lifestyle modifications and medical interventions. First-line approaches involve dietary changes to avoid bladder irritants like caffeine, alcohol, spicy foods, and acidic fruits, as suggested by 1. Stress management techniques and pelvic floor physical therapy can help reduce symptoms. Some key points to consider in managing IC/BPS include:

• Behavioral modification strategies, such as altering urine concentration and volume, avoiding certain foods, and using over-the-counter products like nutraceuticals or phenazopyridine, as mentioned in 1.
• Oral medications, with pentosan polysulfate sodium (Elmiron) at 100mg three times daily being the only FDA-approved oral agent for IC/BPS, although its effectiveness can vary, as noted in 1.
• Other oral medications like amitriptyline and anti-inflammatory medications may provide relief, but their use should be judicious, especially considering the global opioid crisis, as advised in 1.
• Bladder instillations and more invasive options like botulinum toxin injections, sacral neuromodulation, or surgical interventions may be considered for severe cases. It's essential to approach treatment with a multi-modal strategy, combining pharmacologic agents with other therapies and addressing both pain and underlying bladder-related symptoms, as emphasized in 1 and 1. Given the chronic nature of IC/BPS, patients should be informed about the potential for symptom exacerbations and remissions, and the need for ongoing, dynamic management, as stated in 1.

From the FDA Drug Label

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. Administration of oral analgesic medication or suppositories containing belladonna and opium prior to the instillation of RIMSO-50® can reduce bladder spasm 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. ELMIRON® (pentosan polysulfate sodium) is indicated for the relief of bladder pain or discomfort associated with interstitial cystitis.

Treatment Options for Interstitial Cystitis (Bladder Pain Syndrome) include:

• Instillation of dimethyl sulfoxide (RIMSO-50®) into the bladder, with possible use of analgesic lubricant gel and oral analgesic medication or suppositories containing belladonna and opium to reduce bladder spasm 2
• Oral administration of pentosan polysulfate (ELMIRON®) for relief of bladder pain or discomfort 3 Key Considerations:
• Treatment may need to be repeated every two weeks until maximum symptomatic relief is obtained
• Time intervals between therapy may be increased appropriately after initial relief is obtained
• Severe cases may require treatment under anesthesia

From the Research

Definition and Characteristics of Interstitial Cystitis

• Interstitial cystitis, also known as painful bladder syndrome, is a condition characterized by bladder pain, urinary frequency, urgency, and nocturia 4.
• The cause of the condition remains obscure and it is a diagnosis of exclusion, with current theories of pathogenesis including chronic or subclinical infection, autoimmunity, neurogenic inflammation, or bladder urothelial defects 4.
• The International Incontinence Society (ICS) and the European Society for the Study of Interstitial Cystitis (ESSIC) have proposed definitions and classification systems for the condition, with the ESSIC proposing the term "bladder pain syndrome" in 2008 4.

Treatment Options for Interstitial Cystitis

• Treatment strategies for interstitial cystitis can be categorized into four approaches: intravesical drug instillation, systemic (oral) medical therapy, administration of local treatments, and surgical procedures for refractory disease 4.
• Oral therapies include amitriptyline, hydroxyzine, cyclosporine A, and pentosan polysulfate sodium (PPS), although the use of PPS is concerning due to the risk of pigmented maculopathy 5.
• Intravesical drug instillation or oral therapies are the mainstay of treatment, with certolizumab pegol being a pharmacologic therapy currently in clinical development for treatment of IC/BPS symptoms 5.
• Pentosan polysulfate is a heparin-like, sulfated polysaccharide that is used to manage bladder pain and discomfort in adults with interstitial cystitis, and is the only US FDA-approved oral treatment for the relief of bladder pain or discomfort associated with IC 6.

Quality of Life and Treatment Efficacy

• Interstitial cystitis/bladder pain syndrome is a debilitating, chronic condition that is associated with a decrease in work productivity, emotional changes, sleep, sexual dysfunction, and mobility 7.
• Addressing quality of life in patients with IC/BPS is a significant challenge, as its effects on quality of life are highly variable and unable to be differentiated from the effects of comorbid conditions on quality of life 7.
• Future studies will need to address treatment efficacy on the basis of IC/BPS specific quality of life metrics, and multi-modal assessment and therapy to address comorbid disease will also play an important role in the future to ensure comprehensive management of these patients 7.