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 behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures, and major surgery as needed. The approach to treating interstitial cystitis has evolved, with the most recent guidelines [ 1 ] emphasizing a personalized treatment plan rather than a tiered approach. This shift acknowledges the complexity and variability of the condition, ensuring that treatment is tailored to the specific needs and symptoms of each patient.

Treatment Options

• Behavioral/Non-pharmacologic Treatments: Patients should be educated about normal bladder function, the benefits versus risks/burdens of available treatment alternatives, and the potential need for trials of multiple therapeutic options [ 1 ]. This includes lifestyle modifications such as dietary changes, stress management, and bladder training techniques.
• Oral Medications: Options like pentosan polysulfate sodium (Elmiron), antihistamines (e.g., hydroxyzine), and tricyclic antidepressants (e.g., amitriptyline) can be considered for symptom management [ 1 ].
• Bladder Instillations: Medications such as dimethyl sulfoxide (DMSO), heparin, or lidocaine may be directly placed into the bladder to help patients with severe symptoms.
• Procedures and Major Surgery: For refractory cases, options include hydrodistention, Botox injections, neuromodulation therapy, and other surgical interventions [ 1 ].

Considerations

• The treatment of interstitial cystitis remains complex, with no single approach effective for the majority of patients [ 1 ].
• Patient education and shared decision-making are crucial in managing expectations and selecting appropriate treatments [ 1 ].
• The potential for adverse events from certain treatments, such as pentosan polysulfate, should be considered and discussed with patients [ 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:

• Oral medication: pentosan polysulfate (PO) capsules, such as ELMIRON®, taken three times a day to treat the pain or discomfort of interstitial cystitis (IC) 2.
• Intravesical instillation: dimethyl sulfoxide (INH), such as RIMSO-50®, instilled directly into the bladder to provide symptomatic relief 3 3.

From the Research

Treatment Options for Interstitial Cystitis

The treatment options for interstitial cystitis (IC) are varied and can be tailored to each specific patient, as the symptoms and severity of the disease can differ greatly from person to person 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 for those that fail the less invasive therapies.

Pharmacological Therapies

• Pentosan polysulfate sodium (PPS) is a commonly used pharmacological therapy for IC, which has been shown to be efficacious in reducing bladder pain, urinary urgency, and frequency of micturition 5.
• The efficacy of PPS has been confirmed in several randomized controlled trials, including a systematic review of six randomized placebo-controlled studies 5.
• However, the results of another study found no statistically significant difference between PPS and placebo in terms of reducing IC symptoms 6.

Other Treatment Approaches

• Education and lifestyle modifications are recommended as the first line of treatment for IC, and can include dietary changes, stress management, and bladder training 4.
• Physical therapies, such as pelvic floor physical therapy, may also be recommended for some patients with IC.
• Surgical therapies, such as bladder augmentation or urinary diversion, may be considered for patients who do not respond to less invasive therapies.

Safety and Efficacy of Pentosan Polysulfate Sodium

• PPS has been shown to be generally well tolerated, with common side effects including mild haemodilution, nausea, and loss of hair 7.
• However, there have been reports of a potential correlation between prolonged high-dose therapy with PPS and a special kind of maculopathy, although this correlation is still unclear 7.
• Despite this potential correlation, PPS remains an important option in the treatment of IC, and is the only US FDA-approved oral treatment for the relief of bladder pain or discomfort associated with IC 8.