What is the treatment for Interstitial Cystitis?

From the Guidelines

The treatment for Interstitial Cystitis (IC) should be individualized and based on the unique characteristics of each patient, incorporating a multimodal approach that includes behavioral/non-pharmacologic interventions, oral medicines, bladder instillations, procedures, and potentially major surgery. According to the 2022 updated Guideline on the diagnosis and treatment of interstitial cystitis/bladder pain syndrome 1, the approach to treatment has shifted away from tiered recommendations, emphasizing the need for personalized care.

Key components of treatment may include:

• Behavioral and non-pharmacologic interventions such as lifestyle modifications (e.g., dietary changes, stress management, bladder training techniques)
• Oral medications like pentosan polysulfate sodium, which may help repair the bladder lining, although it requires several months to show benefit
• Bladder instillations with medications such as dimethyl sulfoxide (DMSO), heparin, or lidocaine for relief
• Procedures including hydrodistention, Botox injections for reducing bladder spasms, sacral neuromodulation, and in refractory cases, surgery

It's crucial to consider the potential adverse events from treatments like pentosan polysulfate, as highlighted in the updated guideline 1. The role of cystoscopy, especially for patients with Hunner lesions, and the importance of shared decision-making in the treatment process are also emphasized. Given the chronic nature of IC, ongoing management with adjustments to the treatment plan based on symptom response is necessary.

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.

The treatment for Interstitial Cystitis includes:

• Oral medication: pentosan polysulfate (PO) capsules, 100 mg, taken three times a day with water at least 1 hour before meals or 2 hours after meals 2.
• Intravesical instillation: dimethyl sulfoxide (IV), 50 mL, directly into the bladder, remaining for 15 minutes, repeated every two weeks until maximum symptomatic relief is obtained 3.

From the Research

Treatment Options for Interstitial Cystitis

The treatment of Interstitial Cystitis (IC) is multifaceted and can involve various approaches, including oral medications, intravesical therapies, surgical procedures, and alternative therapies.

• Oral Medications: Several oral medications have been used to treat IC, including:
  • Amitriptyline 4, 5, 6
  • Hydroxyzine 4, 5, 6
  • Pentosan polysulfate sodium (PPS) 4, 5, 6, 7
  • Cyclosporine A 5
  • Certolizumab pegol, which is currently in clinical development for IC/BPS treatment 5
• Intravesical Therapies: These involve directly administering medications into the bladder via a catheter, including:
  • Botulinum toxin A 4
  • Dimethyl sulfoxide (DMSO) 4, 6
  • Heparin and glycosaminoglycan substitutes 4
  • Intravesical liposomes, which have shown promise in reducing symptoms 8
• Surgical Procedures: In severe cases where other treatments have failed, surgical options may be considered, including:
  • Partial removal of the urinary bladder
  • Urinary diversion procedures 4
• Alternative Therapies: Other approaches that have been explored for the treatment of IC include:
  • Acupuncture, which has shown good results in chronic pelvic pain syndrome 4
  • Hyperbaric oxygen therapy 4
  • Dietary modifications and other supportive therapies 6

Efficacy and Safety of Treatments

The efficacy and safety of these treatments can vary among individuals, and what works for one person may not work for another. For instance, sodium pentosanpolysulfate has been shown to be effective in reducing pain and improving symptoms in patients with interstitial cystitis, especially those without bladder ulceration 7. Intravesical liposomes have also demonstrated safety and potential efficacy in improving symptoms 8. However, the use of pentosan polysulfate sodium has been associated with a risk of pigmented maculopathy, which is a significant concern 5.

Approach to Treatment

Given the complexity and variability of IC, treatment often involves a trial-and-error approach, with patients potentially trying several different therapies before finding one that is effective for them. The WHO staging scheme provides a basis for pain therapy 4, and a multidisciplinary approach, considering both conventional and alternative therapies, may offer the best outcomes for patients with IC.