What are the treatment options for interstitial cystitis?

Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome

Treatment for interstitial cystitis/bladder pain syndrome (IC/BPS) should follow a multi-modal approach, beginning with conservative therapies and progressing to more invasive options only when symptom control is inadequate for acceptable quality of life. 1

Diagnosis Considerations

Before initiating treatment, proper diagnosis is essential:

• Symptoms should be present for at least 6 weeks with documented negative urine cultures
• Cystoscopy is indicated when Hunner lesions are suspected, as they require specific treatment 1
• Urodynamic studies are not routinely recommended but may be useful in specific cases 1

Treatment Algorithm

First-Line: Behavioral/Non-Pharmacologic Approaches

• Self-care practices and behavioral modifications:
  • Dietary modifications: Identify and avoid bladder irritants (coffee, citrus, spicy foods)
  • Fluid management: Alter concentration/volume of urine through hydration adjustments
  • Stress management techniques to manage flare-ups (meditation, imagery)
  • Application of heat or cold over bladder or perineum
  • Pelvic floor muscle relaxation
  • Bladder training with urge suppression 1

Second-Line: Oral Medications

• Amitriptyline (Grade B evidence): Start at low doses (10mg) and titrate gradually to 75-100mg if tolerated 1
• Cimetidine (Grade B evidence): Shown to improve symptoms, pain, and nocturia 1
• Hydroxyzine (Grade C evidence): May be particularly effective in patients with systemic allergies 1
• Pentosan polysulfate (PPS) (Grade B evidence): The only FDA-approved oral medication for IC/BPS 1
  • Important safety warning: Patients should be counseled on potential risk for macular damage and vision-related injuries 1
  • Some studies show combination of oral and intravesical PPS may be more effective than oral PPS alone (46% vs 24% symptom reduction) 2

Second-Line: Intravesical Treatments

• Dimethyl sulfoxide (DMSO) instillation:
  • FDA-approved for IC/BPS
  • Protocol: 50mL instilled directly into bladder, retained for 15 minutes, repeated every 2 weeks until maximum relief is obtained 3
  • Pre-treatment with lidocaine jelly and/or oral analgesics may reduce discomfort 3
  • Note: Patients will experience garlic-like taste and odor that may last up to 72 hours 3
• Heparin instillation
• Lidocaine instillation 1

Third/Fourth-Line: Procedures

• Cystoscopy with hydrodistension (low pressure, short duration only)
• Botulinum toxin A (100U) for patients who fail conservative therapies
  • Patients must accept possibility of needing intermittent self-catheterization
  • Not appropriate for patients who cannot tolerate catheterization 1

Last Resort: Surgical Options

• Should only be considered after all other treatment options have been exhausted
• May include urinary diversion with or without cystectomy 1

Treatment Pitfalls and Caveats

1. Avoid high-pressure, long-duration hydrodistension due to risk of serious adverse events including bladder rupture 1

2. Avoid long-term systemic glucocorticoids due to serious adverse events and known risks 1

3. Monitor patients on pentosan polysulfate for vision changes, as it has been associated with macular damage 1

4. Recognize treatment limitations:

   • No single treatment is effective for all patients
   • Response to treatment is unpredictable for any individual
   • Most patients benefit from combination therapies 4
   • Improvement may take time - some symptoms may continue to improve over 1-2 years of treatment 5

5. Pain management alone is insufficient - it should be one component of a comprehensive treatment approach 1

Special Considerations

• For patients with Hunner lesions, fulguration is appropriate at any stage of treatment 1
• For patients with very sensitive bladders, initial intravesical treatments may need to be done under anesthesia 3
• Treatment should be adjusted based on symptom severity and patient response

IC/BPS is a chronic condition requiring ongoing management. While there is no cure, most patients can achieve significant symptom improvement with appropriate treatment.