What are the treatment options for interstitial cystitis symptoms?

Treatment Options for Interstitial Cystitis Symptoms

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

Understanding IC/BPS

IC/BPS is a chronic pain syndrome characterized by:

• Bladder/pelvic pain or pressure/discomfort
• Urinary frequency
• Strong urge to urinate
• Symptoms present for at least six weeks with negative urine cultures

Treatment Algorithm

First-Line: Behavioral/Non-Pharmacologic Treatments

1. Patient Education

   • Explain IC/BPS as a chronic condition with symptom fluctuations
   • Discuss that multiple treatment trials may be necessary
   • Set realistic expectations about symptom management 1

2. Self-Care Practices and Behavioral Modifications

   • Dietary modifications:
     • Elimination diet to identify trigger foods
     • Common bladder irritants to avoid: coffee, citrus products, spicy foods
   • Fluid management:
     • Adjust concentration/volume of urine through fluid restriction or hydration
   • Pain management techniques:
     • Application of heat or cold over bladder/perineum
     • Meditation and imagery for flare management
     • Pelvic floor muscle relaxation
     • Bladder training with urge suppression 1

3. Stress Management

   • Implement coping techniques for stress-induced symptom exacerbations
   • Consider psychological support for effective coping 1

4. Over-the-counter products (limited evidence but may help individual patients)

   • Nutraceuticals
   • Calcium glycerophosphates
   • Phenazopyridine (urinary analgesic) 1

Second-Line: Oral Medications

Oral medications (in alphabetical order, no hierarchy implied):

1. Amitriptyline (Evidence Strength: Grade B)

   • Begin at low doses (10 mg)
   • Titrate gradually to 75-100 mg if tolerated
   • Common side effects: sedation, drowsiness, nausea 1

2. Cimetidine (Evidence Strength: Grade B)

   • Has shown clinically significant improvement in IC/BPS symptoms, pain, and nocturia
   • Minimal reported adverse events 1

3. Hydroxyzine (Evidence Strength: Grade C)

   • May be more effective in patients with systemic allergies
   • Common side effects: short-term sedation, weakness 1

4. Pentosan polysulfate (PPS) (Evidence Strength: Grade B)

   • Only FDA-approved oral agent for IC/BPS
   • Important warning: Patients should be counseled on potential risk for macular damage and vision-related injuries 1

Second-Line: Intravesical Treatments

1. Dimethyl sulfoxide (DMSO) (Evidence Strength: Grade B)

   • Administration: 50 mL instilled directly into bladder via catheter
   • Allow to remain for 15 minutes then expel by spontaneous voiding
   • Treatment repeated every two weeks until maximum relief obtained
   • Side effects: garlic-like taste/odor lasting up to 72 hours, potential discomfort during administration 2

2. Heparin (Evidence Strength: Grade C)

   • Intravesical administration

3. Lidocaine (Evidence Strength: Grade B)

   • Intravesical administration for pain relief 1

Third-Line: Procedures

For patients with Hunner's lesions:

• Fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1

Fourth-Line: Neurostimulation

• Trial of neurostimulation may be performed in refractory cases 1

Advanced Options: Major Surgery

• Surgical treatments (other than fulguration of Hunner's lesions) should only be considered after all other treatment alternatives have been exhausted
• Only appropriate when an end-stage small, fibrotic bladder has been confirmed and quality of life suggests a positive risk-benefit ratio 1

Multimodal Pain Management

• Pharmacological approaches combined with stress management and manual therapy
• Non-opioid alternatives should be used preferentially
• Judicious use of chronic opioids only after informed shared decision-making 1

Important Considerations

1. Treatment Efficacy Assessment

   • Periodically reassess efficacy of treatments
   • Discontinue ineffective treatments 1

2. Individualized Approach

   • The 2022 AUA Guideline emphasizes that IC/BPS treatment should be based on the unique characteristics of each patient 1

3. Common Pitfalls to Avoid

   • Relying solely on pain management without addressing underlying bladder symptoms
   • Continuing ineffective treatments without reassessment
   • Progressing to surgical options prematurely
   • Failing to recognize and treat Hunner's lesions when present

4. Special Considerations for Men

   • IC/BPS symptoms in men may overlap with chronic prostatitis/chronic pelvic pain syndrome
   • Treatment approach should include established IC/BPS therapies as well as therapies specific to CP/CPPS when appropriate 1

Remember that IC/BPS is a heterogeneous clinical syndrome, and except for patients with Hunner lesions, initial treatment should typically be nonsurgical 1.