What are the treatment options for interstitial cystitis?

Treatment Options for Interstitial Cystitis

Treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) requires a stepwise approach starting with conservative measures and progressing to more invasive options only when initial treatments fail to provide adequate symptom control. 1

First-Line Treatments: Behavioral and Self-Care Practices

• Patient Education:

  • Educate patients about normal bladder function and the chronic nature of IC/BPS
  • Explain that multiple treatment trials may be necessary to achieve symptom control
  • Set realistic expectations about treatment outcomes 1

• Dietary Modifications:

  • Identify and eliminate trigger foods through an elimination diet
  • Common bladder irritants to avoid: coffee, alcohol, citrus products, spicy foods, artificial sweeteners 2
  • Modify fluid intake to optimize urine concentration and volume

• Stress Management:

  • Implement relaxation techniques, meditation, and imagery
  • Address psychological factors that may exacerbate symptoms 2

• Physical Techniques:

  • Apply heat or cold over the bladder/perineum for pain relief
  • Practice pelvic floor muscle relaxation
  • Implement bladder training with urge suppression 2

Second-Line Treatments: Oral Medications

If symptoms persist after 4-12 weeks of first-line treatments, add oral medications:

• Amitriptyline:

  • Start at low doses (10 mg) and titrate gradually to 75-100 mg if tolerated
  • Common side effects: sedation, drowsiness, dry mouth, constipation 1, 2

• Cimetidine:

  • Provides clinically significant improvement in pain and nocturia
  • Minimal adverse effects reported 1, 2

• Hydroxyzine:

  • Antihistamine that may help with allergic components
  • Evidence strength: Grade C 1

• Pentosan Polysulfate Sodium (PPS):

  • Only FDA-approved oral medication for IC/BPS
  • Evidence strength: Grade B
  • Monitor for potential vision changes (macular damage) 1, 3

Second-Line Treatments: Intravesical Therapies

Consider when oral medications provide inadequate relief:

• Dimethyl Sulfoxide (DMSO):

  • FDA-approved intravesical therapy
  • Administered via bladder instillation 1, 3

• Heparin:

  • Helps restore the glycosaminoglycan layer of the bladder
  • Often combined with lidocaine and sodium bicarbonate 1, 4

• Lidocaine:

  • Provides temporary pain relief
  • Often used in combination with other agents 1

Third-Line Treatment: Cystoscopy with Hydrodistention

• Serves diagnostic and therapeutic purposes
• Allows for identification of Hunner lesions
• Provides temporary symptom relief in some patients 1

Fourth-Line Treatments

• Hunner Lesion Treatment:

  • If Hunner lesions are present, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1

• Neurostimulation:

  • Consider for patients with inadequate symptom control from previous treatments
  • Trial should precede permanent implantation 1

• Botulinum Toxin A (100 U):

  • Appropriate as a fourth-line treatment
  • Patients must be willing to accept the possibility of intermittent self-catheterization
  • Not appropriate for patients who cannot tolerate catheterization 1

Fifth-Line Treatment

• Cyclosporine A:
  • Consider only if other treatments have failed
  • Higher risk of adverse effects
  • Requires careful monitoring 1

Treatment Evaluation and Monitoring

• Assess treatment efficacy every 4-12 weeks
• Use validated symptom scores to track progress
• Discontinue ineffective treatments 1, 2
• Adjust therapy based on symptom response and side effects
• Prepare patients for potential symptom exacerbations and remissions 2

Important Considerations

1. Pain Management:

   • Implement multimodal pain management approaches
   • Consider referral to pain specialists for intractable pain 1

2. Sexual Dysfunction:

   • Address sexual dysfunction as it significantly impacts quality of life
   • Pain during intercourse is common and requires specific management 1

3. Psychological Support:

   • Consider psychological support for depression and anxiety that commonly accompany IC/BPS 1

4. Treatment Success Rates:

   • Patient-reported outcomes suggest medical therapies are perceived as more effective than invasive procedures 5
   • Calcium glycerophosphate, phenazopyridine, and pentosan polysulfate sodium showed highest patient-perceived improvement 5

5. Complementary Approaches:

   • Consider nutraceuticals like L-arginine, bioflavinoids
   • Physical therapy for pelvic floor dysfunction
   • Acupuncture may provide additional relief 6

IC/BPS treatment requires patience and persistence, as no single treatment works for all patients. The stepwise approach allows for systematic trial of therapies while minimizing risks and invasiveness.