What are the treatment options for interstitial cystitis?

Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) should follow a multimodal approach, beginning with conservative therapies and progressing to more invasive options only when initial treatments fail to provide adequate symptom relief. 1

Diagnostic Criteria

Before initiating treatment, confirm the diagnosis of IC/BPS:

• Symptoms present for at least 6 weeks
• Documented negative urine cultures
• Bladder/pelvic pain, pressure, or discomfort
• Urinary frequency and urgency
• Exclusion of other conditions that could cause similar symptoms 1

Treatment Algorithm

First-Line: Behavioral/Non-Pharmacologic Therapies

1. Dietary modifications:

   • Elimination diet to identify trigger foods
   • Avoid common bladder irritants: coffee, citrus, spicy foods 2

2. Stress management techniques:

   • Meditation, imagery, coping strategies 2

3. Physical techniques:

   • Application of heat/cold over bladder/perineum
   • Pelvic floor muscle relaxation
   • Bladder training with urge suppression 2

4. Fluid management:

   • Adjust fluid intake to alter urine concentration/volume 2

Second-Line: Oral Medications

If behavioral therapies provide insufficient relief, add:

1. Amitriptyline:

   • Start at 10mg daily, titrate up to 75-100mg if tolerated
   • Mechanism: Modulates pain perception, reduces bladder irritability
   • Side effects: Sedation, dry mouth, constipation 2

2. Pentosan Polysulfate Sodium (PPS):

   • Only FDA-approved oral medication for IC/BPS
   • Dosage: 100mg three times daily, taken 1 hour before or 2 hours after meals
   • Mechanism: Restores bladder surface glycosaminoglycan layer
   • Warning: Requires monitoring for potential macular damage with long-term use 2, 3

3. Hydroxyzine:

   • Antihistamine that may help with allergic components
   • Mechanism: Reduces mast cell degranulation 2

4. Cimetidine:

   • May reduce mast cell activation in the bladder
   • Provides improvement in pain and nocturia 2

Third-Line: Intravesical Therapies

For patients with inadequate response to oral medications:

1. Dimethyl Sulfoxide (DMSO):

   • FDA-approved intravesical therapy
   • Administration: 50mL instilled into bladder for 15 minutes, expelled by spontaneous voiding
   • Frequency: Every two weeks until maximum relief is obtained
   • Side effects: Garlic-like taste/odor lasting up to 72 hours, potential bladder discomfort 2, 4

2. Heparin:

   • Often combined with lidocaine and sodium bicarbonate
   • Mechanism: Helps restore glycosaminoglycan layer 2

3. Lidocaine:

   • Provides temporary pain relief
   • Often used in combination with other agents 2

Fourth-Line: Advanced Treatment Options

For refractory cases:

1. Intradetrusor Botulinum Toxin A:

   • 100 units recommended
   • Patients must accept possibility of intermittent self-catheterization
   • Mechanism: Reduces bladder contractility 2

2. Cyclosporine A:

   • Higher risk of adverse effects requiring careful monitoring
   • Shows significant effect on pain and frequency 2, 5

3. Manual Physical Therapy:

   • For patients with pelvic floor tenderness
   • Should be performed by appropriately trained clinicians 2

Fifth-Line: Surgical Interventions

Reserved for patients who have failed all other treatment options:

1. Major surgery (e.g., cystectomy with urinary diversion)
   • Only after all other treatments have failed
   • Requires extensive counseling and shared decision-making 1

Special Considerations

Pain Management

• Implement multimodal pain management approaches
• Consider referral to pain specialists for intractable pain
• Prioritize non-opioid alternatives
• Use opioids judiciously only after informed shared decision-making 2

Hunner Lesions

• Patients with Hunner lesions may benefit from cystoscopy with fulguration or resection of lesions 1

Monitoring and Follow-up

• Assess treatment efficacy every 4-12 weeks
• Use validated symptom scores to track progress
• Discontinue ineffective treatments
• Adjust therapy based on symptom response and side effects 2

Medication Cautions

• PPS: Monitor for pigmented maculopathy with chronic use 5
• DMSO: May change effectiveness of other medications; inform physician of all current medications 4
• Amitriptyline: Monitor for sedation, anticholinergic effects
• Anticoagulants: PPS has weak anticoagulant properties; use caution with other anticoagulants 3

Treatment Efficacy

Patient-perceived outcomes suggest that medical therapy is generally superior to invasive therapy for IC/BPS. In one study, medications showing the highest percentage of patient improvement included calcium glycerophosphate, phenazopyridine, and pentosan polysulfate sodium 6.

Combined therapy approaches may offer additional benefits. For example, a randomized double-blind clinical trial showed that combining intravesical and oral PPS resulted in greater symptom improvement (46% reduction) compared to oral PPS alone (24% reduction) 7.

Remember that IC/BPS is a heterogeneous clinical syndrome requiring individualized treatment based on symptom presentation, comorbidities, and patient preferences.