What are the treatment options for interstitial cystitis?

Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

A multimodal approach is recommended for treating interstitial cystitis/bladder pain syndrome (IC/BPS), including oral medications, intravesical therapies, and lifestyle modifications to manage symptoms and improve quality of life. 1

First-Line Treatments

First-line treatments should be implemented for all patients and include:

• Lifestyle modifications:
  • Dietary changes: Elimination diet to identify trigger foods and avoidance of common bladder irritants (coffee, citrus, spicy foods) 1
  • Fluid management: Altering concentration/volume of urine through appropriate hydration 1
  • Stress management techniques: Meditation, imagery, and other coping strategies 1
  • Physical techniques: Application of heat/cold over bladder/perineum, pelvic floor relaxation 1

Second-Line Treatments (Oral Medications)

• Pentosan Polysulfate Sodium (PPS): The only FDA-approved oral medication for IC/BPS 1, 2

  • Dosage: 100 mg three times daily, taken with water 1 hour before or 2 hours after meals 2
  • Mechanism: Restores the bladder surface glycosaminoglycan layer 1
  • Caution: Requires monitoring for potential macular damage with long-term use 1
  • Side effects: Hair loss, diarrhea, nausea, blood in stool, headache, rash 2

• Amitriptyline: Start at 10 mg daily and titrate up to 75-100 mg if tolerated 1

  • Side effects: Sedation, dry mouth, constipation
  • Mechanism: Modulates pain perception and reduces bladder irritability

• Hydroxyzine: Antihistamine that may help with allergic components of IC/BPS 1

  • Mechanism: Reduces mast cell degranulation

• Cimetidine: Provides improvement in pain and nocturia 1

  • Mechanism: May reduce mast cell activation in the bladder

Third-Line Treatments (Intravesical Therapies)

• Dimethyl Sulfoxide (DMSO): FDA-approved intravesical therapy 1, 3

  • Administration: 50 mL instilled directly into bladder via catheter, retained for 15 minutes 3
  • Frequency: Every two weeks until maximum relief is obtained 3
  • Side effects: Garlic-like taste and odor that may last up to 72 hours, potential discomfort during administration 3
  • Pre-treatment: Application of lidocaine jelly to urethra to avoid spasm; oral analgesics or belladonna/opium suppositories may reduce bladder spasm 3

• Heparin: Helps restore glycosaminoglycan layer, often combined with lidocaine and sodium bicarbonate 1

• Lidocaine: Provides temporary pain relief, often used in combination with other agents 1

Fourth-Line Treatments

• Cystoscopy with hydrodistension: Both diagnostic and therapeutic intervention 4

  • For patients with severe IC/BPS with very sensitive bladders, initial treatments may need to be done under anesthesia 3

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

• Pelvic floor physical therapy: Recommended for patients with pelvic floor tenderness 1

  • Includes manual physical therapy techniques and avoidance of strengthening tight pelvic floor muscles

Fifth-Line Treatments

• Intradetrusor botulinum toxin A: Consider when other treatments fail (100 U recommended) 1

  • Patients must accept the possibility of intermittent self-catheterization
  • Mechanism: Reduces bladder contractility and improves symptoms

• Cyclosporine A: Consider if other treatments have failed 1

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

Sixth-Line Treatments

• Surgical interventions: Reserved for patients who have failed all other treatment options 5, 1
  • Diversion with or without cystectomy
  • Substitution cystoplasty
  • Requires extensive counseling and shared decision-making

Pain Management

Pain management should be considered throughout the course of therapy with the goal of maximizing function and minimizing pain and side effects 5, 1:

• Prioritize non-opioid alternatives
• Judicious use of opioids only after informed shared decision-making
• Consider referral to pain specialists for intractable pain

Treatment Assessment and Follow-up

• Assess treatment efficacy every 4-12 weeks using validated symptom scores 1
• Ineffective treatments should be stopped 5
• Adjust therapy based on symptom response and side effects
• Diagnosis should be reconsidered if no improvement within a clinically meaningful timeframe 5

Common Pitfalls and Caveats

1. Misdiagnosis: Ensure proper diagnosis by confirming symptoms for at least 6 weeks with negative urine cultures 1

2. Medication interactions: DMSO may change the effectiveness of other medications; inform physician about all medications before DMSO instillation 3

3. Surgery timing: Patients undergoing surgery should discuss with their doctor when to discontinue PPS prior to surgery 2

4. Anticoagulant effects: PPS is a weak anticoagulant which may increase bleeding; use caution with other anticoagulants or before surgery 2

5. Patient expectations: Set realistic expectations - treatment aims to manage symptoms rather than provide a cure; multiple simultaneous treatments may be needed 5

6. Sexual dysfunction: Address sexual dysfunction as it significantly impacts quality of life 1