What are the treatment options for interstitial cystitis?

Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

A multimodal approach is strongly recommended for treating IC/BPS, including oral medications, intravesical therapies, and lifestyle modifications to manage symptoms and improve quality of life, with surgical interventions reserved only for patients who have failed all other treatment options. 1

Diagnostic Criteria

• Diagnosis requires:
  • 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 causing similar symptoms 1

Treatment Algorithm

First-Line Therapies

1. Lifestyle Modifications:

   • Dietary modifications: Elimination diet to identify trigger foods
   • Avoid common bladder irritants: Coffee, citrus products, spicy foods
   • Fluid management: Adjust concentration/volume of urine
   • Stress management techniques: Meditation, imagery, coping strategies
   • Physical techniques: Heat/cold application over bladder/perineum 1

2. Pelvic Floor Physical Therapy:

   • Recommended for patients with pelvic floor tenderness
   • Manual physical therapy techniques
   • Avoid strengthening already tight pelvic floor muscles
   • Should be performed by appropriately trained clinicians 1

Second-Line Therapies (Oral Medications)

1. Pentosan Polysulfate Sodium (PPS):

   • Only FDA-approved oral medication for IC/BPS
   • Dosage: 100 mg three times daily, taken 1 hour before or 2 hours after meals
   • Mechanism: Restores bladder surface glycosaminoglycan layer
   • Caution: Monitor for potential macular damage with long-term use
   • Common side effects: Hair loss, diarrhea, nausea, blood in stool 1, 2

2. Amitriptyline:

   • Start at 10 mg daily and titrate up to 75-100 mg if tolerated
   • Mechanism: Modulates pain perception and reduces bladder irritability
   • Common side effects: Sedation, dry mouth, constipation 1

3. Other Oral Options:

   • Hydroxyzine: Antihistamine that reduces mast cell degranulation
   • Cimetidine: May reduce mast cell activation in the bladder 1

Third-Line Therapies (Intravesical Treatments)

1. Dimethyl Sulfoxide (DMSO):

   • FDA-approved intravesical therapy for IC/BPS
   • Administration: 50 mL instilled directly into bladder via catheter, retained for 15 minutes
   • Treatment frequency: Every two weeks until maximum relief is obtained
   • Mechanism: Anti-inflammatory and analgesic properties
   • Side effects: Garlic-like taste/odor lasting up to 72 hours
   • Consider pre-treatment with oral analgesics or belladonna/opium suppositories to reduce bladder spasm 1, 3

2. Other Intravesical Options:

   • Heparin: Helps restore glycosaminoglycan layer
   • Lidocaine: Provides temporary pain relief
   • Often used in combination therapies 1

Fourth-Line Therapies

1. Cystoscopy with Hydrodistension:

   • Both diagnostic and therapeutic
   • For patients with Hunner lesions: Consider fulguration or resection 1, 4

2. Intradetrusor Botulinum Toxin A:

   • Recommended dose: 100 U
   • Consider when other treatments fail
   • Patients must accept possibility of intermittent self-catheterization
   • Mechanism: Reduces bladder contractility 1

3. Cyclosporine A:

   • Consider if other treatments have failed
   • Higher risk of adverse effects requiring careful monitoring 1

Fifth-Line Therapies (Surgical Interventions)

1. Major Surgery:
   • Diversion with or without cystectomy
   • Substitution cystoplasty
   • Reserved for patients who have failed ALL other treatment options
   • Requires extensive counseling and shared decision-making 1

Pain Management Considerations

• Implement multimodal pain management approaches
• Prioritize non-opioid alternatives
• Consider referral to pain specialists for intractable pain
• Judicious use of opioids only after informed shared decision-making 1

Follow-up and Monitoring

• Assess treatment efficacy every 4-12 weeks using validated symptom scores
• Discontinue ineffective treatments
• Adjust therapy based on symptom response and side effects
• Reconsider diagnosis if no improvement within a clinically meaningful timeframe 1

Important Cautions

• Patients taking pentosan polysulfate should inform their doctor before surgery
• Monitor for drug interactions, especially with anticoagulants like warfarin, heparin, high-dose aspirin, or NSAIDs 2
• For patients with severe IC with very sensitive bladders, consider initial DMSO treatments under anesthesia 3
• Recognize that no single treatment is effective for all IC patients; a stepwise approach trying different treatments alone or in combination is often necessary 4, 5