What are the treatment options for bladder pain?

Treatment Options for Bladder Pain

Treatment for bladder pain should follow a stepwise approach starting with conservative behavioral therapies as first-line treatment, followed by oral medications, intravesical therapies, and surgical interventions only for refractory cases. 1

First-Line Treatments (For All Patients)

Behavioral Modifications

• Dietary changes:

  • Eliminate bladder irritants (coffee, citrus products, spicy foods)
  • Consider an elimination diet to identify personal trigger foods 2
  • Modify fluid intake to alter urine concentration/volume 1

• Physical techniques:

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

• Lifestyle adjustments:

  • Avoid tight-fitting clothing
  • Manage constipation
  • Modify exercise routines that worsen symptoms 1

• Stress management:

  • Meditation, imagery, and other coping strategies for flare-ups 2

Second-Line Treatments

Oral Medications

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

  • Mechanism: Modulates pain perception and reduces bladder irritability
  • Side effects: Sedation, dry mouth, constipation 1

• Cimetidine: Provides improvement in pain and nocturia

  • Mechanism: May reduce mast cell activation in bladder 2, 1

• Hydroxyzine: Helps with allergic components

  • Mechanism: Reduces mast cell degranulation 2, 1

• Pentosan Polysulfate Sodium (PPS): Only FDA-approved oral medication for IC/BPS

  • Mechanism: Restores bladder surface glycosaminoglycan layer
  • Requires monitoring for potential macular damage with long-term use
  • Clinical trials showed 38% of patients had >50% improvement in bladder pain compared to 18% with placebo 3

Intravesical Treatments

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

  • Administration: Bladder instillation every two weeks until maximum relief 2, 1

• Heparin: Helps restore glycosaminoglycan layer

  • Often combined with lidocaine and sodium bicarbonate 2, 1

• Lidocaine: Provides temporary pain relief

  • Mechanism: Blocks nerve conduction 2, 1

Third-Line Treatments

• Cystoscopy with hydrodistention: For diagnostic purposes and potential therapeutic benefit 2

• Fulguration of Hunner lesions: If identified during cystoscopy 2, 1

Fourth/Fifth-Line Treatments

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

  • Patients must accept possibility of intermittent self-catheterization
  • Mechanism: Reduces bladder contractility 1

• Cyclosporine A: Consider if other treatments have failed

  • Higher risk of adverse effects requiring careful monitoring
  • Shows significant effect on pain and frequency 1

Sixth-Line Treatments (End-Stage Options)

• Surgical interventions: Only after all other options exhausted
  • Diversion with or without cystectomy
  • Substitution cystoplasty 2
  • Note: For patients with end-stage structurally small bladders, diversion is indicated at any time clinician and patient believe appropriate 2

Pain Management Throughout Treatment

• Multimodal pain management approaches should be implemented throughout treatment course 2
• Consider referral to pain specialists for intractable pain
• Prioritize non-opioid alternatives with judicious use of opioids only after informed shared decision-making 1

Treatment Assessment and Follow-Up

• Assess treatment efficacy every 4-12 weeks using validated symptom scores
• Discontinue ineffective treatments
• Reconsider diagnosis if no improvement within clinically meaningful timeframe 2, 1

Important Caveats

1. The evidence supporting neuromodulation, cyclosporine A, and botulinum toxin for IC/BPS is limited by study quality, small sample sizes, and lack of durable follow-up 2

2. None of these advanced therapies have FDA approval for this indication and should be limited to practitioners with experience managing this syndrome 2

3. Cochrane review found very low-certainty evidence for most treatments, highlighting the need for larger, more focused trials 4

4. Pain management alone does not constitute sufficient treatment; addressing underlying bladder-related symptoms is essential 2