What are the diagnosis and management options for interstitial cystitis?

Diagnosis and Management of Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

Interstitial cystitis/bladder pain syndrome (IC/BPS) requires a clinical diagnosis based on symptoms present for at least six weeks with documented negative urine cultures, followed by a multimodal treatment approach that should begin with conservative therapies before progressing to more invasive options. 1

Diagnostic Approach

Clinical Diagnosis

• Symptoms must be present for at least 6 weeks with documented negative urine cultures 1
• Key symptoms to document:
  • Bladder/pelvic pain, pressure, or discomfort
  • Urinary frequency and urgency
  • Location, character, and severity of pain
  • Dyspareunia, dysuria, ejaculatory pain in men
  • Relationship of pain to menstruation in women

Essential Diagnostic Tests

• Urinalysis and urine culture to exclude infection 1
• Brief neurological exam to rule out occult neurological problems
• Evaluation for incomplete bladder emptying to rule out occult retention
• Hematuria workup in patients with unevaluated hematuria or tobacco exposure 1

Specialized Testing

• Cystoscopy is indicated when:

  • Hunner lesions are suspected (only consistent cystoscopic finding diagnostic for IC/BPS) 1
  • Hematuria is present
  • Symptoms are refractory to initial treatment
  • Note: Not recommended for routine diagnosis in all patients, especially younger patients 1

• Urodynamics are not recommended for routine diagnosis but may be useful for:

  • Suspicion of outlet obstruction
  • Possibility of poor detrusor contractility
  • Evaluating patients refractory to behavioral or medical therapies 1

Baseline Assessment

• Document baseline voiding symptoms using a one-day voiding log
• Assess pain using validated tools:
  • Genitourinary Pain Index (GUPI)
  • Interstitial Cystitis Symptom Index (ICSI)
  • Visual Analog Scale (VAS) 1

Management Approach

First-Line: Behavioral and Non-Pharmacologic Treatments

• Patient education about normal bladder function and IC/BPS 1
• Self-care practices:
  • Stress management techniques
  • Dietary modifications (identify and avoid trigger foods)
  • Bladder training and urge suppression techniques
  • Fluid management (modifying concentration/volume of urine)
  • Reduce caffeine intake 2
• Physical therapy for pelvic floor tenderness 2

Pharmacologic Treatments

• Amitriptyline (first-line pharmacologic agent):
  • Start at low doses (10mg) and titrate gradually to 75-100mg as tolerated
  • Has shown clinically significant improvement in IC/BPS symptoms, pain, and nocturia 2
• Pentosan polysulfate sodium (Elmiron):
  • FDA-approved medication for IC/BPS
  • 38% of patients had >50% improvement in bladder pain vs 18% with placebo
  • Monitor for potential maculopathy with long-term use 2
• Other oral medications:
  • Anticholinergics for overactive bladder symptoms
  • NSAIDs for pain relief
  • Cimetidine, hydroxyzine, and cyclosporine A may be considered 2, 3

Intravesical Therapies

• Dimethyl Sulfoxide (DMSO):
  • FDA-approved intravesical therapy
  • Administration: 50mL instilled directly into bladder, retained for 15 minutes
  • Repeat every two weeks until maximum symptomatic relief is obtained 4
  • Consider pre-treatment with oral analgesics or belladonna/opium suppositories to reduce bladder spasm 4
  • For patients with severe IC/BPS and very sensitive bladders, initial treatments may be done under anesthesia 4
• Other intravesical options:
  • Lidocaine, heparin, oxybutynin, and glycosaminoglycan substitution treatments 3

Procedures for Hunner Lesions

• Cystoscopy with fulguration of Hunner lesions 2
• Hydrodistention of the bladder 2

Treatment Monitoring and Adjustment

• Assess treatment efficacy every 4-12 weeks using validated symptom scores 2
• Discontinue ineffective treatments and adjust therapy based on symptom response and side effects 1
• Implement multimodal pain management approaches 1
• Consider referral to pain specialists for intractable pain
• Prioritize non-opioid alternatives, with judicious use of opioids only after informed shared decision-making 2

Important Considerations

• IC/BPS is a heterogeneous clinical syndrome requiring individualized treatment 1
• Except for patients with Hunner lesions, initial treatment should typically be nonsurgical 1
• Concurrent, multi-modal therapies may be offered for better symptom control 1
• Flank pain should always trigger evaluation of the upper urinary tract, as this is not typically part of classic IC/BPS presentation 2
• Regular follow-up is essential to monitor for complications and adjust treatment as needed 2

Treatment Algorithm

1. Begin with behavioral modifications and patient education
2. Add oral medications (starting with amitriptyline)
3. Consider intravesical therapies if oral medications are insufficient
4. For patients with Hunner lesions, proceed directly to cystoscopy with fulguration/hydrodistention
5. Adjust treatment based on symptom response, discontinuing ineffective treatments
6. Refer to specialists for multimodal pain management if pain persists despite treatment