What is the best treatment approach for a 46-year-old female patient with a history of interstitial cystitis (IC) presenting with symptoms of frequency, urgency, and bladder pain, who recently underwent cystoscopy with hydrodistention showing no glomerulation?

Treatment Approach for Interstitial Cystitis in a 46-Year-Old Female with Negative Cystoscopy

A multimodal approach combining amitriptyline as first-line pharmacologic therapy with behavioral modifications is the most effective treatment for this patient with interstitial cystitis/bladder pain syndrome (IC/BPS) who has no Hunner lesions on cystoscopy. 1

Diagnosis Confirmation

The patient's presentation aligns with IC/BPS diagnostic criteria:

• Symptoms present for at least 6 weeks
• Bladder/pelvic pain, especially when bladder is full
• Urinary frequency and urgency
• Negative cystoscopy findings (no glomerulation)

The absence of Hunner lesions on cystoscopy is significant as it guides treatment approach. According to the 2022 AUA guidelines, patients without Hunner lesions should typically receive nonsurgical treatment initially 2.

First-Line Treatment Recommendations

Behavioral/Non-Pharmacologic Therapies

• Stress management practices to improve coping techniques 1
• Bladder training and urge suppression techniques 1
• Dietary modifications to identify and avoid trigger foods 1
  • Reduce caffeine intake to decrease voiding frequency
  • Fluid management to modify concentration/volume of urine
• Physical therapy with manual techniques for pelvic floor tenderness (Grade A evidence) 1

Pharmacologic First-Line Therapy

• Amitriptyline (first-line pharmacologic agent) 1
  • Start at low dose (10mg)
  • Titrate gradually to 75-100mg as tolerated
  • Common side effects: sedation, drowsiness, nausea
  • Has shown clinically significant improvement in IC/BPS symptoms, pain, and nocturia

Second-Line Treatment Options

If inadequate response to first-line therapy after 4-12 weeks:

Oral Medications

• Pentosan polysulfate sodium (Elmiron) - FDA-approved for IC/BPS 3

  • Dosage: 100 mg three times daily, taken 1 hour before or 2 hours after meals
  • Clinical trials show 38% of patients had >50% improvement in bladder pain vs 18% with placebo 1
  • Monitor for potential side effects including hair loss, diarrhea, and rare maculopathy with long-term use
  • Takes 3-6 months for full effect

• Anticholinergics for overactive bladder symptoms 1

  • Options: darifenacin, fesoterodine, solifenacin, tolterodine, or trospium
  • Particularly helpful for bladder spasms

• Other options to consider:

  • NSAIDs for pain relief
  • Cimetidine
  • Hydroxyzine
  • Cyclosporine A (for refractory cases)

Intravesical Therapies

If oral therapies fail after adequate trial:

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

  • Administered via bladder instillation
  • Treatment frequency: every two weeks until maximum relief

• Other intravesical options:

  • Heparin
  • Lidocaine
  • Combination therapies

Treatment Monitoring and Adjustment

• Assess treatment efficacy every 4-12 weeks using validated symptom scores 1
• Discontinue ineffective treatments and adjust therapy based on symptom response
• Consider regular upper tract imaging (ultrasound) to monitor for complications
• Follow-up within 1-2 weeks to assess symptom resolution

Important Considerations

• The 2022 AUA Guideline emphasizes that IC/BPS is heterogeneous and treatment should be individualized 2
• Concurrent, multi-modal therapies are often more effective than single-modality approaches 1
• Cystoscopy with hydrodistention (which the patient already underwent) is primarily diagnostic rather than therapeutic in the absence of Hunner lesions
• If symptoms persist despite treatment, consider:
  • Urine culture to rule out infection
  • Repeat cystoscopy to evaluate for other pathology
  • Referral to pain specialists for intractable pain

Treatment Algorithm

1. Start with behavioral modifications and amitriptyline
2. If inadequate response after 4-12 weeks, add pentosan polysulfate sodium
3. Consider anticholinergics if bladder spasms/overactive bladder symptoms predominate
4. For persistent symptoms, consider intravesical therapies
5. Reserve more invasive procedures for refractory cases

This approach aligns with the most recent guidelines that prioritize non-surgical interventions for IC/BPS patients without Hunner lesions 2, 1.