Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)
The most effective approach for treating interstitial cystitis is a multimodal treatment strategy that combines pharmacologic agents with non-pharmacologic therapies, tailored to the specific symptoms and presence or absence of Hunner lesions. 1
Diagnostic Confirmation
- Diagnosis requires:
- Symptoms present for at least 6 weeks
- Negative urine cultures
- Bladder/pelvic pain, pressure, or discomfort
- Urinary frequency and urgency
- Exclusion of other conditions with similar symptoms 1
First-Line Treatments
Non-Pharmacologic Therapies
- Stress management practices and bladder training to improve coping techniques 1
- Dietary modifications to identify and avoid trigger foods 1
- Physical therapy with manual techniques for pelvic floor tenderness (Grade A evidence) 1
- Fluid management to modify concentration/volume of urine through appropriate hydration 1
- Reduction of caffeine intake to decrease voiding frequency 1
Pharmacologic Therapies
Amitriptyline (first-line oral agent):
- Starting dose of 10mg with gradual titration to 75-100mg as tolerated
- Shows clinically significant improvement in IC/BPS symptoms, pain, and nocturia
- Superior to placebo for symptom improvement (Grade B evidence) 1
Pentosan polysulfate sodium (Elmiron):
- FDA-approved medication for IC/BPS
- Dosage: 100mg three times daily, taken with water at least 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, 2
- Important safety concern: Risk of pigmented maculopathy with long-term use, related to cumulative exposure 1, 3
Other oral medications:
- Anticholinergics for overactive bladder symptoms
- Non-steroidal anti-inflammatory drugs for pain relief
- Cimetidine, hydroxyzine, and cyclosporine A may be considered 1
Second-Line Treatments
Intravesical Therapies
Dimethyl Sulfoxide (DMSO):
Other intravesical options:
Surgical Interventions (for specific cases)
- Cystoscopy with fulguration of Hunner lesions when present 1
- Hydrodistention of the bladder for patients with Hunner lesions 1
Treatment Algorithm
Initial approach: Begin with non-pharmacologic therapies and first-line oral medications
- For patients without Hunner lesions: Start with conservative treatments
- For patients with Hunner lesions: Consider early cystoscopy with fulguration or hydrodistention
If initial treatment inadequate after 4-12 weeks:
- Adjust therapy based on symptom response
- Consider adding intravesical therapies
- Discontinue ineffective treatments 1
For refractory cases:
- Consider multimodal pain management approaches
- Possible referral to pain specialists for intractable pain
- Prioritize non-opioid alternatives 1
Important Considerations and Cautions
Medication interactions: Pentosan polysulfate sodium has anticoagulant properties that may increase bleeding risk. Use caution with:
- Warfarin sodium
- Heparin
- High doses of aspirin
- Anti-inflammatory drugs 2
Monitoring requirements:
- Regular assessment of treatment efficacy every 4-12 weeks using validated symptom scores 1
- Regular upper tract imaging (e.g., ultrasound) to monitor for complications 1
- For patients on pentosan polysulfate sodium: Consider ophthalmologic monitoring due to risk of maculopathy 3
- For patients on DMSO: Eye evaluations including slit lamp examinations prior to and during treatment 4
Common pitfalls:
- Mistaking IC/BPS for urinary tract infection and inappropriately using antibiotics 6
- Failing to recognize flank pain as a sign requiring thorough evaluation of the upper urinary tract 1
- Continuing ineffective treatments beyond 4-12 weeks 1
- Not discussing the risk of maculopathy with patients considering pentosan polysulfate sodium 3
Long-term studies show that some patients maintain positive responses to treatment over extended periods, though symptom improvement may take 1-2 years to fully manifest 7.