What are the American Urological Association (AUA) treatment recommendations for interstitial cystitis?

AUA Treatment Guidelines for Interstitial Cystitis/Bladder Pain Syndrome

The American Urological Association (AUA) recommends a stepwise, tiered approach to treating interstitial cystitis/bladder pain syndrome (IC/BPS), starting with conservative therapies and progressing to more invasive options only when earlier treatments fail, with surgical interventions reserved as a last resort except for Hunner's lesions. 1

Definition and Diagnosis

IC/BPS is defined as:

• An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder
• Associated with lower urinary tract symptoms of more than six weeks duration
• In the absence of infection or other identifiable causes 1

Treatment Principles

1. Treatments are ordered from most to least conservative
2. Multiple simultaneous treatments may be considered if in the patient's best interest
3. Ineffective treatments should be discontinued
4. Pain management should be considered throughout treatment
5. Diagnosis should be reconsidered if no improvement occurs within a clinically meaningful timeframe 1

Treatment Algorithm

First-Line Treatments

• Patient education about normal bladder function
• Self-care practices:
  • Stress management
  • Dietary modifications to avoid trigger foods
  • Bladder training techniques
  • Fluid management (restriction or hydration)
  • Pelvic floor relaxation 1, 2

Second-Line Treatments

• Oral medications:
  • Amitriptyline (start at 10mg, titrate to 75-100mg as tolerated) 2
  • Pentosan polysulfate sodium (Elmiron) - FDA-approved for IC/BPS 2
  • Antihistamines (hydroxyzine, cimetidine)
  • Anticholinergics for overactive bladder symptoms
  • NSAIDs for pain relief 2
• Manual physical therapy for pelvic floor tenderness 2

Third-Line Treatments

• Cystoscopy with hydrodistention 1, 2
• Intravesical treatments:
  • Dimethyl sulfoxide (DMSO) - FDA-approved 2, 3
  • Heparin
  • Lidocaine 2, 3

Fourth-Line Treatments

• Botulinum toxin A (BTX-A) injections into the bladder 1
• Neuromodulation:
  • Sacral neuromodulation
  • Pudendal nerve stimulation 4

Fifth-Line Treatments

• Cyclosporine A (immunosuppressant) 1, 2

Sixth-Line Treatments

• Diversion with or without cystectomy
• Substitution cystoplasty
• Pain management referral 1

Special Considerations

Hunner's Lesions

• If Hunner's lesions are detected, they should be treated at any point in the algorithm with:
  • Cystoscopy with fulguration/resection of lesions 1, 2

Advanced Therapies

The AUA guidelines specifically note that neuromodulation, cyclosporine A, and botulinum toxin treatments have limited supporting evidence due to:

• Small sample sizes
• Study quality issues
• Lack of durable follow-up
• None are FDA-approved for IC/BPS
• Should be limited to practitioners experienced with IC/BPS management 1

Monitoring and Follow-up

• Assess treatment efficacy every 4-12 weeks using validated symptom scores
• Discontinue ineffective treatments
• Regular upper tract imaging to monitor for complications
• Evaluate flank pain thoroughly as it's not typically part of IC/BPS 2

Pharmacotherapy Evidence

• Pentosan polysulfate sodium: 38% of patients had >50% improvement in bladder pain vs 18% with placebo 2
• Amitriptyline: Clinically significant improvement in IC/BPS symptoms, pain, and nocturia with minimal adverse effects 2, 5
• Oral medications generally show modest benefit and should be considered as part of a multimodal approach 6

The AUA guidelines emphasize that IC/BPS treatment requires a stepwise approach, with surgical options reserved for patients who have failed all other treatment modalities, except in cases of Hunner's lesions where surgical intervention may be appropriate earlier in treatment 1.