Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome
Treatment for interstitial cystitis (IC/BPS) should follow a stepwise, tiered approach 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 patients with Hunner's lesions. 1
First-Line Treatments
Conservative Therapies
- Patient education about normal bladder function and self-care practices 1
- Stress management and relaxation techniques 1
- Dietary modifications to identify and avoid trigger foods 1
- Reduce caffeine intake to decrease voiding frequency 1
- Bladder training techniques 1
- Fluid management to modify concentration/volume of urine 1
- Pelvic floor physical therapy for patients with pelvic floor tenderness (Grade A evidence) 1
Second-Line Treatments
Oral Medications
- Amitriptyline: Start at 10mg and gradually titrate to 75-100mg as tolerated (Grade B evidence) 1
- Shows clinically significant improvement in IC/BPS symptoms, pain, and nocturia 1
- Pentosan polysulfate sodium (Elmiron): FDA-approved medication for IC/BPS 1
- Clinical trials show 38% of patients had >50% improvement in bladder pain vs 18% with placebo 1
- Anticholinergics (darifenacin, fesoterodine, solifenacin, tolterodine, trospium) for overactive bladder symptoms 1
- Non-steroidal anti-inflammatory drugs for pain relief 1
- Cimetidine and hydroxyzine may be considered 1
Intravesical Therapies
- Dimethyl Sulfoxide (DMSO): FDA-approved intravesical therapy 1, 2
- Heparin and lidocaine intravesical instillations 1
Third-Line Treatments
Fourth-Line Treatments
- Hunner's lesion treatment: If present, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed (Grade C evidence) 3
- Neurostimulation trial: If successful, permanent neurostimulation devices may be implanted (Grade C evidence) 3
- Options include sacral and pudendal neuromodulation 4
Fifth-Line Treatments
- Cyclosporine A: May be administered if other treatments have failed (Grade C evidence) 3, 1
- Botulinum toxin A (BTX-A) injections into the bladder (Grade C evidence) 3, 1
- Patients must accept the possibility of needing intermittent self-catheterization after treatment 3
Sixth-Line Treatments
- Major surgery: For carefully selected patients when all other therapies have failed (Grade C evidence) 3
- Options include substitution cystoplasty, urinary diversion with or without cystectomy 3
Treatments That Should NOT Be Offered
- Long-term oral antibiotics (Grade B evidence) 3
- Intravesical bacillus Calmette-Guérin outside of investigational settings (Grade B evidence) 3
- Intravesical resiniferatoxin (Grade A evidence) 3
Treatment Monitoring
- Assess treatment efficacy every 4-12 weeks using validated symptom scores 1
- Discontinue ineffective treatments and adjust therapy based on symptom response 1
- Consider regular upper tract imaging to monitor for complications 1
Important Considerations
- For patients with severe IC with very sensitive bladders, initial treatments may need to be done under anesthesia 2
- DMSO may change the effectiveness of other medications, so inform your physician about all current medications 2
- Eye evaluations may be recommended prior to and during DMSO treatment due to potential eye changes observed in animal studies 2
- Flank pain should trigger thorough evaluation of the upper urinary tract as this is not typically part of IC/BPS 1
The most recent guidelines emphasize the importance of a systematic approach to treatment, starting with conservative options and progressing to more invasive therapies only when necessary. This approach maximizes symptom control while minimizing potential treatment complications.