What are the treatment options for interstitial cystitis?

Interstitial Cystitis/Bladder Pain Syndrome: Causes and Treatment

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by bladder/pelvic pain, pressure, or discomfort associated with urinary frequency and urgency for at least 6 weeks, in the absence of infection or other identifiable causes. 1

Causes and Pathophysiology

While the exact cause of IC/BPS remains unknown, it is defined as an unpleasant sensation perceived to be related to the urinary bladder, with symptoms lasting more than six weeks without evidence of infection or other identifiable causes. 1

Diagnosis

Diagnosis of IC/BPS requires:

• Symptoms present for at least 6 weeks
• Documented negative urine cultures
• Bladder/pelvic pain, pressure, or discomfort
• Urinary frequency and urgency
• Exclusion of other conditions with similar symptoms 1

Diagnostic Steps:

1. Rule out infection with urinalysis and urine culture
2. Consider cystoscopy if:
   • Hematuria is present
   • Hunner lesions are suspected
   • Symptoms are refractory to initial treatment 1

Caution: Flank pain in IC/BPS patients should always trigger evaluation of the upper urinary tract, as this is not typically part of classic IC/BPS presentation. 1

Treatment Approach

Treatment follows a stepwise, tiered approach starting with conservative therapies and progressing to more invasive options only when earlier treatments fail. 1

First-Line Treatments: Conservative Therapies

1. Patient Education:

   • Normal bladder function
   • Self-care practices
   • Stress management
   • Bladder training techniques 1

2. Dietary Modifications:

   • Identify and avoid trigger foods
   • Reduce caffeine intake to decrease voiding frequency 1

3. Fluid Management:

   • Modify concentration/volume of urine through appropriate fluid intake 1

4. Physical Therapy:

   • Manual physical therapy techniques for pelvic floor tenderness (Grade A evidence) 1

Second-Line Treatments: Oral Medications

1. Amitriptyline:

   • First-line pharmacologic agent
   • Starting dose: 10mg with gradual titration to 75-100mg as tolerated
   • Shows clinically significant improvement in IC/BPS symptoms, pain, and nocturia (Grade B evidence) 1

2. 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: Acts as a weak anticoagulant; should be used with caution in patients undergoing surgery or taking other anticoagulants 2

3. Other Oral Medications:

   • Anticholinergics for overactive bladder symptoms
   • NSAIDs for pain relief
   • Cimetidine, hydroxyzine, and cyclosporine A may be considered 1, 3

Third-Line Treatments: Intravesical Therapies

1. Dimethyl Sulfoxide (DMSO):

   • FDA-approved intravesical therapy
   • Administration: 50mL instilled directly into bladder via catheter, retained for 15 minutes
   • Treatment frequency: Every two weeks until maximum relief is obtained
   • Side effects: Garlic-like taste and odor lasting up to 72 hours 1, 4
   • Technique: Apply analgesic lubricant gel (e.g., lidocaine jelly) to urethra prior to catheter insertion to avoid spasm 4

2. Other Intravesical Options:

   • Heparin
   • Lidocaine
   • Oxybutynin 1, 3

Fourth-Line Treatments: Advanced Interventions

1. Cystoscopy with Hydrodistention:

   • Both diagnostic and therapeutic
   • Especially beneficial for patients with Hunner lesions 1, 3

2. Botulinum Toxin A (BTX-A) Injections into the bladder 1

3. Neuromodulation:

   • Sacral and pudendal neuromodulation 3

Last Resort Options:

1. Surgical Interventions:
   • Cystoscopy with fulguration/resection of Hunner's lesions
   • Diversion with or without cystectomy
   • Substitution cystoplasty 1

Monitoring and Follow-up

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

Treatment Considerations

1. Multimodal Approach: Combining pharmacologic agents with other therapies is likely most effective 1, 3

2. Medication Precautions:

   • Pentosan polysulfate: Monitor for bleeding risk, especially with concomitant anticoagulants 2
   • DMSO: May change effectiveness of other medications; patients should inform physician of all medications before instillation 4

3. Severe Cases:

   • For patients with very sensitive bladders, initial DMSO treatments may need to be done under anesthesia 4