What is the treatment for painful bladder syndrome (interstitial cystitis)?

Painful Bladder Syndrome: Diagnosis and Treatment

Painful bladder syndrome/interstitial cystitis (PBS/IC) should be treated using 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 Hunner's lesions. 1

What is Painful Bladder Syndrome?

Painful bladder syndrome, also known as interstitial cystitis/bladder pain syndrome (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 lasting more than six weeks
• Occurs in the absence of infection or other identifiable causes 1

The hallmark symptoms include:

• Bladder/pelvic pain that worsens with bladder filling and improves with urination
• Urinary frequency and urgency
• Pain that may worsen with certain foods or drinks
• Pain that may be felt throughout the pelvis, lower abdomen, and back 1

Diagnosis

Diagnosis requires:

• Symptoms present for at least 6 weeks
• Documented negative urine cultures
• Bladder/pelvic pain, pressure, or discomfort
• Exclusion of other conditions that could cause similar symptoms 1

Important diagnostic considerations:

• Rule out infection with urinalysis and urine culture
• Consider cystoscopy if hematuria is present, Hunner lesions are suspected, or symptoms are refractory to initial treatment
• Thoroughly evaluate flank pain, as this is not typically part of IC/BPS 1

Treatment Approach

First-Line Therapies (Conservative Management)

1. Patient Education and Self-Care

   • Education about normal bladder function
   • Stress management techniques
   • Dietary modifications to identify and avoid trigger foods
   • Bladder training techniques
   • Fluid management (modifying concentration/volume of urine)
   • Pelvic floor relaxation 1

2. Physical Therapy

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

Second-Line Therapies (Oral Medications)

1. Amitriptyline (Grade B evidence)

   • Begin at low doses (10 mg) and titrate gradually to 75-100 mg if tolerated
   • Superior to placebo for symptom improvement
   • Common side effects include sedation, drowsiness, and nausea 2, 1

2. Pentosan Polysulfate Sodium (Elmiron) (Grade B evidence)

   • FDA-approved oral agent for IC/BPS
   • Dosage: 100 mg three times daily, taken with water at least 1 hour before or 2 hours after meals 3
   • Important safety warning: Patients should be counseled on potential risk for macular damage and vision-related injuries
   • Ophthalmologic examination recommended before starting therapy and periodically during treatment 2, 3

3. Cimetidine (Grade B evidence)

   • Has shown clinically significant improvement of IC/BPS symptoms, pain, and nocturia 2

4. Hydroxyzine (Grade C evidence)

   • May be more effective in patients with systemic allergies
   • Common side effects include sedation and weakness 2

Third-Line Therapies (Intravesical Treatments)

1. Dimethyl Sulfoxide (DMSO)

   • FDA-approved intravesical therapy
   • Administration: 50 mL instilled directly into the bladder via catheter, retained for 15 minutes
   • Treatment repeated every two weeks until maximum symptomatic relief is obtained 4
   • Consider pre-treatment with oral analgesics or belladonna and opium suppositories to reduce bladder spasm 4

2. Other Intravesical Options

   • Heparin and lidocaine instillations 1, 5

Fourth-Line Therapies (Procedures)

1. Cystoscopy with Hydrodistension

   • Both diagnostic and therapeutic intervention 5
   • Benefits must be balanced against possibility of temporary symptom flare after distention 2

2. Treatment of Hunner Lesions (if present)

   • Fulguration with electrocautery and/or injection of triamcinolone (Grade C evidence) 2

Fifth-Line Therapies (Advanced Interventions)

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

2. Neuromodulation

   • Sacral or pudendal neuromodulation 5

3. Surgical Options (last resort)

   • Diversion with or without cystectomy
   • Substitution cystoplasty 1

Treatment Monitoring

• Assess treatment efficacy every 4-12 weeks using validated symptom scores
• Discontinue ineffective treatments and adjust therapy based on symptom response and side effects
• Regular upper tract imaging (periodic ultrasound) to monitor for complications 1

Important Considerations and Caveats

• Due to the global opioid crisis, judicious use of chronic opioids is advised and only after informed shared decision-making with patients
• Non-opioid alternatives should be used preferentially 2
• Patients with severe IC/BPS with very sensitive bladders may benefit from initial treatments under anesthesia 4
• The evidence base for treating PBS/IC is limited, with many studies having small sample sizes and short follow-up periods 6
• Pentosan polysulfate is the only FDA-approved oral therapy and DMSO is the only FDA-approved intravesical therapy for IC/BPS 6