What are the treatment options for bladder pain syndrome?

Treatment Options for Bladder Pain Syndrome

Treatment for bladder pain syndrome (IC/BPS) should be individualized based on symptom severity and the presence of Hunner lesions, with most patients requiring a multimodal approach starting with conservative measures before progressing to more invasive options. 1

Diagnosis and Initial Assessment

• 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
• Cystoscopy should be performed in patients suspected of having Hunner lesions, as this finding significantly impacts treatment approach 1
• Baseline voiding symptoms and pain levels should be documented using validated tools such as the genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), or visual analog scale (VAS) to measure treatment effects 1

Treatment Categories

Behavioral/Non-Pharmacologic Treatments

• Patient education about normal bladder function, the chronic nature of IC/BPS, and the need for potentially multiple treatment trials is essential 1
• Self-care practices that may improve symptoms include:
  • Dietary modifications (avoiding bladder irritants such as acidic foods, spicy foods, and caffeine) 2
  • Altering urine concentration through fluid management 1
  • Application of local heat or cold over the bladder or perineum 1
  • Stress management techniques and relaxation strategies 1
  • Pelvic floor muscle relaxation and bladder training with urge suppression 1

Oral Medications

• Amitriptyline is recommended as one of the most effective oral medications for IC/BPS 1, 3
• Pentosan polysulfate sodium (Elmiron) has shown efficacy in clinical trials, with 38% of patients showing >50% improvement in bladder pain compared to 18% with placebo 4
• Other oral medication options include:
  • Cimetidine 1
  • Hydroxyzine 1
  • Cyclosporine A (for refractory cases, but requires careful monitoring due to significant adverse effects) 5

Intravesical Treatments

• Dimethyl sulfoxide (DMSO) instillation is FDA-approved for IC/BPS, administered as 50mL directly into the bladder for 15 minutes every two weeks until maximum symptomatic relief is obtained 6
• Other intravesical options include:
  • Heparin instillations 1
  • Lidocaine instillations 1, 5

Procedures

• For patients with Hunner lesions, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1
• Cystoscopy with hydrodistension may serve both diagnostic and therapeutic purposes 1
• Neuromodulation (sacral nerve stimulation) may be considered for patients who fail conservative treatments 1, 5
• Botulinum toxin A injections into the detrusor muscle can be considered for refractory cases 5

Major Surgery

• Surgical interventions such as urinary diversion with or without cystectomy should be reserved for patients with severe, unremitting symptoms that have failed all other treatment options 1, 5
• For patients with end-stage structurally small bladders, diversion may be indicated at any time the clinician and patient believe appropriate 1

Treatment Algorithm

1. First step: Begin with behavioral modifications and patient education 1
2. Second step: If symptoms persist, add oral medications (amitriptyline, pentosan polysulfate, cimetidine, or hydroxyzine) 1
3. Third step: Consider intravesical treatments (DMSO, heparin, or lidocaine) 1, 6
4. Fourth step: For patients with Hunner lesions, proceed directly to fulguration/triamcinolone injection 1
5. Fifth step: Consider neuromodulation or botulinum toxin A injections for refractory cases 1, 5
6. Sixth step: Major surgery (urinary diversion with or without cystectomy) for severe cases unresponsive to all other treatments 1

Important Considerations

• Pain management should be continually assessed and addressed throughout treatment using multimodal approaches 1
• Ineffective treatments should be discontinued after an appropriate trial period 1
• The 2022 AUA guideline emphasizes that IC/BPS is heterogeneous, and treatment should be tailored to specific patient characteristics rather than following a rigid tiered approach 1
• Patients should be informed that IC/BPS is typically a chronic condition requiring ongoing management with periods of symptom exacerbation and remission 1