What are the treatment options for inflammation and pain associated with interstitial cystitis?

Treatment Options for Inflammation and Pain in Interstitial Cystitis

A multimodal approach combining behavioral modifications, oral medications (such as amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate), and intravesical treatments (such as DMSO, heparin, or lidocaine) should be implemented for managing inflammation and pain in interstitial cystitis/bladder pain syndrome (IC/BPS), with treatment selection based on symptom severity and patient characteristics. 1

First-Line Treatment: Behavioral and Self-Care Approaches

• Self-care practices and behavioral modifications should be discussed with all patients as initial management strategies 1

• Specific behavioral modifications include:

  • Altering urine concentration through fluid management (either restriction or additional hydration) 1
  • Application of local heat or cold over the bladder or perineum to manage pain 1
  • Avoidance of known bladder irritants (coffee, citrus products, spicy foods) 1
  • Implementation of an elimination diet to identify personal trigger foods 1
  • Stress management techniques and coping strategies (meditation, imagery) 1
  • Pelvic floor muscle relaxation (avoid strengthening exercises) 1
  • Bladder training with urge suppression 1

• Over-the-counter products that may provide relief include:

  • Quercetin 1
  • Calcium glycerophosphates 1
  • Phenazopyridine (Pyridium) for urinary pain 1

Second-Line Treatment: Oral Medications

• Amitriptyline (Evidence Strength: Grade B)

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

• Cimetidine (Evidence Strength: Grade B)

  • Provides clinically significant improvement in IC/BPS symptoms, pain, and nocturia 1
  • Generally well-tolerated with minimal reported adverse events 1

• Hydroxyzine (Evidence Strength: Grade C)

  • May be particularly effective in patients with concurrent allergies 1
  • Common side effects include sedation and weakness 1

• Pentosan polysulfate (Evidence Strength: Grade B)

  • Only FDA-approved oral medication for IC/BPS 1, 2
  • Mechanism involves repair of damaged glycosaminoglycan (GAG) layer lining the urothelium 3
  • Important safety concern: Patients should be counseled about potential risk for macular damage and vision-related injuries 1
  • Typical dosage is 100 mg three times daily, taken with water at least 1 hour before or 2 hours after meals 2

Second-Line Treatment: Intravesical Therapies

• Dimethyl sulfoxide (DMSO)

  • Administered by instilling 50 mL directly into the bladder via catheter 4
  • Allow to remain for 15 minutes before expelling 4
  • Treatment typically repeated every two weeks until maximum symptomatic relief is obtained 4
  • Application of lidocaine jelly to the urethra prior to catheter insertion can reduce spasm 4

• Heparin

  • Intravesical administration can help repair the damaged GAG layer 1
  • Often combined with lidocaine and sodium bicarbonate for enhanced effect 5

• Lidocaine

  • Provides temporary relief of bladder pain 1
  • Often used in combination with other intravesical agents 5

Pain Management Considerations

• Multimodal pain management approaches should be initiated and maintained throughout treatment 1
• Non-opioid alternatives should be used preferentially due to the chronic nature of IC/BPS 1
• Pain management alone does not constitute sufficient treatment; underlying bladder symptoms must also be addressed 1
• For patients with intractable pain, referral to pain specialists may be necessary 1

Special Considerations for Hunner Lesions

• If Hunner's lesions are identified during cystoscopy, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1
• This approach is more targeted and may provide significant relief for this specific subtype of IC/BPS 1

Treatment Algorithm

1. Start with behavioral modifications and self-care practices for all patients
2. Add oral medications based on symptom profile:
   • For patients with sleep disturbances: Consider amitriptyline
   • For patients with allergic symptoms: Consider hydroxyzine
   • For patients with predominant bladder symptoms: Consider pentosan polysulfate
3. For inadequate response, add intravesical therapies (DMSO, heparin, lidocaine)
4. For patients with Hunner's lesions, proceed with lesion-specific treatments
5. Consider referral for specialized pain management if pain control remains inadequate

Common Pitfalls and Caveats

• Avoid strengthening exercises for pelvic floor muscles, as these may worsen symptoms in IC/BPS patients 1
• Pentosan polysulfate is a weak anticoagulant; caution is advised when used with other anticoagulants or before surgery 2
• Patients using pentosan polysulfate require regular ophthalmologic examinations due to risk of macular damage 1
• IC/BPS is a chronic condition with periods of flares and remissions; patients should be educated about the long-term nature of management 1
• Treatment efficacy for any individual is unpredictable; multiple therapeutic options may need to be tried before adequate symptom control is achieved 1