How to relieve abdominal dull aching pain in cystitis not responding to silodosin (Rapaflo)/dutasteride (Avodart) (8/0.5) mg?

Management of Abdominal Dull Aching Pain in Cystitis Not Relieved by Silodosin/Dutasteride

For patients with cystitis-related abdominal dull aching pain not responding to silodosin/dutasteride, amitriptyline should be initiated at 10 mg daily and gradually titrated up to 75-100 mg as tolerated, as it has been shown to be superior to placebo for interstitial cystitis/bladder pain syndrome (IC/BPS) symptoms. 1

First-Line Approaches

• Implement self-care practices and behavioral modifications that can improve symptoms:

  • Modify fluid intake (either restriction or additional hydration) to alter urine concentration/volume 1
  • Identify and avoid bladder irritants through elimination diet 1
  • Apply heat or cold over the bladder or perineum to manage trigger points 1
  • Practice stress management techniques to manage stress-induced symptom exacerbations 1
  • Implement pelvic floor muscle relaxation and bladder training with urge suppression 1

• Consider over-the-counter products:

  • Nutraceuticals
  • Calcium glycerophosphates
  • Phenazopyridine 1

Second-Line Pharmacologic Treatments

• Oral medications:

  • Amitriptyline: Start at 10 mg and gradually titrate to 75-100 mg if tolerated (Grade B evidence) 1
  • Cimetidine: Has shown clinically significant improvement of IC/BPS symptoms, pain, and nocturia with minimal adverse events (Grade B evidence) 1
  • Hydroxyzine: Particularly effective in patients with systemic allergies (Grade C evidence) 1
  • Pentosan polysulfate (PPS): FDA-approved for IC/BPS but has mixed efficacy results and requires counseling about potential risk for macular damage (Grade B evidence) 1

• Intravesical therapies (administered directly into the bladder):

  • DMSO (dimethyl sulfoxide)
  • Heparin
  • Lidocaine 1

Advanced Treatment Options for Refractory Pain

• Consider switching alpha-blockers:

  • While silodosin has shown efficacy in some BPS/IC patients 2, lack of response suggests trying alternative agents
  • Consider alternative alpha-blockers if appropriate for concurrent BPH symptoms

• Physical therapy approaches:

  • Manual physical therapy techniques targeting pelvic floor dysfunction 1
  • Trigger point therapy for areas of hypersensitivity 1

• For refractory cases:

  • Cystoscopy with hydrodistension for both diagnosis and treatment 1
  • If Hunner's lesions are identified during cystoscopy, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1
  • Consider glycosaminoglycan (GAG) replacement therapy with chondroitin sulfate, hyaluronic acid, or combination products 3

Important Considerations and Pitfalls

• Silodosin/dutasteride combination is primarily indicated for benign prostatic hyperplasia (BPH) rather than cystitis or IC/BPS 4
• Avoid long-term antibiotic administration unless there is confirmed infection, as this has not shown efficacy in IC/BPS and may lead to antibiotic resistance 1
• Do not treat asymptomatic bacteriuria except in specific circumstances (pregnancy, prior to urologic procedures) 5
• Pain management should be considered throughout the course of therapy with the goal of maximizing function and minimizing pain and side effects 1
• Opioids should be used judiciously and only after non-opioid alternatives have been tried, due to the global opioid crisis 1
• Recognize that IC/BPS is often comorbid with other conditions such as allergies, endometriosis, fibromyalgia, and irritable bowel syndrome, which may require separate management 6

Treatment Algorithm

1. Start with behavioral modifications and self-care practices
2. If inadequate relief, initiate amitriptyline at 10 mg daily and gradually increase
3. Consider adding cimetidine or hydroxyzine if amitriptyline alone is insufficient
4. For persistent symptoms, consider intravesical therapies
5. For refractory cases, consider cystoscopy with hydrodistension and evaluation for Hunner's lesions
6. Reserve neurostimulation, cyclosporine A, and botulinum toxin for cases that fail all other treatments 1