What are the treatment options for Interstitial Cystitis (IC), also known as Bladder Pain Syndrome (BPS)?

From the Guidelines

Interstitial cystitis (IC) treatment typically involves a multimodal approach, with the most recent and highest quality study 1 suggesting that patients should be made aware that IC/BPS is typically a chronic disorder requiring continual and dynamic management. The treatment approach should prioritize lifestyle modifications, such as avoiding trigger foods and beverages, stress management, and bladder training techniques.

• Key lifestyle modifications include:
  • Avoiding trigger foods and beverages (coffee, alcohol, spicy foods, citrus)
  • Stress management
  • Bladder training techniques
• Oral medications commonly prescribed include:
  • Amitriptyline (10-75 mg at bedtime)
  • Pentosan polysulfate sodium (Elmiron, 100 mg three times daily)
  • Hydroxyzine (25-75 mg daily)
  • Cimetidine (400 mg twice daily) For pain management, over-the-counter options like ibuprofen or prescription pain medications may be used.
• Other treatment options include:
  • Bladder instillations with medications like dimethyl sulfoxide (DMSO), heparin, or lidocaine
  • Physical therapy targeting pelvic floor dysfunction
  • Sacral neuromodulation, Botox injections into the bladder wall, or rarely, surgical interventions like cystoplasty for severe cases unresponsive to other treatments. As stated in the 2022 study 1, adequate symptom control is achievable but may require trials of multiple therapeutic options to identify the regimen that is effective for that patient. The goal of treatment is to reduce inflammation, decrease pain signals, and restore normal bladder function while improving quality of life, with ongoing management and combinations of these approaches often necessary to control symptoms 1.

From the FDA Drug Label

CLINICAL TRIALS ELMIRON® was evaluated in two clinical trials for the relief of pain in patients with chronic interstitial cystitis (IC). All patients met the NIH definition of IC based upon the results of cystoscopy, cytology, and biopsy. One blinded, randomized, placebo controlled study evaluated 151 patients (145 women, 5 men, 1 unknown) with a mean age of 44 years (range 18 to 81) Approximately equal numbers of patients received either placebo or ELMIRON® 100 mg three times a day for 3 months. Clinical improvement in bladder pain was based upon the patient's own assessment. In this study, 28/74 (38%) of patients who received ELMIRON® and 13/74 (18%) of patients who received placebo, showed greater than 50% improvement in bladder pain (p=0. 005).

The treatment options for Interstitial Cystitis (IC), also known as Bladder Pain Syndrome (BPS), include:

• Pentosan (PO): ELMIRON® 100 mg three times a day for 3 months, which showed greater than 50% improvement in bladder pain in 38% of patients compared to 18% of patients who received placebo 2.
• Other options: The label does not provide information on other treatment options.

From the Research

Treatment Options for Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)

• Multimodal medical regimens, including heparinoid therapy, oral medications to reverse neural upregulation, and control allergies, as well as intravesical therapeutic solutions combining pentosan polysulfate or heparin with lidocaine and sodium bicarbonate, have been shown to be effective in managing IC/BPS symptoms 3.
• Complementary and alternative therapies, such as dietary modification, nutraceuticals, bladder training, neuromodulation, stress reduction, and sex therapy, can be used in conjunction with traditional treatments to customize therapy for individual patients 4.
• Pharmacotherapy options, including oral medications like amitriptyline and pentosan polysulfate sodium, as well as intravesical treatments like dimethyl sulfoxide, botulinum toxin, and hyaluronic acid, are recommended by American and European Urological Association Guidelines 5.
• Other treatment modalities, such as immunomodulating drugs, stem cell therapy, nerve growth factor, and ASP6294, are being researched as potential novel treatments for IC/BPS 5.
• Intravesical therapies, including heparin, hyaluronic acid, chondroitin sulfate, pentosan polysulfate, dimethylsulfoxide, liposomes, and botulinum onabotulinumtoxinA (BoNT-A), are used to treat IC/BPS, with recent advances in liposomal-mediated BoNT-A and other newly developed intravesical therapies showing promise 6.

Pharmacologic Treatments

• Pentosan polysulfate, heparin, antihistamines, tricyclic antidepressants, intravesical dimethyl sulfoxide, and bacille Calmette-Guérin have been used to treat IC, although with limited success 7.
• Suplatast tosilate, resiniferatoxin, botulinum toxin, and gene therapy to modulate the pain response are being investigated as potentially effective new treatment modalities 7.

Multimodal Treatment Approaches

• Multimodal behavioral techniques, alongside oral or minimally invasive treatments, are recommended by American and European Urological Association Guidelines 5.
• Patient-tailored phenotype-directed multimodal therapy is considered the most promising treatment strategy for IC/BPS, with combined phenotypic categorization and specific biomarkers potentially leading to better treatment outcomes 5.