What are the treatment options for interstitial cystitis?

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

Treatment of interstitial cystitis requires a multimodal approach combining behavioral modifications, oral medications, and intravesical treatments, with selection based on symptom severity and patient characteristics. 1

First-Line Treatments: Behavioral and Self-Care Approaches

• Self-care practices and behavioral modifications should be discussed with all patients as initial management strategies 2, 1
• Altering urine concentration through fluid management helps manage symptoms in IC/BPS patients 2, 1
• Avoidance of known bladder irritants (coffee, citrus products, spicy foods) can reduce symptoms 1
• Implementation of an elimination diet helps identify personal trigger foods 2, 1
• Application of local heat or cold over the bladder or perineum can help manage pain 1
• Stress management techniques (meditation, imagery) help manage symptom flares 2, 1
• Pelvic floor muscle relaxation techniques can improve symptoms 2, 1
• Bladder training with urge suppression helps manage frequency symptoms 2, 1
• Over-the-counter products such as quercetin and calcium glycerophosphates may provide relief 1

Second-Line Treatments: Oral Medications

• Amitriptyline (10-100 mg daily) is recommended as a treatment option with superior efficacy to placebo 1
• Pentosan polysulfate (100 mg three times daily) is the only FDA-approved oral medication for IC/BPS 1, 3
• Patients using pentosan polysulfate require regular ophthalmologic examinations due to risk of macular damage 1, 3
• Hydroxyzine and cyclobenzaprine are additional oral options for symptom management 4

Second-Line Treatments: Intravesical Therapies

• Dimethyl sulfoxide (DMSO, RIMSO-50®) is FDA-approved for intravesical use in IC/BPS 5

  • 50 mL is instilled directly into the bladder via catheter and retained for 15 minutes 5
  • Treatment is typically repeated every two weeks until maximum symptomatic relief is obtained 5
  • Side effects include garlic-like taste and odor on breath and skin for up to 72 hours 5
  • Pre-treatment with oral analgesics or belladonna and opium suppositories can reduce bladder spasm 5

• Heparin intravesical therapy helps repair the damaged glycosaminoglycan (GAG) layer 1, 6

• Lidocaine intravesical administration provides rapid temporary relief of bladder pain 1, 6

Special Considerations for Hunner Lesions

• Fulguration and/or injection of triamcinolone can provide significant relief for patients with Hunner's lesions 1
• Cystoscopy with hydrodistention serves both diagnostic and therapeutic purposes for IC/BPS 4, 7

Pain Management Considerations

• Multimodal pain management approaches should be initiated and maintained throughout treatment 2, 1
• Non-opioid alternatives are preferred due to the chronic nature of the condition 1
• Pain management alone does not constitute sufficient treatment; underlying bladder symptoms must also be addressed 1

Advanced Therapies for Refractory Cases

• Neuromodulation options include sacral and pudendal neuromodulation for patients who fail conservative treatments 4
• Cyclosporine and tacrolimus may be considered as immunotherapy options for refractory cases 4
• Surgical interventions such as diversion with or without cystectomy are reserved for end-stage disease 2

Important Clinical Considerations

• IC/BPS is a chronic condition with periods of flares and remissions; patients should be educated about the long-term nature of management 2, 1
• Treatment efficacy for any individual is unpredictable; multiple therapeutic options may need to be tried before adequate symptom control is achieved 2, 1
• Avoid strengthening exercises for pelvic floor muscles, as these may worsen symptoms 1
• Patients undergoing surgery should discuss with their doctor when to discontinue medications like pentosan polysulfate prior to surgery 3
• Regular reassessment of treatment efficacy is essential, and ineffective treatments should be discontinued 2