What is the first line of treatment for a patient with interstitial cystitis and glomerulations?

First-Line Treatment for Interstitial Cystitis with Glomerulations

The first-line treatment for interstitial cystitis with glomerulations should be behavioral and self-care approaches, including dietary modifications, stress management, and pelvic floor relaxation techniques. 1

Initial Management Approach

• Behavioral modifications and self-care practices should be discussed with all patients as initial management strategies for interstitial cystitis/bladder pain syndrome (IC/BPS) 1
• Altering urine concentration through fluid management can help reduce symptoms by diluting irritants in the urine 1
• Application of local heat or cold over the bladder or perineum can provide symptomatic relief 1
• Avoidance of known bladder irritants (coffee, citrus products, spicy foods) should be recommended to all patients 1
• Implementation of an elimination diet can help identify personal trigger foods 1
• Stress management techniques such as meditation and imagery can help manage symptoms 1
• Pelvic floor muscle relaxation (not strengthening) exercises should be recommended 1
• Bladder training with urge suppression can help manage frequency symptoms 1

Second-Line Oral Medications

• Amitriptyline is recommended as a second-line treatment option at dosages of 10-100 mg per day, with evidence showing superiority to placebo for symptom improvement 1
• Pentosan polysulfate sodium (Elmiron) is the only FDA-approved oral medication for IC/BPS, typically dosed at 100 mg three times daily 1, 2
• Clinical trials showed that 38% of patients who received pentosan polysulfate showed greater than 50% improvement in bladder pain compared to 18% with placebo 2
• Patients should be informed about the risk of pigmented maculopathy with long-term pentosan polysulfate use, requiring regular ophthalmologic examinations 1, 3

Second-Line Intravesical Therapies

• Heparin administered intravesically can help repair the damaged glycosaminoglycan (GAG) layer of the bladder 1
• Lidocaine can provide temporary relief of bladder pain when administered intravesically 1
• Intravesical liposomes have shown efficacy similar to oral pentosan polysulfate in reducing urinary frequency, pain, and urgency 4

Special Considerations for Glomerulations

• Glomerulations (pinpoint petechial hemorrhages) may be detected on cystoscopy and can be consistent with IC/BPS but are not specific to this condition 5
• Glomerulations may also be present in asymptomatic patients undergoing cystoscopy for other conditions 5
• The presence of glomerulations should not significantly alter the treatment approach, as they are not pathognomonic for IC/BPS 6

Treatment Algorithm

1. Start with behavioral modifications and self-care approaches for all patients 1
2. If symptoms persist after 4-8 weeks, add oral medications:
   • Amitriptyline (starting at 10 mg and titrating up to 100 mg as tolerated) 1
   • Pentosan polysulfate sodium (100 mg three times daily) 2
3. For patients who fail to respond to oral medications, consider intravesical therapies 1
4. For patients with Hunner's lesions specifically, consider fulguration and/or injection of triamcinolone 1

Common Pitfalls and Caveats

• Avoid strengthening exercises for pelvic floor muscles, as these may worsen symptoms 1
• Pentosan polysulfate may take 3-6 months to show significant improvement in symptoms 2, 7
• 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 1
• Patients using pentosan polysulfate should be monitored for potential side effects including hair loss, diarrhea, nausea, blood in stool, headache, rash, and liver function abnormalities 2