What are the next steps in managing interstitial cystitis (IC) and painful bladder syndrome in women who have not responded to dietary changes and oral medications?

Treatment of Bladder Lesions in Women with IC and Painful Bladder Syndrome After Failure of Diet and Oral Medications

For women with interstitial cystitis (IC) and painful bladder syndrome who have failed dietary modifications and oral medications, cystoscopy with hydrodistension should be performed to identify Hunner lesions, which if present, should be treated with fulguration and/or triamcinolone injection as the next step in management. 1, 2

Diagnostic Assessment Before Treatment Escalation

• Cystoscopy with hydrodistension serves multiple purposes: identifying Hunner lesions, assessing bladder capacity, and potentially providing therapeutic benefit 1
• Document baseline symptoms using validated tools such as the genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), or visual analog scale (VAS) to measure treatment effects 1
• Assess the impact on quality of life, as IC/BPS causes significant psychological distress, sexual dysfunction, and reduced quality of life compared to other urological conditions 1

Treatment Algorithm Based on Cystoscopic Findings

If Hunner Lesions Are Present:

• Fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed as the primary treatment 1, 3
• This approach is considered a third-line treatment in the AUA guidelines but is the most effective intervention for this specific subtype of IC/BPS 1, 2
• Hunner lesions can be easier to identify after distention when cracking and mucosal bleeding become evident 1

If No Hunner Lesions Are Present:

1. Intravesical Treatments (Second-Line):

   • Dimethyl sulfoxide (DMSO) instillation - 50 mL directly into the bladder for 15 minutes, repeated every two weeks until maximum relief is obtained 4, 5
   • Heparin instillations may provide relief by helping repair the damaged glycosaminoglycan (GAG) layer 2, 3
   • Lidocaine instillations can provide temporary relief of bladder pain 2, 5

2. Advanced Intravesical Options:

   • Continuous lidocaine-releasing intravesical system (LiRIS) has shown promise in clinical trials for sustained relief 6
   • Combination instillations (e.g., "cocktails" containing multiple agents) may be more effective than single agents 5

3. Neuromodulation (Fourth-Line):

   • Consider sacral neuromodulation if intravesical treatments fail 1, 7
   • This approach requires a trial period before permanent implantation 1

4. Immunomodulatory Therapy (Fifth-Line):

   • Cyclosporine A may be considered if other treatments have failed 1
   • This therapy requires careful monitoring due to potential side effects 1

5. Botulinum Toxin (Fifth-Line):

   • Intradetrusor botulinum toxin A injections may be beneficial 1
   • Patients must be willing to accept the possibility of needing intermittent self-catheterization after treatment 1

Multimodal Pain Management Throughout Treatment

• Implement multimodal pain management approaches including pharmacological options, stress management, and manual therapy 1, 3
• Pain management should be continually assessed for effectiveness due to its importance to quality of life 1
• Consider referral to pain specialists if pain control is inadequate with standard approaches 1

Major Surgery (Sixth-Line)

• For patients with severe, unremitting symptoms that have failed all other treatment options, consider substitution cystoplasty or urinary diversion with or without cystectomy 1, 2
• This option should be reserved for carefully selected patients with end-stage, small, fibrotic bladders where quality of life suggests a positive risk-benefit ratio 1

Important Considerations and Pitfalls

• Treatments that should NOT be offered include long-term oral antibiotic administration and intravesical BCG 1
• Treatment efficacy for any individual is unpredictable; multiple therapeutic options may need to be tried before adequate symptom control is achieved 2, 3
• IC/BPS is a chronic condition with periods of flares and remissions; patients should be educated about the long-term nature of management 2
• Ineffective treatments should be discontinued after an appropriate trial period 1
• Sexual dysfunction is common and significantly impacts quality of life; successful treatment of IC/BPS symptoms can improve sexual function 1