What is the recommended treatment for a patient with interstitial cystitis (IC)/bladder pain syndrome (BPS) and Hunner's ulcer who has failed behavioral modification?

Treatment of Hunner's Ulcer in Interstitial Cystitis/Bladder Pain Syndrome

For a patient with interstitial cystitis/bladder pain syndrome and Hunner's ulcer who has failed behavioral modification, fulguration (with electrocautery) and/or injection of triamcinolone should be performed as the primary treatment. 1

Diagnostic Confirmation and Treatment Approach

• Cystoscopy with hydrodistension is essential to confirm the presence of Hunner's lesions, which appear as inflammatory lesions or ulcerations in the bladder 1, 2
• Hunner's lesions become easier to identify after distention when cracking and mucosal bleeding become evident 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

First-Line Treatment for Hunner's Lesions

• Fulguration with electrocautery and/or triamcinolone injection is the recommended treatment for Hunner's lesions 1, 2
• This approach provides rapid symptom relief with improvement measured in months after a single procedure 1, 3
• Clinical studies show 81.8-90% of patients report subjective improvement following lesion treatment 4
• Treatment does not decrease bladder capacity, even with multiple procedures 1

Treatment Efficacy and Follow-up

• Patients should be informed that periodic retreatment is likely necessary as symptoms can recur 1, 3
• Time to repeat fulguration procedures averages 12 months (range 6-21 months) 4
• For triamcinolone injections, median time between treatments is approximately 8 months 4
• Long-term follow-up shows that by 48 months after initial fulguration, approximately 57% of patients require repeat treatment 3

Multimodal Pain Management

• Implement multimodal pain management approaches alongside lesion treatment 1, 2
• Pain management should include pharmacological options, stress management, and manual therapy when available 1
• Consider referral to pain specialists if pain control remains inadequate 2

Advanced Treatment Options if Fulguration/Triamcinolone Fails

1. Oral medications:

   • Pentosan polysulfate sodium (Elmiron) may be considered, though patients should be monitored for potential side effects including vision changes 5
   • Cyclosporine A (1.5 mg/kg or less) following lesion fulguration has shown promising results in maintaining symptom relief and reducing the need for repeated procedures 6

2. Intravesical treatments:

   • Dimethyl sulfoxide (DMSO) instillation can be administered every two weeks until maximum symptomatic relief is obtained 7

3. Other interventions:

   • Neuromodulation may be considered, though it is more effective for frequency/urgency than for pain 1
   • Intradetrusor botulinum toxin A injections may be beneficial, but patients must accept the possibility of requiring intermittent self-catheterization 1

Important Considerations and Cautions

• Treatments that should NOT be offered include long-term oral antibiotic administration 1
• Major surgery (substitution cystoplasty, urinary diversion with/without cystectomy) should be reserved only for patients with severe, unremitting symptoms who have failed all other treatment options 1, 2
• Only 7.2% of patients with Hunner's lesions ultimately require cystectomy when managed with appropriate endoscopic treatments 4
• Monitor for side effects of medications - particularly with cyclosporine, which requires monitoring for renal function, blood pressure, and potential neutropenia 6

Treatment Algorithm for Hunner's Lesions

1. Confirm diagnosis with cystoscopy with hydrodistension 1, 2
2. Perform fulguration with electrocautery and/or triamcinolone injection of identified lesions 1
3. Implement multimodal pain management 1, 2
4. Schedule follow-up to assess treatment response 1
5. Repeat fulguration/injection when symptoms recur (typically 8-12 months) 3, 4
6. Consider adjunctive treatments (oral medications, intravesical therapies) for patients with inadequate response 8, 6
7. Reserve major surgical interventions for treatment-refractory cases 1