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

From the Guidelines

Treatment for Interstitial Cystitis (IC) should be individualized and based on the unique characteristics of each patient, incorporating behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures, and major surgery as needed. According to the most recent guidelines 1, the approach to treating IC/BPS has shifted away from tiered treatments towards a more personalized strategy. This involves considering various treatment modalities, including:

• Behavioral modifications such as dietary changes, stress management, and pelvic floor physical therapy
• Oral medications like pentosan polysulfate sodium (Elmiron) at 100mg three times daily, which may take 3-6 months to show benefit, as well as amitriptyline and antihistamines for pain and urgency management
• Bladder instillations with DMSO, heparin, or lidocaine cocktails
• More invasive options for severe cases, including hydrodistention, Botox injections, sacral neuromodulation, or surgical interventions

Key considerations in managing IC/BPS include:

• The importance of patient awareness and avoidance of specific behaviors that worsen symptoms, as suggested by clinical experience and limited literature 1
• The use of pentosan polysulfate, the only FDA-approved oral agent for IC/BPS, with discussion of its benefits and risks with the patient before initiating or continuing treatment 1
• The initiation of multimodal pain management approaches, which may include pharmacological, stress management, and manual therapy techniques, with referral to specialists as needed for complex presentations or intractable pain 1

In terms of specific treatment options, the following may be considered:

• Pentosan polysulfate sodium (Elmiron) at 100mg three times daily for its potential to repair the bladder lining
• Amitriptyline starting at 10-25mg at bedtime for pain and urgency management
• Antihistamines like hydroxyzine (25mg at bedtime) to reduce mast cell activity in the bladder
• Bladder instillations with DMSO, heparin, or lidocaine cocktails for direct treatment of the bladder
• More invasive options, such as hydrodistention, Botox injections, sacral neuromodulation, or surgical interventions, for severe cases unresponsive to other treatments.

From the FDA Drug Label

Instillation of 50 mL of RIMSO-50® (dimethyl sulfoxide) directly into the bladder may be accomplished by catheter or asepto syringe and allow to remain for 15 minutes. It is recommended that the treatment be repeated every two weeks until maximum symptomatic relief is obtained. ELMIRON® is used to treat the pain or discomfort of interstitial cystitis (IC). You should take 1 capsule of ELMIRON® by mouth three times a day, with water at least 1 hour before meals or 2 hours after meals.

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

• Intravesical instillation of dimethyl sulfoxide (RIMSO-50®) every two weeks until maximum symptomatic relief is obtained 2
• Oral administration of pentosan polysulfate sodium (ELMIRON®) at a dose of 1 capsule (100 mg) three times a day, with water at least 1 hour before meals or 2 hours after meals 3 Key considerations:
• Treatment should be individualized and monitored by a healthcare professional
• Patients should be informed about potential side effects and interactions with other medications

From the Research

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

• Oral medications:
  • Pentosan polysulfate sodium 4, 5, 6, 7
  • Antihistamines (e.g. hydroxyzine) 4, 6, 7
  • Tricyclic antidepressants (e.g. amitriptyline) 4, 5, 6, 7
  • Immune modulators 4
• Intravesical instillations:
  • Dimethyl sulfoxide 4, 5, 6, 8
  • Pentosan polysulfate sodium 4, 5, 7
  • Heparin 4, 6, 7, 8
  • Lidocaine 6, 7, 8
  • Botulinum toxin (BTX) 5, 8
  • Chondroitin sulfate 5, 8
  • Hyaluronic acid 5, 8
• Dietary changes and supplements 4
• Behavioral interventions and patient education 7
• Minimally invasive procedures:
  • Fulguration (if Hunner ulcers are found on cystoscopy) 6
  • Hydrodistention 6
  • Sacral neuromodulation 6
  • Intradetrusor onabotulinumtoxinA 6

Multimodal Therapy

• Combination of oral medications, intravesical instillations, and behavioral interventions 5, 7
• Patient-tailored phenotype-directed multimodal therapy is the most promising treatment strategy 5