What are the treatment options for interstitial cystitis?

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

A multimodal approach combining behavioral modifications, oral medications, and intravesical treatments should be implemented for managing inflammation and pain in interstitial cystitis/bladder pain syndrome (IC/BPS), with treatment 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 1
• Dietary modifications including avoidance of known bladder irritants (coffee, citrus, spicy foods) can reduce symptoms 1
• Implementation of an elimination diet helps 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) can reduce symptoms 1
• Bladder training with urge suppression helps manage frequency 1
• Over-the-counter products like quercetin and calcium glycerophosphates may provide relief 2, 1

Second-Line Treatments

Oral Medications

• Amitriptyline (10-100 mg daily) is recommended with Grade B evidence strength 1
• Pentosan polysulfate (100 mg three times daily) is the only FDA-approved oral medication for IC/BPS 1
• Cimetidine and hydroxyzine are additional second-line oral medication options 2

Intravesical Treatments

• Dimethyl sulfoxide (DMSO) - administered as 50 mL instillation directly into the bladder for 15 minutes, repeated every two weeks until maximum relief is obtained 2, 3
• Heparin - helps repair the damaged glycosaminoglycan (GAG) layer 1
• Lidocaine - provides temporary relief of bladder pain 1

Treatment for Hunner Lesions

• Cystoscopy should be performed in patients for whom Hunner lesions are suspected 2
• If Hunner's lesions are present, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 2, 4
• Hunner lesions can be easier to identify after distention when cracking and mucosal bleeding become evident 2

Advanced Treatment Options (Third to Fifth Line)

• Sacral neuromodulation may be considered if other treatments have not provided adequate symptom control 2, 5
• Cyclosporine A may be administered as an oral medication for refractory cases 2
• Intradetrusor botulinum toxin A injections may be beneficial, but patients must be willing to accept the possibility of needing intermittent self-catheterization 2

Pain Management

• Multimodal pain management approaches should be initiated and maintained throughout treatment 2, 1
• Pain management alone does not constitute sufficient treatment; underlying bladder symptoms must also be addressed 2
• If pain management is inadequate, consider referral to pain specialists 2

Important Considerations and Pitfalls

• Document baseline symptoms using validated tools such as the genitourinary pain index (GUPI) or interstitial cystitis symptom index (ICSI) to measure treatment effects 2
• Avoid strengthening exercises for pelvic floor muscles, as these may worsen symptoms 1
• Patients using pentosan polysulfate require regular ophthalmologic examinations due to risk of macular damage 1
• Treatments that should NOT be offered include long-term oral antibiotic administration 4
• DMSO administration may cause a garlic-like taste and odor on breath and skin for up to 72 hours 3
• IC/BPS is a chronic condition; patients should be educated about the long-term nature of management 1, 4
• Treatment efficacy for any individual is unpredictable; multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 6