What are the treatment options for interstitial cystitis?

Treatment Options for Interstitial Cystitis

Begin with behavioral modifications and self-care practices as first-line therapy, then add oral amitriptyline or pentosan polysulfate as second-line treatment, reserving intravesical therapies and advanced interventions for refractory cases. 1, 2

First-Line: Behavioral and Self-Care Modifications

All patients should start with these non-pharmacologic interventions before escalating to medications 1, 2:

Dietary and Fluid Management:

• Implement an elimination diet to identify personal trigger foods, particularly avoiding coffee, citrus products, and spicy foods 2
• Alter urine concentration through strategic fluid management—either restrict fluids to reduce frequency or increase hydration to dilute irritants 1, 2

Physical Symptom Management:

• Apply heat or cold directly over the bladder or perineum for pain relief 1, 2
• Practice pelvic floor muscle relaxation techniques (not strengthening exercises, which can worsen symptoms) 1, 2
• Implement bladder training with urge suppression strategies 1, 2

Stress and Psychological Management:

• Use meditation and guided imagery to manage stress-induced symptom flares 1, 2
• Recognize that psychological stress heightens pain sensitivity in IC/BPS patients specifically 1

Over-the-Counter Options:

• Consider quercetin, calcium glycerophosphates, or phenazopyridine for symptom relief 1, 2

Second-Line: Oral Pharmacotherapy

Amitriptyline (Grade B Evidence):

• Start at 10 mg daily and titrate upward based on response and tolerability 1, 2
• This tricyclic antidepressant has demonstrated superiority over placebo for symptom improvement 1, 2
• Common side effects include sedation, drowsiness, and nausea, which are not life-threatening but can compromise quality of life 1, 2

Pentosan Polysulfate (FDA-Approved):

• The only FDA-approved oral medication for IC/BPS, dosed at 100 mg three times daily 2, 3
• Take with water at least 1 hour before meals or 2 hours after meals 3
• Works by repairing the damaged glycosaminoglycan (GAG) layer lining the urothelium 4
• Critical caveat: Requires regular ophthalmologic examinations due to risk of pigmented maculopathy with chronic use 2, 5
• Many patients may choose to avoid or discontinue this medication given the concerning eye toxicity 5

Alternative Oral Agents:

• Hydroxyzine and cimetidine are additional second-line options 2
• Cyclosporine A may be considered for refractory cases 2, 5

Second-Line: Intravesical Therapies

Dimethyl Sulfoxide (DMSO):

• Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding 2, 6
• Repeat every two weeks until maximum symptomatic relief is obtained 6
• Apply lidocaine jelly to the urethra before catheter insertion to prevent spasm 6
• Patients will experience a garlic-like taste within minutes that may last several hours, with breath and skin odor persisting up to 72 hours 6
• Consider oral analgesics or belladonna/opium suppositories before instillation to reduce bladder spasm 6

Heparin:

• Repairs the damaged GAG layer with clinically significant symptom improvement 2

Lidocaine:

• Provides rapid-onset temporary relief of bladder pain 2

Treatment for Hunner Lesions (Specific Subtype)

If Hunner lesions are identified on cystoscopy 2:

• Perform fulguration with laser or electrocautery and/or inject triamcinolone directly into the lesions 2
• These lesions become easier to identify after bladder distention when cracking and mucosal bleeding become evident 2

Advanced/Third-Line Interventions

For patients who fail conservative and second-line therapies 2:

• Sacral neuromodulation may be considered 2
• Intradetrusor botulinum toxin A injections, but patients must accept the possibility of needing intermittent self-catheterization 2

Pain Management Principles

Multimodal approach is essential:

• Pain management alone does not constitute sufficient treatment—you must also address the underlying bladder symptoms 1, 2
• Preferentially use non-opioid alternatives given the chronic nature of IC/BPS and the opioid crisis 1, 2
• If using chronic opioids, engage in informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse 1
• Refer to pain specialists if pain management remains inadequate 2

Critical Pitfalls to Avoid

Avoid pelvic floor strengthening exercises—these worsen symptoms; use relaxation techniques instead 2

Document baseline symptoms using validated tools (Genitourinary Pain Index, Interstitial Cystitis Symptom Index) to objectively measure treatment effects 2

Educate patients about the chronic nature of IC/BPS:

• This is typically a chronic disorder requiring continual and dynamic management 1
• The typical course involves symptom exacerbations and remissions 1
• No single treatment is effective for the majority of patients 1
• Acceptable symptom control may require trials of multiple therapeutic options, including combination therapy 1, 2

Anticoagulation considerations:

• Pentosan polysulfate is a weak anticoagulant 3
• Patients must inform their doctor before surgery or starting anticoagulant therapy (warfarin, heparin, high-dose aspirin, NSAIDs like ibuprofen) 3