What are the treatment options for interstitial cystitis?

Treatment for Interstitial Cystitis

Begin with behavioral modifications and self-care practices for all patients, then escalate systematically through oral medications (amitriptyline or pentosan polysulfate), intravesical therapies (DMSO, heparin, lidocaine), and finally advanced interventions for refractory cases. 1, 2

First-Line: Behavioral Modifications and Self-Care

Start every patient with these foundational strategies before escalating to pharmacotherapy 1, 2:

• Dietary modifications: Eliminate known bladder irritants including coffee, citrus products, and spicy foods; implement an elimination diet to identify personal trigger foods 1, 2
• Fluid management: Alter urine concentration through strategic fluid intake to dilute urinary irritants 1, 2
• Physical interventions: Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2
• Stress management: Use meditation, imagery, and other stress reduction techniques 1, 2
• Pelvic floor therapy: Focus on muscle relaxation techniques, not strengthening exercises which can worsen symptoms 1, 2
• Bladder training: Implement urge suppression techniques to manage frequency 1, 2
• Over-the-counter supplements: Consider quercetin and calcium glycerophosphates for additional symptom relief 1

Second-Line: Oral Medications

If symptoms persist after 4-8 weeks of behavioral modifications, add oral pharmacotherapy 2:

Amitriptyline (Preferred Initial Oral Agent)

• Dosing: Start at 10 mg daily, titrate up to 100 mg per day as tolerated 1
• Evidence: Superior to placebo for symptom improvement (Grade B evidence) 1
• Side effects: Sedation, drowsiness, and nausea are common; counsel patients accordingly 1

Pentosan Polysulfate Sodium (FDA-Approved)

• Dosing: 100 mg three times daily 1, 3
• Mechanism: Repairs damaged glycosaminoglycan (GAG) layer of the bladder urothelium 3
• Critical warning: Recent findings of pigmented maculopathy with chronic use require mandatory ophthalmologic monitoring with slit lamp examinations 1, 4
• Patient counseling: Many patients choose to discontinue or avoid this medication due to ocular toxicity concerns 4

Alternative Oral Agents

• Cimetidine and hydroxyzine: Additional second-line options for antihistamine effects 1, 4

Second-Line: Intravesical Therapies

For patients failing oral medications or requiring more aggressive intervention 1, 2:

Dimethyl Sulfoxide (DMSO) - FDA-Approved

• Dosing: Instill 50 mL directly into bladder via catheter, retain for 15 minutes, repeat every 2 weeks until maximum symptomatic relief achieved 5, 6
• Preparation: Apply lidocaine jelly to urethra before catheter insertion to prevent spasm 5
• Adjunctive therapy: Administer oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 5
• Patient counseling: Garlic-like taste within minutes lasting several hours; breath and skin odor may persist up to 72 hours 5
• Anesthesia consideration: For patients with severe IC and very sensitive bladders, perform initial 2-3 treatments under saddle block anesthesia 5

Heparin (Intravesical)

• Mechanism: Repairs damaged GAG layer of bladder 1, 7
• Clinical benefit: Provides clinically significant symptom improvement 1

Lidocaine (Intravesical)

• Effect: Provides rapid onset temporary relief of bladder pain 1
• Combination therapy: Can be combined with pentosan polysulfate or heparin plus sodium bicarbonate for immediate symptom relief 7

Third-Line: Cystoscopy with Hydrodistension

Perform cystoscopy when diagnosis is uncertain or to identify Hunner lesions 8, 1:

• Diagnostic value: Determines anatomic bladder capacity and identifies fibrosis-related capacity reduction 8
• Glomerulation detection: May be present but is not specific to IC/BPS; can occur in asymptomatic patients 2
• Avoid high-pressure, long-duration hydrodistension: Pressures >80-100 cm H₂O or duration >10 minutes increase risk of bladder rupture and sepsis without consistent benefit (Grade C recommendation against) 8

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, perform fulguration and/or triamcinolone injection immediately 8, 1:

• Technique: Use laser or electrocautery for fulguration 8, 1
• Timing: Lesions are easier to identify after distention when cracking and mucosal bleeding become evident 1
• Efficacy: Provides significant symptom relief in this specific IC/BPS subtype 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these therapies for patients who have failed all previous treatments and require specialized care 8:

Sacral Neuromodulation

• Indication: Consider trial if other treatments have not provided adequate symptom control 8, 1
• Approach: Perform trial stimulation; if successful, proceed with permanent device implantation 8
• Evidence: Grade C, limited by small sample sizes and lack of durable follow-up 8

Cyclosporine A (Oral)

• Indication: For refractory cases unresponsive to conventional therapies 8, 1
• Evidence: Grade C, not FDA-approved for IC/BPS 8
• Limitation: Should be prescribed only by practitioners experienced in managing IC/BPS 8

Intradetrusor Botulinum Toxin A

• Indication: For refractory cases with adequate patient counseling 8, 1
• Critical requirement: Patients must accept the possibility of requiring intermittent self-catheterization post-treatment 8, 1
• Evidence: Grade C, not FDA-approved for IC/BPS 8

Sixth-Line: Major Surgery

Reserve substitution cystoplasty or urinary diversion with/without cystectomy only for carefully selected patients who have failed all other therapies 8:

• Benefit: Relieves frequency and nocturia; sometimes relieves pain 8
• Patient selection: Critical to ensure all conservative measures have been exhausted 8

Multimodal Pain Management Throughout Treatment

Initiate and maintain multimodal pain management approaches throughout all treatment phases, prioritizing non-opioid alternatives 1:

• Inadequate pain control: Refer to pain specialists when standard approaches fail 1
• Critical principle: Pain management alone is insufficient; underlying bladder symptoms must be simultaneously addressed 1

Treatments That Should NOT Be Offered

Contraindicated Therapies (Strong Evidence Against)

• Long-term oral antibiotics: No significant benefit over placebo (20% vs 16% improvement); risk of antibiotic resistance and adverse events (Grade B Standard against) 8
• Intravesical BCG: No efficacy compared to placebo with potentially life-threatening adverse events (Grade B Standard against) 8
• Intravesical resiniferatoxin: No statistically significant benefit with high adverse event rates (52-89%) (Grade A Standard against) 8
• High-pressure, long-duration hydrodistension: Increased risk of bladder rupture and sepsis without consistent benefit (Grade C Recommendation against) 8
• Systemic long-term glucocorticoids: Serious adverse events (diabetes, pneumonia with septic shock, hypertension) outweigh minimal benefits in small studies (Grade C Recommendation against) 8

Critical Pitfalls and Caveats

• Avoid pelvic floor strengthening exercises: These worsen symptoms; focus exclusively on relaxation techniques 1, 2
• Pentosan polysulfate ocular toxicity: Mandatory ophthalmologic monitoring including slit lamp examinations before and during treatment 1, 5
• Chronic disease education: IC/BPS has periods of flares and remissions; set realistic expectations about long-term management 1, 2
• Unpredictable treatment response: Multiple therapeutic trials may be necessary before achieving adequate symptom control 1, 2
• Document baseline symptoms: Use validated tools (GUPI or ICSI) to objectively measure treatment effects 1
• DMSO garlic odor: Warn patients about garlic-like taste and breath/skin odor lasting up to 72 hours to prevent treatment discontinuation 5
• Pregnancy and nursing: Discuss advisability of DMSO use with pregnant or nursing patients 5