First-Line Treatment for Interstitial Cystitis
The first-line treatment for interstitial cystitis consists of patient education combined with behavioral modifications and self-care practices, including dietary changes, fluid management, stress reduction techniques, and pelvic floor muscle relaxation. 1, 2
Initial Management: Education and Behavioral Modifications
All patients should begin with comprehensive education about IC/BPS as a chronic condition with symptom exacerbations and remissions, understanding that no single treatment works for the majority and multiple therapeutic trials may be necessary. 1, 2
Dietary and Fluid Management
- Avoid known bladder irritants including coffee, citrus products, and spicy foods 2
- Implement an elimination diet to identify personal trigger foods that worsen symptoms 1, 2
- Alter urine concentration through either fluid restriction or additional hydration depending on individual symptom patterns 1, 2
Physical and Behavioral Strategies
- Apply local heat or cold over the bladder or perineum to manage pain 2
- Practice pelvic floor muscle relaxation (NOT strengthening exercises, which can worsen symptoms) 1, 2
- Use bladder training with urge suppression techniques 1, 2
- Avoid tight-fitting clothing and address constipation, as both can exacerbate symptoms 1
Stress Management and Symptom Control
- Implement stress management techniques such as meditation and imagery to manage flare-ups and stress-induced exacerbations 1, 2
- Consider over-the-counter products including quercetin, calcium glycerophosphates, and phenazopyridine, though evidence is limited 1, 2
Critical Pitfall to Avoid
Do NOT perform pelvic floor strengthening exercises, as these can worsen symptoms in IC/BPS patients; only relaxation techniques should be used 1, 2. This is a common error that can significantly compromise patient outcomes.
When to Escalate Beyond First-Line Treatment
If behavioral modifications and self-care practices fail to provide adequate symptom control after an appropriate trial period, second-line treatments include oral medications (amitriptyline, pentosan polysulfate, cimetidine, or hydroxyzine) and intravesical therapies (dimethyl sulfoxide, heparin, or lidocaine) 1, 2. The AUA guidelines explicitly designate these as second-line options, not first-line 1.
Multimodal pain management should be initiated early and maintained throughout treatment, combining pharmacological approaches with stress management and manual therapy when available 1, 2. However, pain management alone is insufficient—underlying bladder symptoms must be addressed concurrently 1, 2.