What are the treatment options for interstitial cystitis?

Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Begin with patient education, behavioral modifications, and self-care practices as first-line therapy, then escalate systematically through oral medications (amitriptyline or pentosan polysulfate), intravesical therapies (DMSO, heparin, lidocaine), and finally neuromodulation or surgical options if conservative measures fail. 1

Understanding IC/BPS Before Treatment

IC/BPS is a chronic disorder requiring continual management with symptom exacerbations and remissions. 1 No single treatment works for the majority of patients, and acceptable symptom control typically requires trials of multiple therapeutic options including combination therapy. 1 Pain is the hallmark symptom and may be described as pressure or discomfort rather than pain per se, often throughout the pelvis including suprapubic area, urethra, vulva, vagina, rectum, lower abdomen, and back. 1

First-Line: Behavioral and Self-Care Modifications

All patients should start here regardless of symptom severity:

• Fluid management: Alter urine concentration and volume through either fluid restriction or additional hydration based on individual symptom patterns. 1

• Dietary modifications: Avoid common bladder irritants including coffee, citrus products, spicy foods, and alcohol. 2 Use an elimination diet to identify personal trigger foods. 1, 2

• Heat/cold application: Apply heat or cold over the bladder or perineum for symptom relief. 1, 2

• Stress management: Implement meditation, imagery, and other stress reduction techniques since psychological stress heightens pain sensitivity in IC/BPS patients. 1, 2

• Pelvic floor muscle relaxation: Focus on relaxation techniques, NOT strengthening exercises which may worsen symptoms. 1, 2 This is a critical pitfall to avoid.

• Bladder training: Use urge suppression techniques to gradually increase voiding intervals. 1, 2

• Over-the-counter options: Consider quercetin, calcium glycerophosphates, or phenazopyridine for symptom relief. 1, 2

Second-Line: Oral Medications

When behavioral modifications provide insufficient relief:

Amitriptyline (Grade B Evidence)

• Start at 10 mg daily and titrate upward to balance efficacy against side effects. 1 Superior to placebo for symptom improvement. 1, 2
• Common adverse effects include sedation, drowsiness, and nausea, which are not life-threatening but can compromise quality of life. 1, 2
• Typical dosage range: 10-100 mg per day. 2

Pentosan Polysulfate Sodium (Elmiron)

• The only FDA-approved oral medication for IC/BPS. 2, 3
• Dosage: 100 mg three times daily, taken with water at least 1 hour before or 2 hours after meals. 3
• Critical caveat: Requires regular ophthalmologic examinations due to risk of macular damage. 2 This is a serious safety concern that must be monitored.
• Acts as a weak anticoagulant; avoid concurrent use with warfarin, heparin, high-dose aspirin, or NSAIDs without physician consultation. 3
• Most common side effects: hair loss, diarrhea, nausea, blood in stool, headache, rash, upset stomach, abnormal liver function tests, dizziness, and bruising. 3

Alternative Oral Options

• Cimetidine and hydroxyzine are additional second-line options. 2

Second-Line: Intravesical Therapies

Consider when oral medications are insufficient or as combination therapy:

Dimethyl Sulfoxide (DMSO/RIMSO-50)

• The only FDA-approved intravesical therapy for IC/BPS. 2, 4
• Administration: Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding. 4
• Frequency: Repeat every 2 weeks until maximum symptomatic relief is obtained, then increase intervals appropriately. 4
• Apply analgesic lubricant gel (lidocaine jelly) to urethra before catheter insertion to prevent spasm. 4
• Consider oral analgesics or belladonna/opium suppositories before instillation to reduce bladder spasm. 4
• For severe cases with very sensitive bladders, perform initial 2-3 treatments under anesthesia (saddle block suggested). 4
• Patients will experience a garlic-like taste within minutes that may last several hours, with breath and skin odor persisting up to 72 hours. 4
• Eye evaluations including slit lamp examinations should be performed before and periodically during treatment due to animal studies showing eye changes with prolonged high-dose DMSO. 4

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder. 2
• Provides clinically significant symptom improvement. 2

Lidocaine

• Provides rapid-onset temporary relief of bladder pain. 2
• Can be combined with other intravesical agents. 2

Combination Intravesical Therapy

• Multiple agents (heparin, lidocaine, others) can be combined for enhanced effect. 2

Treatment for Hunner Lesions (When Present)

If Hunner lesions are identified on cystoscopy:

• Perform fulguration with laser or electrocautery and/or inject triamcinolone directly into the lesions. 2 This provides significant relief for this specific IC/BPS subtype. 2
• Hunner lesions are easier to identify after bladder distention when cracking and mucosal bleeding become evident. 2
• Cystoscopy should be performed when Hunner lesions are suspected. 2

Third-Line: Advanced Therapies

When second-line treatments fail to provide adequate symptom control:

Sacral Neuromodulation

• Consider for refractory cases. 2

Intradetrusor Botulinum Toxin A

• May be beneficial but patients must accept the possibility of requiring intermittent self-catheterization. 2

Cyclosporine A

• Oral immunotherapy for refractory cases. 2, 5

Pain Management Throughout Treatment

Pain management is essential but insufficient as monotherapy:

• Implement multimodal pain management approaches throughout the treatment course. 1, 2
• Prioritize non-opioid alternatives due to the chronic nature of IC/BPS and the global opioid crisis. 1
• If using chronic opioids, employ informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse/misuse. 1
• Pain management alone does not constitute sufficient treatment; underlying bladder symptoms must also be addressed. 1, 2
• Refer to pain specialists if pain management is inadequate. 2

Monitoring and Reassessment

• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) to objectively measure treatment effects. 2
• Reassess symptoms at each follow-up visit and adjust therapy accordingly. 2
• Stop ineffective treatments rather than continuing them indefinitely. 1
• Reconsider the diagnosis if no improvement occurs within a clinically meaningful timeframe. 1

Surgical Options (Last Resort)

Only after all other treatment options have failed:

• Urinary diversion with or without cystectomy. 1
• Substitution cystoplasty. 1
• Exception: For end-stage structurally small bladders, diversion may be indicated earlier when clinician and patient agree it is appropriate. 1

Critical Pitfalls to Avoid

• Do NOT prescribe pelvic floor strengthening exercises—these worsen symptoms; focus on relaxation instead. 1, 2
• Do NOT forget ophthalmologic monitoring for patients on pentosan polysulfate. 2
• Do NOT use pain management as sole therapy—always address underlying bladder symptoms. 1, 2
• Do NOT continue ineffective treatments—trial multiple options systematically. 1
• Do NOT overlook Hunner lesions—they require specific treatment with fulguration/injection. 2