What are the treatment options for bladder pain?

Treatment Options for Bladder Pain

For bladder pain, begin with behavioral modifications and self-care practices, then escalate to oral medications (amitriptyline, pentosan polysulfate, cimetidine, or hydroxyzine) or intravesical treatments (dimethyl sulfoxide, heparin, or lidocaine) if first-line measures fail, while implementing multimodal pain management throughout. 1

Initial Diagnostic Considerations

Before initiating treatment, exclude reversible causes:

• Obtain urinalysis to rule out infection or microhematuria 1, 2
• Perform cystoscopy if Hunner lesions are suspected, as these require specific treatment (fulguration or triamcinolone injection) and respond well to early intervention 1, 2
• Measure post-void residual in patients with emptying symptoms, neurologic disorders, diabetes, or prior pelvic surgery to exclude urinary retention 1, 2
• Establish baseline pain levels using validated tools (GUPI, ICSI, or VAS) and obtain a voiding diary to track treatment response 1

First-Line Treatments (Implement for All Patients)

Behavioral Modifications and Self-Care

These strategies should be discussed and implemented as feasible for every patient with bladder pain: 1

• Fluid management: Reduce daily fluid intake by approximately 25% (roughly 300 mL), which significantly improves urgency, frequency, and nocturia 3. Avoid both excessive restriction and overhydration 1
• Dietary modifications: Eliminate common bladder irritants including coffee, citrus products, alcohol, and caffeine 1
• Use an elimination diet to identify individual food triggers 1
• Apply local heat or cold over the bladder or perineum for symptomatic relief 1
• Implement stress management practices (meditation, imagery) to manage flare-ups and improve coping, as psychological stress heightens pain sensitivity 1
• Practice pelvic floor muscle relaxation and bladder training with urge suppression techniques 1
• Consider over-the-counter products such as quercetin, calcium glycerophosphates, or phenazopyridine, though evidence is limited 1

Pain Management Foundation

Initiate multimodal pain management approaches early, combining pharmacological agents with stress management and manual therapy if available 1. Pain management alone is insufficient—treat underlying bladder symptoms concurrently 1. Use non-opioid alternatives preferentially, reserving chronic opioids only after informed shared decision-making and with periodic monitoring for efficacy and potential misuse 1.

Second-Line Oral Medications

If first-line treatments fail, offer one of these oral medications (no hierarchy implied; efficacy is unpredictable for individuals): 1

Amitriptyline (Grade B Evidence)

• Superior to placebo for IC/BPS symptom improvement 1
• Start at 10 mg and titrate gradually to 75-100 mg if tolerated 1
• Common adverse effects include sedation, drowsiness, and nausea, though not life-threatening 1

Pentosan Polysulfate (Grade B Evidence)

• The only FDA-approved oral agent for IC/BPS 4
• Dosing: 100 mg three times daily 4
• In clinical trials, 38% of patients showed >50% improvement in bladder pain at 3 months (vs. 18% placebo) 4
• Critical caveat: Counsel patients on potential risk for macular damage and vision-related injuries before initiating or continuing treatment 1
• Most patients who respond do so within 3-6 months; fewer than 1.5% report first onset of relief after 6 months 4

Cimetidine (Grade B Evidence)

• Clinically significant improvement in IC/BPS symptoms, pain, and nocturia with no reported adverse effects 1

Hydroxyzine (Grade C Evidence)

• Results in clinically significant improvement compared to placebo 1
• Patients with systemic allergies may be more likely to respond 1
• Common adverse effects include short-term sedation and weakness 1

Second-Line Intravesical Treatments

May be administered if oral medications are ineffective or not tolerated (no hierarchy implied): 1

• Dimethyl sulfoxide (DMSO) 1
• Heparin 1
• Lidocaine 1

These treatments have Grade B or C evidence and are associated with minor adverse events 1.

Third-Line and Beyond: Escalating Interventions

Minimally Invasive Therapies

If second-line treatments fail after adequate trial: 1, 2

• Botulinum toxin injection into the bladder 2
• Sacral neuromodulation 2
• Percutaneous or implantable tibial nerve stimulation 1

Invasive Therapies (Reserved for Refractory Cases)

Only after other treatment options have failed: 1

• Urinary diversion with or without cystectomy 1
• Substitution cystoplasty 1

Critical Management Principles

Reassess treatment efficacy periodically and stop ineffective treatments 1. No single treatment is effective for the majority of patients; acceptable symptom control may require trials of multiple therapeutic options, including combination therapy 1.

Reconsider the diagnosis if no improvement occurs within a clinically meaningful timeframe 1. IC/BPS is typically chronic with symptom exacerbations and remissions, requiring continual and dynamic management 1.

For patients with Hunner lesions specifically, fulguration (laser or electrocautery) and/or triamcinolone injection is the most effective intervention and should be performed early without requiring failure of other treatments first 1, 2.