What are the treatment options for interstitial cystitis?

Treatment for Interstitial Cystitis/Bladder Pain Syndrome

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 only for refractory cases. 1, 2

First-Line: Behavioral Modifications and Self-Care

All patients should start with conservative measures before pharmacologic intervention 1, 2:

Dietary Management

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods 1
• Implement an elimination diet to identify personal trigger foods 1
• Alter urine concentration through strategic fluid management to dilute urinary irritants 1, 2

Physical and Stress Management

• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2
• Practice stress management techniques such as meditation and imagery 1, 2
• Perform pelvic floor muscle relaxation exercises—NOT strengthening exercises, which may worsen symptoms 1, 2
• Implement bladder training with urge suppression techniques 1, 2

Over-the-Counter Options

• Consider quercetin and calcium glycerophosphates for symptom relief 1

Second-Line: Oral Medications

When behavioral modifications prove insufficient, advance to pharmacologic therapy 3:

Amitriptyline (Preferred Initial Oral Agent)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 1, 2
• Has Grade B evidence for symptom improvement superior to placebo 1
• Common side effects include sedation, drowsiness, and nausea 1

Pentosan Polysulfate Sodium (Elmiron)

• The only FDA-approved oral medication for IC/BPS 1, 4
• Dose: 100 mg three times daily 1, 2
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 1, 2
• May take several months to achieve optimal therapeutic response 5, 6

Alternative Oral Options

• Cimetidine and hydroxyzine are additional second-line choices 3, 1

Second-Line: Intravesical Therapies

Intravesical treatments can be used concurrently with or following oral medications 3:

Dimethyl Sulfoxide (DMSO)

• The only FDA-approved intravesical therapy for IC/BPS 4
• Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding 7
• Repeat every two weeks until maximum symptomatic relief is obtained 7
• Apply lidocaine jelly to the urethra prior to catheter insertion to avoid spasm 7
• Warn patients about garlic-like taste within minutes that may last several hours, and body odor lasting up to 72 hours 7
• Consider oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 7

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder 1, 2
• Provides clinically significant symptom improvement 1, 2

Lidocaine

• Provides rapid onset temporary relief of bladder pain 1, 2

Combination Therapy

• Intravesical pentosan polysulfate combined with oral pentosan polysulfate shows superior efficacy (46% symptom reduction at 12 weeks vs. 24% with oral alone) 5

Third-Line: Cystoscopy with Hydrodistension

Perform cystoscopy when second-line treatments fail 2:

• Determines anatomic bladder capacity and identifies fibrosis-related capacity reduction 2
• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 2
• Glomerulations or Hunner's ulcers found at cystoscopy are diagnostic 8

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone 1, 2:

• Provides significant symptom relief in this specific subtype 1, 2
• Lesions are easier to identify after distention when cracking and mucosal bleeding become evident 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these therapies for patients who have failed all other treatments, and limit to practitioners with experience managing IC/BPS 3:

Sacral Neuromodulation

• Consider only after all other treatments have failed 1, 2
• Has Grade C evidence with limited sample sizes and lack of durable follow-up 3, 2
• Not FDA-approved for IC/BPS 3

Cyclosporine A

• Reserved for refractory cases 1, 2
• Has Grade C evidence and is not FDA-approved for IC/BPS 3, 2

Intradetrusor Botulinum Toxin A

• Consider for refractory cases 1, 2
• Counsel patients on the possibility of requiring intermittent self-catheterization post-treatment 1, 2
• Has Grade C evidence and is not FDA-approved for IC/BPS 3, 2

Pain Management Throughout Treatment

Initiate multimodal pain management approaches and maintain throughout treatment, with non-opioid alternatives preferred due to the chronic nature of the condition 1, 2:

• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 1, 2
• If pain management is inadequate, refer to pain specialists 1

Treatments That Should NOT Be Offered

Long-Term Oral Antibiotics

• No significant benefit over placebo with Grade B evidence against 2
• Risk antibiotic resistance and adverse events 2

Intravesical BCG

• No efficacy compared to placebo with potentially life-threatening adverse events 2
• Grade B evidence against 2

Intravesical Resiniferatoxin

• No statistically significant benefit with high adverse event rates 2
• Grade A evidence against 2

High-Pressure, Long-Duration Hydrodistension

• Increases risk of bladder rupture and sepsis without consistent benefit 2
• Grade C recommendation against 2

Systemic Long-Term Glucocorticoids

• Serious adverse events outweigh minimal benefits 2
• Grade C recommendation against 2

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used 1, 2
• Document baseline symptoms using validated tools (GUPI or ICSI) to measure treatment effects 1
• Educate patients that IC/BPS is a chronic condition with flares and remissions requiring long-term management 1
• Treatment efficacy is unpredictable for any individual—multiple therapeutic options may need to be tried before adequate symptom control is achieved 1
• Ensure ophthalmologic examinations for patients on pentosan polysulfate 1, 2