What are the treatment options for interstitial cystitis?

Treatment Options 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 reserve advanced interventions only for refractory cases. 1, 2, 3

First-Line: Behavioral Modifications and Self-Care

All patients should start with conservative measures before pharmacologic intervention 1, 2, 3:

Dietary Management

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods 1, 2, 3
• Implement an elimination diet to identify personal trigger foods 1, 2, 3
• Alter urine concentration through strategic fluid management to help dilute urinary irritants 1, 2, 3

Physical and Behavioral Interventions

• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2, 3
• Practice stress management techniques such as meditation and imagery 1, 2, 3
• Perform pelvic floor muscle relaxation exercises—avoid strengthening exercises as these may worsen symptoms 1, 2, 3
• Use bladder training with urge suppression techniques to manage frequency 1, 2, 3

Over-the-Counter Options

• Consider quercetin and calcium glycerophosphates for symptom relief 1
• Cimetidine and hydroxyzine are additional second-line options 1

Second-Line: Oral Medications

Amitriptyline (Preferred Initial Oral Agent)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 1, 2, 3
• Has Grade B evidence showing superiority to placebo for symptom improvement 1, 2, 3
• Common side effects include sedation, drowsiness, and nausea 1

Pentosan Polysulfate Sodium (Elmiron®)

• The only FDA-approved oral medication for IC/BPS 1, 4, 5
• Dose: 100 mg three times daily 1, 4
• Must be taken at least 1 hour before meals or 2 hours after meals 4
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 1, 2, 3
• Acts as a weak anticoagulant—inform patients undergoing surgery or taking warfarin, heparin, high-dose aspirin, or NSAIDs 4
• Most common side effects include hair loss, diarrhea, nausea, blood in stool, headache, rash, upset stomach, abnormal liver function tests, dizziness, and bruising 4

Second-Line: Intravesical Therapies

These can be used concurrently with or following oral medications 1, 2, 3:

Dimethyl Sulfoxide (DMSO/RIMSO-50®)

• The only FDA-approved intravesical therapy for IC/BPS 6, 5
• Administer 50 mL instillation directly into the bladder for 15 minutes 1, 6
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals appropriately 1, 6
• Apply analgesic lubricant gel (such as lidocaine jelly) to the urethra prior to catheter insertion to avoid spasm 6
• Administer oral analgesic medication or belladonna/opium suppositories prior to instillation to reduce bladder spasm 6
• Patients may experience a garlic-like taste within minutes that lasts several hours, with breath and skin odor persisting up to 72 hours 6
• In severe cases with very sensitive bladders, initial treatments should be done under anesthesia (saddle block suggested) 6

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder 1, 2, 3
• Provides clinically significant symptom improvement 1, 2, 3

Lidocaine

• Provides rapid onset temporary relief of bladder pain 1, 2, 3

Third-Line: Cystoscopy with Hydrodistension

• Perform when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction 2, 3
• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 2, 3

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, 3
• Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 1
• This intervention provides significant symptom relief for this specific subtype 1, 2, 3

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these only for patients who have failed all other treatments 2, 3:

Sacral Neuromodulation

• Has Grade C evidence with limited sample sizes and lack of durable follow-up 2, 3
• Not FDA-approved for IC/BPS 2, 3

Cyclosporine A

• For refractory cases with Grade C evidence 2, 3
• Not FDA-approved for IC/BPS 2, 3

Intradetrusor Botulinum Toxin A

• Has Grade C evidence and is not FDA-approved for IC/BPS 2, 3
• Patients must be willing to accept the possibility of requiring intermittent self-catheterization post-treatment 1, 2, 3

Pain Management Throughout Treatment

• Initiate and maintain multimodal pain management approaches throughout treatment, with non-opioid alternatives preferred due to the chronic nature of the condition 1, 2, 3
• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 1, 2, 3
• If pain management is inadequate, consider referral to pain specialists 1

Treatments That Should NOT Be Offered

• Long-term oral antibiotics: No significant benefit over placebo with risk of antibiotic resistance (Grade B evidence against) 2, 3
• Intravesical BCG: No efficacy compared to placebo with potentially life-threatening adverse events (Grade B evidence against) 2, 3
• Intravesical resiniferatoxin: No statistically significant benefit with high adverse event rates (Grade A evidence against) 2, 3
• High-pressure, long-duration hydrodistension: Increased risk of bladder rupture and sepsis without consistent benefit (Grade C recommendation against) 2, 3
• Systemic long-term glucocorticoids: Serious adverse events outweigh minimal benefits (Grade C recommendation against) 2, 3

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used 1, 2, 3
• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) to measure treatment effects 1
• Ensure ophthalmologic examinations for patients on pentosan polysulfate, including slit lamp examinations prior to and periodically during treatment 1, 2, 3, 6
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 1, 2, 3
• Treatment efficacy for any individual is unpredictable—multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 2, 3
• Counsel patients taking pentosan polysulfate about anticoagulant effects before surgery or when combining with warfarin, heparin, high-dose aspirin, or NSAIDs 4