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 (starting with amitriptyline), intravesical therapies, and finally advanced interventions only for refractory cases. 1, 2, 3

First-Line: Behavioral Modifications and Self-Care

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

• Dietary modifications: Eliminate known bladder irritants including coffee, citrus products, and spicy foods; implement an elimination diet to identify personal trigger foods 1, 2, 3
• Fluid management: Alter urine concentration through strategic fluid intake to dilute urinary irritants 1, 2, 3
• Physical interventions: Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2, 3
• Stress management: Use meditation and imagery techniques to reduce symptoms 1, 2, 3
• Pelvic floor therapy: Focus exclusively on muscle relaxation techniques—avoid strengthening exercises as these may worsen symptoms 1, 2, 3
• Bladder training: Implement urge suppression techniques to manage frequency 1, 2, 3
• Over-the-counter supplements: Consider quercetin and calcium glycerophosphates for symptom relief 1

Second-Line: Oral Medications

When behavioral modifications prove insufficient, advance to pharmacologic therapy: 2, 3

• Amitriptyline is the preferred initial oral agent: Start at 10 mg daily and titrate up to 100 mg per day as tolerated; has Grade B evidence for symptom improvement superior to placebo 1, 2, 3
• Common side effects include sedation, drowsiness, and nausea 1
• Pentosan polysulfate sodium (PPS): The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 1, 2, 3
• Critical caveat for PPS: Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity—many patients may choose to avoid this medication given this serious adverse effect 2, 3, 4
• Alternative oral agents: Cimetidine and hydroxyzine are additional second-line options 1, 4

Second-Line: Intravesical Therapies

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

• Heparin: Repairs the damaged glycosaminoglycan (GAG) layer of the bladder and provides clinically significant symptom improvement 1, 2, 3
• Lidocaine: Provides rapid onset temporary relief of bladder pain 1, 2, 3
• Dimethyl sulfoxide (DMSO): The only FDA-approved intravesical therapy; instill 50 mL directly into the bladder for 15 minutes, repeated every two weeks until maximum symptomatic relief is obtained 1, 5, 6
• Apply analgesic lubricant gel (such as lidocaine jelly) to the urethra prior to catheter insertion to avoid spasm 5
• Consider oral analgesic medication or belladonna/opium suppositories prior to instillation to reduce bladder spasm 5

Third-Line: Cystoscopy with Hydrodistension

Perform cystoscopy when second-line treatments fail: 2, 3

• Determines anatomic bladder capacity and identifies 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 (easier to identify after distention when cracking and mucosal bleeding become evident): 1

• Perform fulguration (with laser or electrocautery) and/or injection of triamcinolone to provide significant symptom relief 1, 2, 3

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these 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; not FDA-approved for IC/BPS 1, 2, 3
• Cyclosporine A: Oral medication for refractory cases with Grade C evidence; not FDA-approved for IC/BPS 1, 2, 3
• Intradetrusor botulinum toxin A injections: Has Grade C evidence and is not FDA-approved for IC/BPS; patients must be willing to accept the possibility of needing 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, refer to pain specialists 1

Treatments That Should NOT Be Offered

• Long-term oral antibiotics: No significant benefit over placebo with risk of antibiotic resistance and adverse events (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: Increases 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

• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) to measure treatment effects 1
• Educate patients on the chronic nature of IC/BPS requiring long-term management with periods of flares and remissions 1, 3
• Treatment efficacy for any individual is unpredictable—multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 3