What are the treatment options for bladder pain?

Treatment of Bladder Pain

Bladder pain treatment should begin with behavioral modifications and non-pharmacologic therapies, followed by oral medications, then bladder instillations, with procedures and surgery reserved for refractory cases—except when Hunner lesions are identified on cystoscopy, which should be treated immediately with fulguration and/or triamcinolone injection. 1

Initial Diagnostic Considerations

Before initiating treatment, confirm the diagnosis by:

• Obtaining urinalysis and urine culture to exclude infection, as bladder pain with sterile urine for >6 weeks is required for IC/BPS diagnosis 1
• Performing cystoscopy when Hunner lesions are suspected, as this is the only reliable method to identify these lesions and represents a distinct phenotype requiring specific treatment 1, 2
• Documenting baseline symptoms using voiding logs, pain scales (VAS), and validated questionnaires (ICSI, GUPI) to measure treatment response 1, 2

Treatment Algorithm by Category

Behavioral/Non-Pharmacologic Therapies (Initial Approach)

Start all patients with:

• Patient education about the chronic nature of IC/BPS, including expected flares and remissions 2
• Dietary modifications to identify and avoid bladder irritants (caffeine, alcohol, acidic foods, artificial sweeteners) 3
• Stress management and psychological support, as IC/BPS causes significant psychological distress and reduced quality of life 2, 3
• Pelvic floor physical therapy and biofeedback for patients with pelvic floor dysfunction 4, 3

Oral Medications (Second-Line)

When behavioral measures are insufficient:

• Amitriptyline is likely to offer the greatest response among oral medications for IC/BPS 3
• Pentosan polysulfate sodium (Elmiron®) is FDA-approved for relief of bladder pain or discomfort associated with interstitial cystitis, though recent guidelines note potential adverse events including retinal toxicity that require monitoring 1, 5
• Antimuscarinics or beta-3 agonists can address frequency/urgency symptoms 4

Critical caveat: The 2022 AUA guideline specifically highlights concerns about pentosan polysulfate adverse events, requiring informed discussion with patients 1

Bladder Instillations (Third-Line)

For patients not responding to oral therapies:

• Dimethyl sulfoxide (RIMSO-50®) instillation: 50 mL retained for 15 minutes, repeated every 2 weeks until maximum relief, then interval extended 6
• Lidocaine instillations can provide symptomatic relief 2, 3
• Glycosaminoglycan replenishment therapy addresses potential urothelial defects 3, 7

Important technique: Apply lidocaine jelly to the urethra before catheterization to prevent spasm; consider oral analgesics or belladonna/opium suppositories before instillation 6

Treatment of Hunner Lesions (Immediate When Identified)

This is the exception to the stepwise approach:

• Fulguration (laser or electrocautery) and/or triamcinolone injection should be performed immediately when Hunner lesions are identified, without requiring failure of other treatments first 1, 2
• Hunner lesions represent a distinct inflammatory phenotype (pancystitis with B cell abnormalities) that responds specifically to directed therapy 2, 8
• Cystoscopy with hydrodistension helps identify these lesions, which become more evident after distention when cracking and mucosal bleeding occur 2

Advanced Procedures (Fourth-Line)

For severe, refractory cases:

• Intradetrusor botulinum toxin A injections may provide benefit 2, 4, 3
• Sacral neuromodulation should be restricted to patients with predominant frequency/urgency (NOT pain-predominant disease) who have failed all conservative, oral, and intravesical therapies 9
• Cyclosporine A may be considered in experienced hands, but requires intense monitoring due to significant adverse events 2, 3

Critical pitfall: Sacral neuromodulation is Grade C evidence, not FDA-approved for IC/BPS, and should only be offered by experienced practitioners willing to provide long-term care—and explicitly NOT for pain-predominant patients 9

Major Surgery (Last Resort)

Reserved for severe, unremitting symptoms affecting quality of life after all other options have failed:

• Urinary diversion with or without cystectomy 1, 2
• Substitution cystoplasty 2

Note: For end-stage structurally small bladders, diversion may be indicated earlier when clinician and patient agree 1

Multimodal Pain Management Throughout

• Implement pain management strategies at every stage with the goal of maximizing function while minimizing pain and side effects 1, 2
• Consider referral to pain specialists if standard approaches provide inadequate control 2
• Combine pharmacological options with stress management and manual therapy 2

Treatments to AVOID

• Long-term oral antibiotic administration should NOT be offered 2
• Intravesical BCG should NOT be used 2

Key Principles for Treatment Selection

The 2022 AUA guideline eliminated the rigid first-through-sixth-line tier system, emphasizing that:

• Treatment must be tailored to each patient's phenotype (Hunner vs. non-Hunner, pain-predominant vs. frequency-predominant) 1
• Multiple concurrent therapies may be appropriate based on symptom severity and patient preferences 1
• Ineffective treatments should be discontinued after an appropriate trial period 1, 2
• Reassess diagnosis if no improvement occurs within a clinically meaningful timeframe 1