What are the treatment options for interstitial cystitis symptoms?

Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Begin with behavioral modifications and self-care practices for all patients, then add oral amitriptyline (starting at 10 mg daily) as the first-line pharmacologic agent, with intravesical dimethyl sulfoxide reserved for inadequate responders—this stepwise approach reflects the 2022 AUA guideline's shift away from rigid treatment tiers toward concurrent multimodal therapy tailored to symptom severity. 1

Initial Management: Behavioral and Non-Pharmacologic Interventions

All patients must receive education about IC/BPS as a chronic disorder requiring continual management, with symptom control often requiring trials of multiple therapeutic options before achieving adequate relief. 1

Dietary and Fluid Modifications:

• Implement an elimination diet to identify personal trigger foods, with particular attention to common bladder irritants including coffee, citrus products, and spicy foods. 2
• Alter urine concentration through strategic fluid management—either restricting fluids to reduce frequency or increasing hydration to dilute irritants depending on individual symptom patterns. 1, 2

Physical and Behavioral Techniques:

• Apply heat or cold directly over the bladder or perineum for pain relief. 2
• Practice pelvic floor muscle relaxation techniques—avoid strengthening exercises as these may worsen symptoms. 1, 2
• Implement bladder training with urge suppression to gradually increase voiding intervals. 1, 2
• Use stress management strategies including meditation and guided imagery to manage symptom exacerbations. 1, 2

Over-the-Counter Options:

• Consider quercetin, calcium glycerophosphates, or phenazopyridine for symptomatic relief. 1, 2

Oral Pharmacologic Therapy

Amitriptyline (Grade B Evidence):

• Start at 10 mg daily and titrate upward based on response and tolerability. 1, 2
• Superior to placebo for symptom improvement but adverse effects are common, including sedation, drowsiness, and nausea—these side effects substantially impact quality of life despite not being life-threatening. 1, 2

Pentosan Polysulfate:

• The only FDA-approved oral medication for IC/BPS, dosed at 100 mg three times daily. 2, 3
• Critical caveat: Patients require regular ophthalmologic examinations due to risk of macular damage with long-term use. 2

Additional Oral Options:

• Hydroxyzine and cimetidine serve as second-line antihistamine options. 2
• Cyclosporine A may be considered for refractory cases. 2

Intravesical Therapies

Dimethyl Sulfoxide (DMSO):

• The only FDA-approved intravesical therapy for IC/BPS. 4, 3
• Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding. 4
• Apply lidocaine jelly to the urethra before catheter insertion to prevent spasm. 4
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals between treatments. 4
• Consider oral analgesics or belladonna/opium suppositories before instillation to reduce bladder spasm. 4
• For patients with severe IC/BPS and very sensitive bladders, perform the initial 2-3 treatments under anesthesia (saddle block suggested). 4

Alternative Intravesical Agents:

• Heparin repairs the damaged glycosaminoglycan layer and provides clinically significant symptom improvement. 2
• Lidocaine provides rapid-onset temporary relief of bladder pain. 2

Management of Hunner Lesions

Cystoscopy is mandatory when Hunner lesions are suspected—this remains the only reliable method to identify these lesions, which represent a distinct IC/BPS phenotype requiring specific treatment. 1, 2

• Hunner lesions become easier to identify after bladder distention when cracking and mucosal bleeding become evident. 2
• Perform fulguration (laser or electrocautery) and/or inject triamcinolone directly into the lesions for significant symptom relief. 2

Advanced Interventions for Refractory Cases

Neuromodulation:

• Sacral neuromodulation may be considered when other treatments fail to provide adequate symptom control. 2
• Pudendal neuromodulation represents an alternative neuromodulation target. 5

Intradetrusor Botulinum Toxin A:

• May provide benefit but patients must accept the possibility of requiring intermittent self-catheterization due to potential urinary retention. 2

Pain Management Principles

Multimodal pain management must be initiated and maintained throughout treatment, but pain management alone does not constitute sufficient treatment—the underlying bladder symptoms must also be addressed. 1, 2

• Prioritize non-opioid alternatives given the chronic nature of IC/BPS and the global opioid crisis. 1
• Use chronic opioids judiciously and only after informed shared decision-making, with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse. 1
• Refer to pain specialists when pain management proves inadequate despite multimodal approaches. 2

Critical Clinical Pitfalls

• Do not perform pelvic floor strengthening exercises—these worsen symptoms; focus on relaxation techniques instead. 1, 2
• Document baseline symptoms using validated tools (Genitourinary Pain Index or Interstitial Cystitis Symptom Index) to objectively measure treatment effects. 2
• Educate patients that IC/BPS follows a chronic course with symptom exacerbations and remissions—adequate symptom control is achievable but unpredictable for any individual. 1
• No single treatment is effective for the majority of patients; combination therapy is often necessary. 1
• Symptoms must be present for at least six weeks with documented negative urine cultures before diagnosing IC/BPS. 1