How to manage interstitial cystitis?

Management of 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

First-Line: Behavioral Modifications and Self-Care

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

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods from the diet 1, 2
• Implement an elimination diet to identify personal trigger foods that worsen symptoms 3, 1
• Alter urine concentration through strategic fluid management—either restrict fluids to concentrate urine less frequently or increase hydration to dilute irritants, depending on individual response 3, 1
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 3, 1
• Practice stress management techniques such as meditation and imagery to reduce stress-induced symptom exacerbations 3, 1
• Perform pelvic floor muscle relaxation exercises—NOT strengthening exercises, which may worsen symptoms 3, 1
• Implement bladder training with urge suppression techniques 3, 2
• Consider over-the-counter products such as calcium glycerophosphates or phenazopyridine for symptom relief 3, 2

Critical pitfall: Avoid pelvic floor strengthening exercises and certain types of exercise that may exacerbate symptoms; only relaxation techniques should be used 3, 1.

Second-Line: Oral Medications

When behavioral modifications prove insufficient, advance to pharmacologic therapy 1:

Amitriptyline (First Choice)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 3, 1
• Has Grade B evidence showing superiority to placebo for symptom improvement 3, 1
• Common side effects include sedation, drowsiness, and nausea, though not life-threatening 3, 2

Pentosan Polysulfate Sodium

• The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 1, 4
• Requires mandatory ophthalmologic monitoring due to risk of pigmented maculopathy and macular damage 1, 5
• Must be taken at least 1 hour before meals or 2 hours after meals 4
• Many patients now choose not to start or discontinue this medication due to serious ocular toxicity concerns 5

Alternative Oral Agents

• Hydroxyzine and cimetidine are additional second-line options 3, 2
• Cyclosporine A may be considered for refractory cases but has limited evidence (Grade C) 1, 2

Second-Line: Intravesical Therapies

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

Dimethyl Sulfoxide (DMSO)

• Instill 50 mL directly into the bladder for 15 minutes using catheter or aseptic syringe 6
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals appropriately 6
• Apply lidocaine jelly to urethra prior to catheter insertion to avoid spasm 6
• Patients will experience a garlic-like taste within minutes that may last several hours, with breath and skin odor persisting up to 72 hours 6
• Consider oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 6

Heparin

• Repairs the damaged glycosaminoglycan layer of the bladder and provides clinically significant symptom improvement 1, 2

Lidocaine

• Provides rapid onset temporary relief of bladder pain 1, 2
• Can be combined with heparin or pentosan polysulfate and sodium bicarbonate for immediate symptom relief 7

Third-Line: Cystoscopy with Hydrodistension

• Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction 1
• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 1

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy 2:

• Perform fulguration (with laser or electrocautery) and/or injection of triamcinolone for significant symptom relief 1, 2
• Lesions become easier to identify after distention when cracking and mucosal bleeding become evident 2

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these for patients who have failed all other treatments 1:

• Sacral neuromodulation has Grade C evidence with limited sample sizes and is not FDA-approved for IC/BPS 1, 2
• Intradetrusor botulinum toxin A injections may be beneficial but patients must accept the possibility of needing intermittent self-catheterization 1, 2
• These therapies should be limited to practitioners with experience managing IC/BPS and willingness to provide long-term care 3

Pain Management Throughout Treatment

• Implement multimodal pain management approaches throughout treatment, with non-opioid alternatives strongly preferred due to the chronic nature of the condition 3, 1, 2
• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 3, 1, 2
• Use chronic opioids judiciously only after informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse 3
• Consider referral to pain specialists if pain management is inadequate 2

Patient Education and Expectations

• Educate patients that IC/BPS is typically a chronic disorder requiring continual and dynamic management with symptom exacerbations and remissions 3, 1
• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment effects 2
• Inform patients that no single treatment is effective for the majority and acceptable symptom control may require trials of multiple therapeutic options including combination therapy 3, 1

Treatments That Should NOT Be Offered

• Do not offer long-term oral antibiotics, intravesical BCG, intravesical resiniferatoxin, high-pressure long-duration hydrodistension, or systemic long-term glucocorticoids due to lack of efficacy or increased risk of adverse events 1