Management of Interstitial Cystitis/Bladder Pain Syndrome
Begin with behavioral modifications and dietary changes for all patients, then escalate systematically through oral medications (amitriptyline or pentosan polysulfate), intravesical therapies (DMSO, heparin, lidocaine), cystoscopy with hydrodistension, treatment of Hunner lesions if present, and reserve advanced interventions (neuromodulation, cyclosporine, botulinum toxin) only for refractory cases that have failed all other treatments. 1
First-Line: Behavioral Modifications and Self-Care (Required for All Patients)
Eliminate bladder irritants including coffee, citrus products, and spicy foods from the diet 1, 2. Implement an elimination diet to identify personal trigger foods 1, 2.
Manage fluid intake strategically to dilute urinary irritants and alter urine concentration 1, 2.
Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2.
Practice stress management techniques such as meditation and imagery to reduce symptom flares 1, 2.
Perform pelvic floor muscle relaxation exercises only—never strengthening exercises, as these worsen symptoms 1, 2. Consider referral for appropriate manual physical therapy techniques 3.
Consider over-the-counter supplements including quercetin and calcium glycerophosphates for additional symptom relief 2, 4.
Second-Line: Oral Medications
Start amitriptyline at 10 mg daily and titrate up to 100 mg per day as tolerated, with Grade B evidence showing superiority over placebo for symptom improvement 1, 2. Common side effects include sedation, drowsiness, and nausea 2.
Pentosan polysulfate sodium (Elmiron) 100 mg three times daily is the only FDA-approved oral medication for IC/BPS 1, 5. Take each capsule with water at least 1 hour before meals or 2 hours after meals 5. Mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity 1, 2.
Alternative second-line oral options include cimetidine and hydroxyzine 3, 2.
Critical pitfall: Pentosan polysulfate is a weak anticoagulant—patients must inform their doctor before surgery or starting warfarin, heparin, high-dose aspirin, or NSAIDs 5.
Second-Line: Intravesical Therapies (Can Be Used Concurrently with Oral Medications)
Dimethyl sulfoxide (DMSO) is the only FDA-approved intravesical therapy 6, 7. Instill 50 mL directly into the bladder via catheter, allow to remain for 15 minutes, then expel by spontaneous voiding 6. Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals appropriately 6. Apply lidocaine jelly to the urethra before catheter insertion to avoid spasm 6. Consider oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 6.
Heparin intravesical therapy repairs the damaged glycosaminoglycan layer and provides clinically significant symptom improvement 1, 2.
Lidocaine intravesical therapy provides rapid onset temporary relief of bladder pain 1, 2.
Third-Line: Cystoscopy with Hydrodistension
Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction 1, 8.
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, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone to provide significant symptom relief 1, 2, 8. Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 2.
Fifth-Line: Advanced Interventions for Refractory Cases Only
Reserve these therapies exclusively for patients who have failed all other treatments, as they have limited evidence (Grade C), small sample sizes, lack of durable follow-up, and are not FDA-approved for IC/BPS 3, 1.
Sacral neuromodulation may be considered if other treatments have not provided adequate symptom control 1, 2.
Cyclosporine A may be administered orally for refractory cases 1, 2.
Intradetrusor botulinum toxin A injections may be beneficial, but patients must accept the possibility of needing intermittent self-catheterization 1, 2.
Pain Management Throughout All Treatment Phases
Initiate multimodal pain management approaches and maintain throughout treatment, with non-opioid alternatives strongly preferred due to the chronic nature of the condition 1, 2.
Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 1, 2.
Refer to pain specialists if pain management is inadequate 2.
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.
Critical Documentation and Patient Education
Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment effects 2.
Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 2.
Set realistic expectations: Treatment efficacy for any individual is unpredictable, and multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 2.