What are the treatment options for interstitial cystitis?

Treatment Options 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 reserve 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: 1, 2, 3

Dietary Management

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods to reduce symptom burden 1, 2, 3
• Implement an elimination diet to systematically identify personal trigger foods that worsen symptoms 1, 2, 3
• Increase fluid intake strategically to dilute urinary irritants and alter urine concentration 1, 2, 3

Physical and Behavioral Interventions

• Apply local heat or cold directly over the bladder or perineum for symptomatic pain relief 1, 2, 3
• Practice stress management techniques such as meditation and guided imagery to reduce symptom flares 1, 2, 3
• Perform pelvic floor muscle RELAXATION exercises only—avoid strengthening exercises as these may worsen symptoms 1, 2, 3
• Use bladder training with urge suppression techniques to manage urinary frequency 1, 2, 3

Over-the-Counter Options

• Consider quercetin and calcium glycerophosphates as adjunctive therapies for symptom relief 1

Second-Line: Oral Medications

Amitriptyline (Preferred Initial Agent)

• Start amitriptyline at 10 mg daily at bedtime and titrate upward to 100 mg per day as tolerated 1, 2, 3
• This tricyclic antidepressant has Grade B evidence showing superiority over placebo for symptom improvement 1, 2
• Common side effects include sedation, drowsiness, and nausea—counsel patients accordingly 1

Pentosan Polysulfate Sodium (FDA-Approved)

• Pentosan polysulfate is the only FDA-approved oral medication for IC/BPS, dosed at 100 mg three times daily 1, 2, 3, 4
• Take each capsule with water at least 1 hour before meals or 2 hours after meals 4
• Mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity—this is a critical safety consideration 1, 3, 4
• The medication works by repairing the damaged glycosaminoglycan (GAG) layer of the bladder 5
• Patients should be counseled that pentosan polysulfate is a weak anticoagulant and may increase bleeding risk 4

Additional Second-Line Oral Options

• Cimetidine and hydroxyzine are alternative second-line oral medications 1

Second-Line: Intravesical Therapies

These can be used concurrently with or following oral medications: 1, 2, 3

Dimethyl Sulfoxide (DMSO)

• Instill 50 mL of DMSO directly into the bladder via catheter and allow to remain for 15 minutes 1, 6
• Apply lidocaine jelly to the urethra prior to catheter insertion to prevent spasm 6
• Repeat treatment every two weeks until maximum symptomatic relief is obtained, then increase intervals appropriately 1, 6
• Consider administering oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 6
• DMSO is the only FDA-approved intravesical therapy for IC/BPS 7

Heparin

• Heparin repairs the damaged GAG layer and provides clinically significant symptom improvement 1, 2, 3

Lidocaine

• Intravesical lidocaine provides rapid onset temporary relief of bladder pain 1, 2, 3

Third-Line: Cystoscopy with Hydrodistension

• Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction 2, 3
• Avoid high-pressure and long-duration hydrodistension procedures as these increase risk of bladder rupture and sepsis without consistent benefit 2, 3

Fourth-Line: Treatment of Hunner Lesions

• If Hunner lesions are identified on cystoscopy, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone for significant symptom relief 1, 2, 3
• Hunner lesions become easier to identify after bladder distention when cracking and mucosal bleeding become evident 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these options only for patients who have failed all other treatments: 1, 2, 3

Sacral Neuromodulation

• Consider sacral neuromodulation for refractory cases, though evidence is Grade C with limited sample sizes and lack of durable follow-up 1, 2, 3
• This intervention is not FDA-approved for IC/BPS 2, 3

Cyclosporine A

• Cyclosporine A may be administered orally for refractory cases with Grade C evidence 1, 2, 3
• Not FDA-approved for IC/BPS 2, 3

Intradetrusor Botulinum Toxin A

• Botulinum toxin A injections may be beneficial but have Grade C evidence 1, 2, 3
• Patients must be willing to accept the possibility of needing intermittent self-catheterization post-treatment 1, 2, 3
• Not FDA-approved for IC/BPS 2, 3

Pain Management Throughout Treatment

• Initiate and maintain multimodal pain management approaches throughout treatment, with non-opioid alternatives strongly preferred due to the chronic nature of IC/BPS 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 despite multimodal approaches, refer to pain specialists 1

Treatments That Should NOT Be Offered

• Do NOT prescribe long-term oral antibiotics—Grade B evidence shows no significant benefit over placebo with risk of antibiotic resistance 2, 3
• Do NOT use intravesical BCG—Grade B evidence shows no efficacy compared to placebo with potentially life-threatening adverse events 2, 3
• Do NOT use intravesical resiniferatoxin—Grade A evidence shows no statistically significant benefit with high adverse event rates 2, 3
• Do NOT perform high-pressure, long-duration hydrodistension—Grade C recommendation against due to increased risk of bladder rupture and sepsis 2, 3
• Do NOT prescribe systemic long-term glucocorticoids—Grade C recommendation against due to serious adverse events outweighing minimal benefits 2

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used as strengthening may worsen symptoms 1, 2, 3
• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) to objectively measure treatment effects 1
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 1, 3
• Treatment efficacy for any individual is unpredictable—multiple therapeutic options may need to be tried sequentially before adequate symptom control is achieved 1, 3
• Ensure ophthalmologic examinations are scheduled for all patients taking pentosan polysulfate 1, 3, 4
• Counsel patients taking pentosan polysulfate to avoid anticoagulant therapy (warfarin, heparin, high-dose aspirin, NSAIDs) until discussing with their physician 4