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 advance 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 pharmacologic intervention: 1, 2, 3

Dietary Management

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods 1, 2, 3
• Implement an elimination diet to identify personal trigger foods 1, 3
• Alter urine concentration through strategic fluid management to dilute urinary irritants 1, 2, 3

Physical and Behavioral Interventions

• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2, 3
• Practice stress management techniques such as meditation and imagery 1, 2, 3
• Perform pelvic floor muscle relaxation exercises—NOT strengthening exercises, which may worsen symptoms 1, 2, 3
• Use bladder training with urge suppression techniques to manage frequency 1, 2, 3

Over-the-Counter Options

• Consider quercetin and calcium glycerophosphates for symptom relief 1

Second-Line: Oral Medications

Amitriptyline (Preferred Initial Agent)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 1, 2, 3
• Has Grade B evidence showing superiority to placebo for symptom improvement 1, 2, 3
• Common side effects include sedation, drowsiness, and nausea 1

Pentosan Polysulfate Sodium (Elmiron)

• The only FDA-approved oral medication for IC/BPS 1, 4, 5
• Dose: 100 mg three times daily, taken with water at least 1 hour before meals or 2 hours after meals 1, 4
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and pigmented maculopathy 1, 3, 6
• Many patients now choose not to start or discontinue this medication due to ocular toxicity concerns 6

Alternative Oral Agents

• Hydroxyzine and cimetidine are additional second-line options 1
• Cyclosporine A may be used for refractory cases (Grade C evidence, not FDA-approved for IC/BPS) 2, 3, 6

Second-Line: Intravesical Therapies

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

Dimethyl Sulfoxide (DMSO)

• The only FDA-approved intravesical therapy for IC/BPS 7, 5
• Administer 50 mL instillation directly into the bladder for 15 minutes 1, 7
• Repeat every two weeks until maximum symptomatic relief is obtained 1, 7
• Patients may experience a garlic-like taste within minutes that can last several hours, with odor on breath and skin persisting up to 72 hours 7
• Apply lidocaine jelly to the urethra prior to catheter insertion to avoid spasm 7

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder 1, 2, 3
• Provides clinically significant symptom improvement 1, 2, 3

Lidocaine

• Provides rapid onset temporary relief of bladder pain 1, 2, 3

Third-Line: Cystoscopy with Hydrodistension

• Perform 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 to minimize risk of bladder rupture and sepsis 2, 3

Fourth-Line: Treatment of Hunner Lesions

• Perform cystoscopy in patients for whom Hunner lesions are suspected 1
• Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 1
• If Hunner lesions are present, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone 1, 2, 3
• This provides significant symptom relief for this specific subtype 1, 2, 3

Fifth-Line: Advanced Interventions for Refractory Cases

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

Sacral Neuromodulation

• Has Grade C evidence with limited sample sizes and lack of durable follow-up 2, 3
• Not FDA-approved for IC/BPS 2, 3

Intradetrusor Botulinum Toxin A

• Has Grade C evidence and is not FDA-approved for IC/BPS 2, 3
• Patients must be willing to accept the possibility of requiring intermittent self-catheterization post-treatment 1

Pain Management Throughout Treatment

• Initiate and maintain multimodal pain management approaches throughout treatment, with non-opioid alternatives preferred due to the chronic nature of the condition 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, consider referral to pain specialists 1

Treatments That Should NOT Be Offered

• Long-term oral antibiotics: no significant benefit over placebo with risk of antibiotic resistance (Grade B evidence against) 2, 3
• Intravesical BCG: no efficacy compared to placebo with potentially life-threatening adverse events (Grade B evidence against) 2, 3
• Intravesical resiniferatoxin: no statistically significant benefit with high adverse event rates (Grade A evidence against) 2, 3
• High-pressure, long-duration hydrodistension: increased risk of bladder rupture and sepsis without consistent benefit (Grade C recommendation against) 2, 3
• Systemic long-term glucocorticoids: serious adverse events outweigh minimal benefits (Grade C recommendation against) 2, 3

Critical Pitfalls to Avoid

• Do not prescribe pelvic floor strengthening exercises—only relaxation techniques should be used 1, 2, 3
• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to 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 before adequate symptom control is achieved 1, 3
• Ensure ophthalmologic examinations for patients on pentosan polysulfate 1, 3, 6
• Patients undergoing surgery should discuss when to discontinue pentosan polysulfate prior to surgery 4
• Avoid anticoagulant therapy (warfarin, heparin, high-dose aspirin, NSAIDs) while on pentosan polysulfate without physician consultation, as it is a weak anticoagulant 4