What are the treatment options for interstitial cystitis?

Treatment 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 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 1, 2, 3
• Implement an elimination diet to identify personal trigger foods 1, 2, 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 only—never strengthening exercises, as these worsen symptoms 1, 2, 3
• Use bladder training with urge suppression techniques 1, 2
• Consider over-the-counter products like quercetin and calcium glycerophosphates 1

Second-Line: Oral Medications

When behavioral modifications prove insufficient, advance to pharmacologic therapy: 1, 2, 3

Amitriptyline (Preferred Initial Oral 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
• Common side effects include sedation, drowsiness, and nausea 1

Pentosan Polysulfate Sodium

• The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 1, 2, 3, 4
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 1, 2, 3
• Given recent concerns about pigmented maculopathy with chronic use, many patients choose not to start or discontinue this medication 5

Alternative Oral Options

• Cimetidine and hydroxyzine are additional second-line options 1

Second-Line: Intravesical Therapies

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

Dimethyl Sulfoxide (DMSO)

• The only FDA-approved intravesical therapy for IC/BPS 6, 4
• Instill 50 mL directly into the bladder via catheter, retain 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
• In severe cases with very sensitive bladders, perform initial treatments under anesthesia (saddle block suggested) 6

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

When second-line treatments fail: 2, 3

• Perform cystoscopy 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

If Hunner lesions are identified on cystoscopy: 1, 2, 3

• 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 distention when cracking and mucosal bleeding become evident 1

Fifth-Line: Advanced Interventions for Refractory Cases

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

Sacral Neuromodulation

• Has Grade C evidence with limited sample sizes and lack of durable follow-up 1, 2, 3
• Not FDA-approved for IC/BPS 2, 3

Cyclosporine A

• Has Grade C evidence and is not FDA-approved for IC/BPS 1, 2, 3

Intradetrusor Botulinum Toxin A

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

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, 3
• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 1, 3
• If pain management is inadequate, refer to pain specialists 1

Treatments That Should NOT Be Offered

The following have Grade A-C evidence AGAINST their use: 2, 3

• Long-term oral antibiotics (no benefit over placebo, risk of antibiotic resistance) 2, 3
• Intravesical BCG (no efficacy, potentially life-threatening adverse events) 2, 3
• Intravesical resiniferatoxin (no significant benefit, high adverse event rates) 2, 3
• High-pressure, long-duration hydrodistension (increased risk of bladder rupture and sepsis) 2, 3
• Systemic long-term glucocorticoids (serious adverse events outweigh minimal benefits) 2, 3

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used 1, 2, 3
• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) 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 7, 1, 3
• Ensure regular ophthalmologic examinations for patients using pentosan polysulfate 1, 2, 3

Special Considerations for Male Patients

• IC/BPS should be strongly considered in men whose pain is perceived to be related to the bladder 7
• Certain men have symptoms meeting criteria for both IC/BPS and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) 7
• In such cases, the treatment approach can include established IC/BPS therapies as well as therapies more specific to CP/CPPS 7