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 (amitriptyline or pentosan polysulfate), intravesical therapies (DMSO, heparin, lidocaine), 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
• Over-the-counter products such as quercetin and calcium glycerophosphates may provide symptomatic relief 1

Fluid and Physical Interventions

• Alter urine concentration through strategic fluid management to dilute urinary irritants 1, 2, 3
• Apply local heat or cold over the bladder or perineum for pain relief 1, 2, 3

Behavioral Techniques

• Practice stress management techniques including meditation and imagery 1, 2, 3
• Perform pelvic floor muscle relaxation exercises—avoid strengthening exercises as these may worsen symptoms 1, 2, 3
• Use bladder training with urge suppression techniques to manage frequency 1, 2, 3

Second-Line: Oral Medications

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, 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 1, 4, 6
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 1, 2, 3, 4
• Must be taken continuously for relief; it is not a pain medication like aspirin 4
• Take with water at least 1 hour before meals or 2 hours after meals 4
• Most common side effects include hair loss, diarrhea, nausea, blood in stool, headache, rash, upset stomach, abnormal liver function tests, dizziness, and bruising 4

Additional Second-Line Oral Options

• Cimetidine and hydroxyzine are additional oral medication options 1

Second-Line: Intravesical Therapies

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

Dimethyl Sulfoxide (DMSO/RIMSO-50)

• The only FDA-approved intravesical therapy for IC/BPS 6, 5
• Administer 50 mL instillation directly into the bladder for 15 minutes 1, 6
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals between treatments 1, 6
• Apply analgesic lubricant gel (such as lidocaine jelly) to the urethra prior to catheter insertion to avoid spasm 6
• Administer oral analgesic medication or suppositories containing belladonna and opium prior to instillation to reduce bladder spasm 6
• Patients may experience a garlic-like taste within minutes that may last several hours, and an odor on breath and skin that may remain for up to 72 hours 6
• In patients with severe IC and very sensitive bladders, initial treatments should be done under anesthesia (saddle block has been 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

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

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these interventions 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 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 needing 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 have no significant benefit over placebo (Grade B evidence against) 2, 3
• Intravesical BCG has no efficacy compared to placebo and potentially life-threatening adverse events (Grade B evidence against) 2, 3
• Intravesical resiniferatoxin has no statistically significant benefit and high adverse event rates (Grade A evidence against) 2, 3
• High-pressure, long-duration hydrodistension increases risk of bladder rupture and sepsis without consistent benefit (Grade C recommendation against) 2, 3
• Systemic long-term glucocorticoids have serious adverse events that outweigh minimal benefits (Grade C recommendation against) 2

Critical Pitfalls to Avoid

• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) 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, 4
• Patients on pentosan polysulfate should inform their doctor before undergoing surgery or beginning anticoagulant therapy such as warfarin, heparin, high doses of aspirin, or anti-inflammatory drugs like ibuprofen 4