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 systematically escalate through oral medications, intravesical therapies, cystoscopy with hydrodistension, and reserve advanced interventions only for refractory cases that have failed all other treatments. 1, 2, 3

First-Line: Behavioral Modifications and Self-Care

Start every patient with conservative measures before considering pharmacologic intervention 2, 3:

• Eliminate bladder irritants including coffee, citrus products, and spicy foods from the diet 2, 3, 4
• Implement an elimination diet to systematically identify personal trigger foods that worsen symptoms 2, 3, 4
• Manage fluid intake strategically to dilute urinary irritants and alter urine concentration 2, 3, 4
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 2, 3, 4
• Practice stress management techniques such as meditation and imagery to reduce symptom flares 2, 3, 4
• Perform pelvic floor muscle relaxation exercises only—never strengthening exercises, as these may worsen symptoms 2, 3, 4
• Consider bladder training with urge suppression techniques 1, 2
• Try over-the-counter products such as quercetin and calcium glycerophosphates, which may provide relief 2, 5

Second-Line: Oral Medications

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

Amitriptyline (Preferred First Oral Agent)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 2, 3, 4
• Has Grade B evidence showing superiority to placebo for symptom improvement 2, 3
• Common side effects include sedation, drowsiness, and nausea 2

Pentosan Polysulfate Sodium (Elmiron)

• The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 2, 3, 6
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 2, 3, 6
• Must be taken at least 1 hour before meals or 2 hours after meals 6
• Is a weak anticoagulant; avoid concurrent use with warfarin, heparin, high-dose aspirin, or NSAIDs without physician consultation 6

Alternative Second-Line Oral Options

• Cimetidine and hydroxyzine are additional options 2, 7

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 8, 9
• Instill 50 mL directly into the bladder via catheter, allow to remain for 15 minutes, then expel by spontaneous voiding 8
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals between treatments 8
• Apply lidocaine jelly to the urethra before catheter insertion to avoid spasm 8
• Patients may experience a garlic-like taste within minutes that can last several hours, and an odor on breath and skin for up to 72 hours 8
• Consider oral analgesics or belladonna/opium suppositories before instillation to reduce bladder spasm 8

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer and provides clinically significant symptom improvement 2, 3, 4

Lidocaine

• Provides rapid onset temporary relief of bladder pain 2, 3, 4

Third-Line: Cystoscopy with Hydrodistension

• Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction 3, 4
• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 3, 4
• Serves both diagnostic and therapeutic purposes 10, 11

Fourth-Line: Treatment of Hunner Lesions

• If Hunner lesions are identified on cystoscopy, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone 1, 2, 3, 4
• Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 2
• This intervention can provide significant symptom relief for this specific IC/BPS subtype 2, 3, 4

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these only for patients who have failed all other treatments 1, 3, 4:

Sacral Neuromodulation

• May be considered if other treatments have not provided adequate symptom control 2, 3, 4
• Has Grade C evidence with limited sample sizes and lack of durable follow-up 1, 3
• Not FDA-approved for IC/BPS 1, 3

Cyclosporine A

• May be administered orally for refractory cases 2, 3, 4
• Has Grade C evidence and is not FDA-approved for IC/BPS 1, 3

Intradetrusor Botulinum Toxin A

• May be beneficial, but patients must accept the possibility of needing intermittent self-catheterization 2, 3, 4
• Has Grade C evidence and is not FDA-approved for IC/BPS 1, 3

Sixth-Line: Surgical Options

• Urinary diversion with or without cystectomy, or substitution cystoplasty should only be considered for end-stage structurally small bladders after all other options have failed 1

Pain Management Throughout All Treatment Phases

• Initiate multimodal pain management approaches and maintain them throughout treatment, with non-opioid alternatives strongly preferred due to the chronic nature of the condition 2, 3, 4
• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 2, 3, 4
• If pain management is inadequate, refer to pain specialists 2

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used, as strengthening may worsen symptoms 2, 3, 4
• Ensure ophthalmologic examinations for all patients on pentosan polysulfate due to risk of macular damage 2, 3, 6
• 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 3
• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment effects 2, 4
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 2, 3, 4
• Set realistic expectations—treatment efficacy is unpredictable, and multiple therapeutic options may need to be tried before adequate symptom control is achieved 2, 3, 4

Treatment Algorithm Summary

The AUA guidelines recommend a stepwise approach where treatments are ordered from most to least conservative, with surgical treatment appropriate only after other options have been found ineffective 1. Initial treatment level depends on symptom severity, and multiple simultaneous treatments may be considered if in the patient's best interests 1. Ineffective treatments should be stopped, and diagnosis should be reconsidered if no improvement occurs within a clinically meaningful timeframe 1.