Interstitial Cystitis vs Bladder Pain Syndrome: Treatment Approach
Terminology and Definition
Interstitial cystitis (IC) and bladder pain syndrome (BPS) are now considered the same condition, referred to as IC/BPS, defined as unpleasant bladder-related sensation (pain, pressure, discomfort) with lower urinary tract symptoms lasting more than six weeks, in the absence of infection or other identifiable causes. 1
The key distinction that matters clinically is not IC versus BPS, but rather whether Hunner lesions are present on cystoscopy, as this fundamentally changes treatment approach. 1, 2
Diagnostic Considerations
Basic assessment includes urinalysis and urine culture to exclude infection and other conditions. 1
Cystoscopy is not required for diagnosis in uncomplicated presentations but should be performed when diagnosis is uncertain or when Hunner lesions are suspected. 1
Hunner lesions (inflammatory ulcerations) are the only consistent cystoscopic finding diagnostic for IC/BPS, while glomerulations are non-specific and can occur in asymptomatic patients. 1
Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment response. 2, 3
Treatment Algorithm: Stepwise Conservative to Aggressive Approach
First-Line Treatments (Offer to ALL Patients)
Begin with behavioral modifications and patient education before escalating to pharmacologic interventions. 1
Dietary modifications: Eliminate bladder irritants including coffee, citrus products, and spicy foods; implement elimination diet to identify personal triggers. 1, 4, 3
Fluid management: Alter urine concentration through strategic fluid intake to dilute urinary irritants. 1, 2, 4
Local temperature therapy: Apply heat or cold over bladder or perineum for symptomatic pain relief. 1, 2, 4
Stress management: Use meditation, imagery, and relaxation strategies to manage symptom flares. 1, 4, 3
Pelvic floor muscle relaxation (NOT strengthening exercises, which may worsen symptoms): Consider referral for manual physical therapy. 1, 4, 3
Bladder training with urge suppression to improve bladder control. 1, 2, 4
Over-the-counter supplements: Trial of quercetin or calcium glycerophosphates may provide relief. 1, 4
Second-Line Treatments
Initiate multimodal pain management with oral and/or intravesical medications when first-line measures provide inadequate symptom control. 1
Oral Medications:
Amitriptyline 10-100 mg daily is recommended as one of the most effective oral medications (Evidence Strength Grade B). 1, 2, 4, 5
Pentosan polysulfate sodium (Elmiron) 100 mg three times daily is the only FDA-approved oral medication for IC/BPS. 4, 6, 7, 5
Alternative oral options: Cimetidine and hydroxyzine may be considered. 1, 2, 4, 3
Intravesical Treatments:
Dimethyl sulfoxide (DMSO) 50 mL instillation is the only FDA-approved intravesical therapy. 8, 7
Heparin instillations repair the damaged glycosaminoglycan layer and provide clinically significant improvement. 1, 2, 4, 3
Lidocaine instillations provide rapid onset temporary relief of bladder pain. 1, 2, 4, 3
Pain Management Throughout Treatment:
Implement multimodal pain management approaches (pharmacological, stress management, manual therapy) continuously throughout treatment. 1, 4, 3
Non-opioid alternatives are strongly preferred given the chronic nature of IC/BPS. 3
Pain management alone is insufficient—underlying bladder symptoms must also be addressed. 1, 4, 3
Refer to pain specialists if pain control is inadequate with primary treatment. 1, 4
Third-Line Treatment
- Cystoscopy with hydrodistension serves both diagnostic and therapeutic purposes when second-line treatments fail. 1, 2, 3
Fourth-Line Treatment: Hunner Lesions
If Hunner lesions are identified on cystoscopy, fulguration (laser or electrocautery) and/or triamcinolone injection should be performed immediately, as this provides significant symptom relief. 1, 2, 4, 3
- Hunner lesions become easier to identify after distention when cracking and mucosal bleeding occur. 1, 4
Fifth-Line Treatments (Refractory Cases Only)
These interventions should be limited to practitioners with experience managing IC/BPS and willingness to provide long-term post-intervention care. 1
Sacral neuromodulation: Trial first; if successful, implant permanent device. 1, 2, 3
Intradetrusor botulinum toxin A injections: Patients must accept possibility of requiring intermittent self-catheterization post-treatment. 1, 4, 3
Important limitation: None of these therapies are FDA-approved for IC/BPS, and evidence is limited by small sample sizes and lack of durable follow-up. 1
Sixth-Line Treatment: Major Surgery
Major surgery (substitution cystoplasty, urinary diversion with or without cystectomy) should be reserved only for carefully selected patients with severe, unremitting symptoms who have failed all other treatment options. 1, 2
- Surgical treatments are appropriate only after exhausting all other alternatives, or when end-stage small fibrotic bladder is confirmed and quality of life warrants major surgery. 1
Treatments That Should NOT Be Offered
Long-term oral antibiotics show no significant efficacy versus placebo and risk fostering antibiotic-resistant organisms (Evidence Strength Grade B). 1
Intravesical bacillus Calmette-Guérin (BCG) shows no efficacy compared to placebo with potentially life-threatening adverse events (Evidence Strength Grade B). 1
Critical Clinical Pitfalls
Avoid pelvic floor strengthening exercises—these worsen symptoms; only relaxation techniques should be used. 4, 3
Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management. 2, 3
Set realistic expectations: Treatment efficacy is unpredictable for any individual; multiple therapeutic trials may be needed before adequate symptom control is achieved. 3
Discontinue ineffective treatments after an appropriate trial period rather than continuing indefinitely. 2