What treatment options are available for a patient with non-bacterial cystitis, suspected interstitial cystitis, and symptoms of bladder pain and urgency?

Treatment of Non-Bacterial Cystitis/Interstitial Cystitis

For non-bacterial cystitis suspected to be interstitial cystitis/bladder pain syndrome (IC/BPS), begin with behavioral modifications and self-care practices, then add oral medications or bladder instillations as needed, using concurrent multimodal therapy rather than sequential single-agent trials. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis requires:

• Symptoms present for at least 6 weeks with documented negative urine cultures 1
• Document specific characteristics: number of voids per day, constant urge sensation, location/character/severity of pain or pressure, relationship to bladder filling, and improvement with voiding 1
• Obtain baseline voiding diary (minimum one day) and pain scores using validated tools (GUPI, ICSI, or VAS) to measure treatment response 1
• Consider cystoscopy if Hunner lesions are suspected, as these patients respond well to specific treatments and should not be required to fail other therapies first 1

First-Line Treatment Approach: Behavioral and Non-Pharmacologic

Implement these measures immediately as they form the foundation of management:

Self-Care and Behavioral Modifications 1

• Dietary modifications: Eliminate common bladder irritants (caffeine, alcohol, acidic foods, artificial sweeteners) and use an elimination diet to identify personal triggers 1
• Fluid management: Adjust concentration and volume of urine through strategic hydration—neither excessive restriction nor overhydration 1
• Bladder training with urge suppression: Teach patients to void on schedule rather than responding to every urge 1
• Pelvic floor muscle relaxation (not strengthening exercises, which may worsen symptoms) 1
• Heat or cold application over bladder or perineum for symptom relief 1
• Avoid constipation, tight-fitting clothing, and activities that increase pelvic floor tension 1

Stress Management and Pain Coping 1

• Initiate stress management practices early, as psychological stress heightens pain sensitivity in IC/BPS patients 1
• Consider meditation, imagery, and other techniques for managing flare-ups 1
• Implement multimodal pain management including pharmacological and manual therapy approaches from the outset 1

Concurrent Oral Medication Options

The 2022 AUA guidelines no longer recommend sequential tier-based treatment; instead, oral medications can be started concurrently with behavioral measures: 1

Pentosan Polysulfate Sodium (Elmiron)

• FDA-approved specifically for IC/BPS at 100 mg three times daily, taken 1 hour before or 2 hours after meals 2
• Important caveat: Recent evidence has identified potential retinal toxicity with long-term use; the 2022 guideline includes new statements about monitoring for adverse events from pentosan polysulfate 1
• Acts as a weak anticoagulant—avoid concurrent use with warfarin, heparin, high-dose aspirin, or NSAIDs without physician consultation 2
• Common side effects include hair loss, diarrhea, nausea, and abnormal liver function tests 2

Other Oral Medications

While specific agents beyond pentosan polysulfate are not detailed in the provided guidelines, the 2022 update categorizes oral medicines as a distinct treatment category that can be combined with other modalities 1

Bladder Instillation Therapy

Intravesical treatments represent another concurrent option, particularly for patients with suspected glycosaminoglycan layer defects 3

• Hyaluronic acid instillations aim to repair damaged bladder lining and show good response rates 3
• Consider potassium sensitivity testing to predict therapeutic success, though this test is not recommended for routine diagnosis 1, 3

Treatment Monitoring and Adjustment

Reassess treatment efficacy periodically and discontinue ineffective therapies: 1

• Use baseline voiding diaries and pain scores to objectively measure response 1
• If pain management is inadequate, escalate to multidisciplinary approach with appropriate referrals 1
• Educate patients that IC/BPS is typically chronic with exacerbations and remissions, requiring dynamic management 1
• No single treatment benefits the majority of patients—acceptable symptom control often requires trials of multiple therapeutic options 1

Advanced Interventions for Refractory Cases

For patients who fail behavioral, oral, and instillation therapies:

• Procedures (including neuromodulation) are reserved for refractory cases 4
• Major surgery is considered only after exhausting less invasive options, except for patients with Hunner lesions who may benefit from earlier procedural intervention 1

Critical Pitfalls to Avoid

• Do not perform routine cystoscopy on all IC/BPS patients—the benefit/risk ratio is unfavorable, especially in younger patients with low Hunner lesion prevalence 1
• Do not use urodynamics for routine diagnosis—they are only indicated when suspecting outlet obstruction, poor detrusor contractility, or explaining treatment refractoriness 1
• Do not delay treatment waiting for definitive diagnosis—IC/BPS is primarily a clinical diagnosis of exclusion after ruling out infection and malignancy 1
• Do not treat as bacterial cystitis—standard antibiotics offer no relief and delay appropriate management 5

Special Considerations for Male Patients

In men with bladder-related pain, strongly consider IC/BPS diagnosis even though historically considered rare 1

• Symptoms overlap significantly with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) 1
• When symptoms meet criteria for both conditions, treatment can include IC/BPS therapies plus CP/CPPS-specific approaches 1
• Pain perceived as bladder-related (rather than prostatic/perineal) favors IC/BPS diagnosis 1