What are the treatment options for a patient with interstitial cystitis?

Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Begin with behavioral modifications and dietary changes for all patients, then escalate systematically through oral medications, intravesical therapies, cystoscopy with hydrodistension, treatment of Hunner lesions if present, and reserve advanced interventions only for refractory cases that have failed all other treatments. 1

First-Line: Behavioral Modifications and Self-Care

All patients should start with conservative measures before progressing to pharmacologic interventions. 1

• Eliminate bladder irritants including coffee, citrus products, and spicy foods from the diet 1, 2
• Implement an elimination diet to systematically identify personal trigger foods that worsen symptoms 1, 2
• Manage fluid intake strategically to dilute urinary irritants and alter urine concentration 1, 2
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2
• Practice stress management techniques such as meditation and imagery to reduce symptom flares 1, 2
• Perform pelvic floor muscle relaxation exercises (not strengthening exercises, which may worsen symptoms) and consider referral for manual physical therapy 1, 2
• Consider over-the-counter products such as quercetin and calcium glycerophosphates for additional symptom relief 2

Second-Line: Oral Medications

When behavioral modifications provide insufficient relief, initiate oral pharmacotherapy. 1

• Amitriptyline is the preferred oral medication, starting at 10 mg daily and titrating up to 100 mg per day as tolerated, with Grade B evidence for symptom improvement 1, 2
  • Common side effects include sedation, drowsiness, and nausea 2
• Pentosan polysulfate sodium (Elmiron) 100 mg three times daily is the only FDA-approved oral medication for IC/BPS 1, 2, 3
  • Mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity 1, 2
• Alternative second-line oral options include cimetidine and hydroxyzine 1, 2

Second-Line: Intravesical Therapies

Intravesical instillations can be used concurrently with or following oral medications. 1

• Dimethyl sulfoxide (DMSO) is the only FDA-approved intravesical therapy, administered as 50 mL instillation directly into the bladder for 15 minutes, repeated every two weeks until maximum relief is obtained 2, 4, 3
  • Patients may experience a garlic-like taste within minutes that can last several hours, and an odor on breath and skin may persist up to 72 hours 4
  • Administration of oral analgesic medication or belladonna/opium suppositories prior to instillation can reduce bladder spasm 4
  • In patients with very sensitive bladders, initial treatments should be done under anesthesia 4
• Heparin intravesical therapy repairs the damaged glycosaminoglycan layer and provides clinically significant symptom improvement 1, 2
• Lidocaine intravesical therapy provides rapid onset temporary relief of bladder pain 1, 2

Third-Line: Cystoscopy with Hydrodistension

When second-line treatments fail, perform cystoscopy to assess anatomic bladder capacity and identify Hunner lesions. 1

• Cystoscopy determines anatomic bladder capacity and identifies fibrosis-related capacity reduction 1
• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 1
• Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 2

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, they should be treated immediately as this provides significant symptom relief. 1

• Perform fulguration (with laser or electrocautery) and/or injection of triamcinolone for Hunner lesions 1, 2

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these invasive options only for patients who have failed all previous treatment tiers. 1

• Sacral neuromodulation may be considered if other treatments have not provided adequate symptom control 1, 2
• Cyclosporine A may be administered orally for refractory cases 1, 2
• Intradetrusor botulinum toxin A injections may be beneficial, but patients must accept the possibility of needing intermittent self-catheterization 1, 2

Pain Management Throughout All Treatment Phases

Multimodal pain management should be initiated and maintained throughout treatment, with non-opioid alternatives strongly preferred due to the chronic nature of the condition. 1, 2

• Pain management alone does not constitute sufficient treatment; underlying bladder symptoms must also be addressed 1, 2
• If pain management is inadequate, consider referral to pain specialists 2

Critical Documentation and Patient Education

• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment effects 1, 2
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 1, 2
• Set realistic expectations, as treatment efficacy for any individual is unpredictable and multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 2

Common Pitfalls to Avoid

• Do not prescribe pelvic floor strengthening exercises, as these may worsen symptoms; only relaxation exercises are appropriate 1, 2
• Do not rely on pain management alone without addressing underlying bladder symptoms 1, 2
• Do not forget ophthalmologic monitoring for patients on pentosan polysulfate 1, 2