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

Treatment and Medication for 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 if needed, and reserve advanced interventions only for cases that fail all other treatments. 1

First-Line: Behavioral Modifications (Start Immediately for All Patients)

Eliminate bladder irritants from the diet, specifically coffee, citrus products, and spicy foods, and implement an elimination diet to identify personal trigger foods that worsen symptoms. 1, 2

• Manage fluid intake strategically to dilute urinary irritants and alter urine concentration—this means either restricting fluids if overhydrated or increasing hydration if urine is too concentrated. 1, 2

• Apply local heat or cold directly over the bladder or perineum to provide symptomatic pain relief for trigger points and areas of hypersensitivity. 1, 2

• Practice stress management techniques including meditation and imagery to reduce symptom flares, as psychological stress is directly associated with heightened pain sensitivity in IC/BPS patients. 1, 2

• Perform pelvic floor muscle relaxation exercises (not strengthening exercises, which can worsen symptoms), and consider referral for manual physical therapy techniques. 1, 2

• Consider over-the-counter options including nutraceuticals, calcium glycerophosphates, or phenazopyridine for symptomatic relief. 2, 3

Multimodal Pain Management (Initiate Simultaneously with First-Line)

Initiate multimodal pain management approaches combining pharmacological agents with stress management techniques from the outset, as pain management is critical to quality of life but must be combined with treatment of underlying bladder symptoms—pain management alone is insufficient. 2, 1, 4

• Prioritize non-opioid alternatives strongly given the chronic nature of IC/BPS and the opioid crisis. 4

• If opioids are considered, use only after informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential abuse. 4

Second-Line: Oral Medications (When First-Line Provides Inadequate Control)

No single oral agent has proven superior, so selection depends on patient-specific factors and adverse effect profiles. 1, 4

Amitriptyline

• Start at 10 mg daily and titrate gradually up to 75-100 mg per day as tolerated for symptom improvement (Grade B evidence). 1, 4

• Warn patients that adverse effects are common and may compromise quality of life, including sedation, dry mouth, and constipation. 4

Pentosan Polysulfate Sodium (Elmiron)

• This is the only FDA-approved oral medication for IC/BPS, dosed at 100 mg three times daily. 1, 5

• Mandatory ophthalmologic monitoring is required due to risk of macular damage and pigmented maculopathy with chronic use—counsel patients on vision-related injury risks before initiating or continuing treatment. 1, 4, 5

• Many patients will choose to either not start or discontinue this medication after learning of the ocular toxicity risk. 5

Hydroxyzine

• Consider as an equally appropriate second-line option, particularly in patients with systemic allergies. 1, 4

• Common adverse effects include short-term sedation and weakness. 4

Cimetidine

• May provide clinically significant improvement in symptoms, pain, and nocturia with no adverse effects reported in studies. 1, 4

Second-Line: Intravesical Therapies (Can Be Used Alone or Combined with Oral Medications)

Dimethyl Sulfoxide (RIMSO-50)

• Instill 50 mL directly into the bladder via catheter, allow to remain for 15 minutes, then expel by spontaneous voiding. 6

• Apply lidocaine jelly to the urethra prior to catheter insertion to avoid spasm. 6

• Repeat treatment every two weeks until maximum symptomatic relief is obtained, then increase intervals between treatments appropriately. 6

• Administer oral analgesic medication or belladonna/opium suppositories prior to instillation to reduce bladder spasm. 6

• In patients with severe IC/BPS and very sensitive bladders, perform the initial treatment (and possibly second and third) under anesthesia (saddle block has been suggested). 6

• Warn patients that a garlic-like taste may occur within minutes and last several hours, with breath and skin odor persisting up to 72 hours. 6

• Consider baseline and periodic slit lamp eye examinations, as animal studies showed eye changes with large doses over prolonged periods. 6

Heparin

• Repairs the damaged glycosaminoglycan layer and provides clinically significant symptom improvement. 1

Lidocaine

• Provides rapid onset temporary relief of bladder pain. 1

Third-Line: Cystoscopy with Hydrodistension (When Second-Line Treatments Fail)

• Perform cystoscopy to determine anatomic bladder capacity and identify fibrosis-related capacity reduction. 1

• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis. 1

• Use this procedure to identify presence or absence of Hunner lesions, which dictates subsequent treatment. 2, 1

Fourth-Line: Treatment of Hunner Lesions (If Identified on Cystoscopy)

If Hunner lesions are identified, perform fulguration and/or injection of triamcinolone, which can provide significant symptom relief. 1

Fifth-Line: Advanced Interventions for Refractory Cases Only

• Consider sacral neuromodulation if other treatments have not provided adequate symptom control. 1, 7

• Administer cyclosporine A orally for refractory cases (immunotherapy option). 1, 7, 5

• Consider intradetrusor botulinum toxin A injections, but patients must accept the possibility of needing intermittent self-catheterization. 1

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 over time. 2, 1

• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term, continual, and dynamic management. 2, 1, 4

• Set realistic expectations that treatment efficacy for any individual is unpredictable, and multiple therapeutic options (including combination therapy) may need to be tried before adequate symptom control is achieved—no single treatment is effective for the majority of patients. 2, 1, 4

Common Pitfalls to Avoid

Do not perform cystoscopy for every IC/BPS patient, as the benefits/risks ratio is unfavorable for younger patients who have a much lower prevalence of Hunner lesions. 2

• Periodically reassess efficacy of treatment and stop ineffective treatments rather than continuing them indefinitely. 2

• Do not rely on pain management alone without addressing underlying bladder symptoms—this is insufficient treatment. 1, 4

• Avoid chronic opioid use unless absolutely necessary, with careful monitoring if prescribed. 4

• Screen for pentosan polysulfate vision risks before and during treatment, as many patients will decline or discontinue this medication after learning of ocular toxicity. 1, 4, 5