What are the considerations for using triamcinolone (corticosteroid) injections in a patient with interstitial cystitis?

Triamcinolone Injection for Interstitial Cystitis/Bladder Pain Syndrome

If Hunner lesions are present on cystoscopy, fulguration with electrocautery and/or injection of triamcinolone should be performed, as this constitutes one of the few IC/BPS therapies resulting in improvement measured in months with only a single exposure. 1

Diagnostic Prerequisites

Before considering triamcinolone injection, cystoscopy under anesthesia must be performed to identify Hunner lesions, which appear as circumscribed inflammatory ulcerations in the bladder wall that become more evident with mild distention when cracking and mucosal bleeding occur. 1 Biopsy should be obtained to rule out malignancy, carcinoma in situ, or other bladder pathology before proceeding with therapeutic intervention. 2, 3

Injection Technique and Dosing

The recommended approach is submucosal injection of triamcinolone acetonide 40 mg/mL, administered in 0.5 mL aliquots (total volume 10 mL) into the center and periphery of the Hunner lesion(s) using an endoscopic needle under general anesthesia. 2, 3 This technique differs from simple fulguration alone and can be performed after electrocautery or as monotherapy. 1

The injection should be placed into the submucosal space rather than superficially, as proper depth is critical for efficacy and to avoid complications. 4

Expected Outcomes and Efficacy

• Symptom improvement occurs in approximately 70-91% of patients treated with triamcinolone injection, with significant reductions in validated symptom scores (IPSS decreasing from mean 21.1 to 11.3, PUF scores from 20.0 to 11.0). 2, 3
• The treatment provides relief lasting several months, with median time to repeat treatment ranging from 8-12 months. 3
• Unlike many IC/BPS therapies, Hunner lesion treatment with triamcinolone results in improvement measured in months rather than weeks, making it one of the more durable single-exposure treatments available. 1

Retreatment Strategy

Symptoms and Hunner lesions commonly recur, and periodic retreatment should be anticipated and discussed with patients before initial therapy. 1 Approximately 74% of patients require repeat injections, with the number of treatments not significantly diminishing bladder capacity. 3 Repeat cystoscopy should be performed when symptoms recur to confirm lesion recurrence before additional treatment. 3

Combination Approaches

For refractory or ulcerative cases, triamcinolone can be combined with:

• Intravesical hydrocortisone (200 mg) and heparin (25,000 IU) weekly for 6 weeks, which showed 73% complete pain relief in one study. 5
• Intravesical DMSO with triamcinolone instillations, which demonstrated significant improvements in bladder capacity (median increase 75 mL), inter-void interval, and nocturia. 6
• Systemic intramuscular triamcinolone 40 mg weekly for 6 weeks for ulcerative, refractory, and recurrent cases that do not respond adequately to local treatment alone. 5

Critical Safety Considerations

Systemic long-term oral glucocorticoid administration should not be offered for IC/BPS, as risks clearly outweigh benefits despite reported efficacy rates of 47-64%, given serious adverse events including new-onset diabetes, pneumonia with septic shock, and hypertension in small studies. 1 This prohibition does not preclude short-term glucocorticoid therapy for symptom flares. 1

Local triamcinolone injection is generally well-tolerated with no significant perioperative complications reported in published series. 2, 3 However, atrophy of subcutaneous tissue may occur if injection is not properly administered into the submucosal space. 4

When Triamcinolone Fails

For patients who do not achieve adequate symptom control with repeated fulguration and triamcinolone injections, adjunctive treatment with cyclosporine should be considered before proceeding to cystectomy. 3 In one series, 47.2% of patients required cyclosporine, and only 7.2% ultimately required cystectomy. 3

Advanced immunosuppressive therapies approved for inflammatory bowel disease (TNF-α antagonists, vedolizumab, ustekinumab, JAK inhibitors) may also be considered for chronic antibiotic-refractory pouchitis in similar inflammatory bladder conditions, though evidence specific to IC/BPS is limited. 1

Common Pitfalls to Avoid

• Do not delay endoscopic evaluation and treatment in patients with suspected Hunner lesions—early progression from conservative treatments to endoscopic management provides excellent symptom control. 3, 7
• Do not use high-pressure (>80-100 cm H₂O), long-duration (>10 minutes) hydrodistension, as this increases serious adverse events including bladder rupture without consistent benefit increase. 1
• Do not offer intravesical resiniferatoxin, as high-quality RCTs showed no benefit over placebo despite adverse event rates of 52-89%. 1
• Do not assume treatment failure means wrong diagnosis—recurrence is the natural history of Hunner lesions, and repeat treatment is expected rather than indicative of treatment failure. 1, 3