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

Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Begin with behavioral modifications and dietary elimination, then escalate systematically through oral medications (amitriptyline or cimetidine preferred), intravesical therapies, cystoscopy with hydrodistension, and reserve advanced interventions only for refractory cases that have failed all other treatments. 1

First-Line: Behavioral Modifications and Self-Care

All patients must start here before any pharmacologic intervention. 1

• Eliminate bladder irritants including coffee, citrus products, and spicy foods from the diet 1, 2
• Implement a systematic elimination diet to identify personal trigger foods that exacerbate symptoms 1, 2
• Manage fluid intake strategically: increase daytime hydration to dilute urinary irritants while restricting evening fluids to reduce nocturia 1, 2
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 3
• Practice stress management techniques such as meditation and imagery to reduce symptom flares 1
• Perform pelvic floor muscle relaxation exercises (not strengthening exercises), with consideration for referral to manual physical therapy 1

Second-Line: Oral Medications

When first-line measures fail, choose between amitriptyline or cimetidine based on predominant symptoms. 1, 2

Amitriptyline (Preferred for General IC/BPS Symptoms)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 1
• Grade B evidence for symptom improvement 1
• Common adverse effects may compromise quality of life, requiring careful monitoring 2

Cimetidine (Preferred When Nocturia is Predominant)

• Specifically improves nocturia with Grade B evidence and no reported adverse events 2
• Superior choice when nighttime urinary frequency is the most bothersome symptom 2

Alternative Second-Line Options

• Hydroxyzine is equally appropriate as amitriptyline or cimetidine, with Grade B or C evidence and minor adverse events 1
• Pentosan polysulfate sodium (Elmiron) 100 mg three times daily is the only FDA-approved oral medication, but mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity 1, 4

Second-Line: Intravesical Therapies

Can be used concurrently with oral medications or when oral medications fail. 1

• 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
• Dimethyl sulfoxide (RIMSO-50): instill 50 mL directly into the bladder via catheter, allow to remain for 15 minutes, repeat every two weeks until maximum symptomatic relief is obtained 5
• Apply analgesic lubricant gel (lidocaine jelly) to the urethra prior to catheter insertion to avoid spasm 5
• Administer oral analgesic medication or belladonna/opium suppositories prior to instillation to reduce bladder spasm 5

Third-Line: Cystoscopy with Hydrodistension

Perform only when second-line treatments fail. 1

• 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
• Identify Hunner lesions during cystoscopy for targeted treatment 1

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, treat them directly. 1

• Fulguration and/or injection of triamcinolone can provide significant symptom relief 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these only after all other treatments have failed. 1

• Sacral neuromodulation may be considered if other treatments have not provided adequate symptom control 1
• Cyclosporine A may be administered orally for refractory cases 1, 4
• Intradetrusor botulinum toxin A injections may be beneficial, but patients must accept the possibility of needing intermittent self-catheterization 1

Pain Management Throughout All Treatment Phases

Pain management is mandatory but never sufficient as monotherapy. 1, 2

• Initiate multimodal pain management approaches and maintain them throughout treatment 1, 2, 3
• Strongly prefer non-opioid alternatives 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

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
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 1
• Set realistic expectations: treatment efficacy for any individual is unpredictable, and multiple therapeutic options may need to be tried before adequate symptom control is achieved 1

Common Pitfalls to Avoid

• Do not skip first-line behavioral modifications—jumping directly to medications without dietary elimination and lifestyle changes reduces treatment success 1
• Do not use pentosan polysulfate without ophthalmologic monitoring—macular damage is a serious risk 1, 4
• Do not perform high-pressure hydrodistension—this increases risk of bladder rupture 1
• Do not rely on pain management alone—bladder-specific treatments must be included 1
• Do not use opioids as first-line pain management—the chronic nature of IC/BPS makes non-opioid alternatives strongly preferred 1, 2