What is the recommended treatment approach for a patient with interstitial cystitis?

Treatment Approach for Interstitial Cystitis/Bladder Pain Syndrome

Begin with behavioral modifications and self-care practices for all patients, then systematically escalate through oral medications (starting with amitriptyline), intravesical therapies, and finally advanced interventions only for refractory cases. 1, 2, 3

Initial Management: Behavioral and Self-Care (Start Here for All Patients)

The 2022 AUA guideline fundamentally restructured IC/BPS treatment away from rigid "first-line through sixth-line" tiers toward a more flexible, individualized approach—but behavioral modifications remain the universal starting point. 1

Dietary Management

• Eliminate known bladder irritants including coffee, citrus products, and spicy foods 2, 3
• Implement an elimination diet to identify personal trigger foods that worsen symptoms 1, 2
• Alter urine concentration through strategic fluid management (either restriction or additional hydration depending on symptoms) 1, 2

Physical Symptom Management

• Apply local heat or cold over the bladder or perineum for pain relief 1, 2
• Practice pelvic floor muscle relaxation techniques—avoid strengthening exercises as these worsen symptoms 1, 2, 3
• Implement bladder training with urge suppression once pain is adequately controlled 1, 2

Stress and Psychological Management

• Use stress management techniques including meditation and imagery to manage symptom exacerbations 1, 2
• Address psychological stress, which is directly associated with heightened pain sensitivity in IC/BPS patients 1

Over-the-Counter Options

• Consider quercetin, calcium glycerophosphates, or phenazopyridine for symptom relief 2, 4

Second-Line: Oral Medications

When behavioral modifications prove insufficient after 6-8 weeks, advance to pharmacologic therapy. 1, 3

Amitriptyline (First Choice Oral Medication)

• Start at 10 mg daily at bedtime and titrate up to 100 mg per day as tolerated 1, 2, 3
• Grade B evidence shows superiority to placebo for symptom improvement 1, 2
• Common side effects include sedation, drowsiness, and nausea—these are not life-threatening but can compromise quality of life 1
• Low-dose initiation helps minimize adverse effects while achieving therapeutic benefit 1

Pentosan Polysulfate Sodium

• The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 2, 3
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and irreversible retinal changes 1, 2, 3
• The 2022 guideline added specific warnings about potential adverse events from this medication 1

Additional Oral Options

• Cimetidine and hydroxyzine are second-line alternatives 2
• Cyclosporine A may be considered for refractory cases (Grade C evidence) 2, 3

Second-Line: Intravesical Therapies (Can Be Used Concurrently with Oral Medications)

Dimethyl Sulfoxide (DMSO)

• Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding 5
• Repeat every two weeks until maximum symptomatic relief is obtained 5
• Apply lidocaine jelly to the urethra before catheter insertion to prevent spasm 5
• For patients with very sensitive bladders, perform initial treatments under anesthesia (saddle block suggested) 5

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder 2, 3
• Provides clinically significant symptom improvement 2

Lidocaine

• Provides rapid onset temporary relief of bladder pain 2, 3
• Can be combined with heparin or pentosan polysulfate plus sodium bicarbonate as an intravesical cocktail 6

Third-Line: Cystoscopy with Hydrodistension

Perform cystoscopy under anesthesia when second-line treatments fail or when Hunner lesions are suspected. 1, 3

• Use low-pressure, short-duration hydrodistension only—avoid high-pressure, long-duration distension due to risk of bladder rupture and sepsis 1, 3
• Allows determination of anatomic bladder capacity and identification of fibrosis-related capacity reduction 1, 3
• Mild distention makes Hunner lesions easier to identify when cracking and mucosal bleeding become evident 1, 2
• One or two exposures can result in clinically significant relief of bladder pain 1

Fourth-Line: Treatment of Hunner Lesions (If Present)

If Hunner lesions are identified on cystoscopy, perform fulguration with electrocautery and/or injection of triamcinolone immediately. 1, 2, 3

• This constitutes one of the few IC/BPS therapies resulting in improvement measured in months with only a single exposure 1
• Symptoms can recur and patients require periodic retreatment as response decreases over time 1
• Multiple electrocauterizations do not significantly diminish bladder capacity 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these interventions for patients who have failed all conservative, oral, and intravesical therapies over an adequate 3-6 month trial period. 3, 7

Sacral Neuromodulation

• Only consider for patients with predominant frequency/urgency symptoms—NOT for pain-predominant disease 1, 7
• Grade C evidence with limited sample sizes and lack of long-term follow-up data 3, 7
• Not FDA-approved for IC/BPS (approved for frequency/urgency indication) 1, 7
• Perform a trial of nerve stimulation first; only implant permanent device if trial is successful 1

Intradetrusor OnabotulinumtoxinA

• May be administered if other treatments have failed (Grade C evidence) 1, 3
• Patients must be willing to accept the possibility of requiring intermittent self-catheterization 1, 3

Pain Management Throughout Treatment

Implement multimodal pain management approaches from the beginning, but pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed. 1, 2, 3

• Prioritize non-opioid alternatives due to the chronic nature of IC/BPS and the global opioid crisis 1
• If using chronic opioids, employ informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse 1
• Consider referral to pain specialists if pain management is inadequate 2

Treatments That Should NOT Be Offered

• Long-term oral antibiotics (Grade B evidence against use) 1
• Intravesical BCG 1
• Intravesical resiniferatoxin 3
• High-pressure, long-duration hydrodistension 3
• Systemic long-term glucocorticoids 3

Critical Pitfalls to Avoid

• Never prescribe pelvic floor strengthening exercises—only relaxation techniques should be used, as strengthening worsens symptoms 1, 2, 3
• Document baseline symptoms using validated tools (genitourinary pain index or interstitial cystitis symptom index) to objectively measure treatment effects 2
• Educate patients that IC/BPS is a chronic disorder with symptom exacerbations and remissions requiring long-term management 1, 3
• Counsel patients that treatment efficacy is unpredictable and multiple therapeutic options may need to be tried before adequate symptom control is achieved 1, 3
• Ensure ophthalmologic examinations for all patients on pentosan polysulfate—if retinal changes develop, risks and benefits must be reevaluated as changes may be irreversible 1, 3
• Recognize that IC/BPS is heterogeneous with different phenotypes—except for patients with Hunner lesions, initial treatment should typically be nonsurgical 1
• Consider concurrent, multimodal therapies rather than sequential monotherapy for better outcomes 1