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

Management of Interstitial Cystitis/Bladder Pain Syndrome

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

First-Line: Behavioral Modifications and Self-Care

All patients should start with conservative measures before any pharmacologic intervention. 1, 2

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
• Regulate fluid intake to alter urine concentration and dilute urinary irritants 1, 2

Physical Interventions

• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2
• Focus on pelvic floor muscle relaxation techniques—avoid strengthening exercises as these may worsen symptoms 1, 2
• Implement bladder training with urge suppression techniques to manage frequency 1, 2

Stress Management

• Practice meditation and imagery techniques to manage stress-induced symptom exacerbations 1, 2
• Recognize that psychological stress is associated with heightened pain sensitivity in IC/BPS patients 1

Over-the-Counter Options

• Consider quercetin, calcium glycerophosphates, or phenazopyridine for symptom relief 1, 2

Second-Line: Oral Medications

When behavioral modifications prove insufficient, advance to pharmacologic therapy. 2, 4

Amitriptyline (Preferred Initial Oral Agent)

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 1, 2
• Has Grade B evidence showing 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

Pentosan Polysulfate Sodium

• The only FDA-approved oral medication for IC/BPS 2, 4
• Dose: 100 mg three times daily 2, 4
• Requires mandatory ophthalmologic monitoring due to risk of macular damage and ocular toxicity 2, 4

Additional Second-Line Options

• Cimetidine and hydroxyzine may be considered as alternative oral medications 2

Second-Line: Intravesical Therapies

These can be used concurrently with or following oral medications. 2, 4

Dimethyl Sulfoxide (DMSO)

• Instill 50 mL directly into the bladder via catheter, allow to remain 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 prior to catheter insertion to avoid spasm 5
• Consider oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 5
• In patients with very sensitive bladders, the initial 2-3 treatments should be done under anesthesia (saddle block suggested) 5

Heparin

• Repairs the damaged glycosaminoglycan (GAG) layer of the bladder 2, 4
• Provides clinically significant symptom improvement 2, 4

Lidocaine

• Provides rapid onset temporary relief of bladder pain 2, 4
• Can be combined with heparin or pentosan polysulfate and sodium bicarbonate for enhanced effect 6

Third-Line: Cystoscopy with Hydrodistension

Perform when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction. 3, 4

• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 3, 4
• Use cystoscopy to identify Hunner lesions, which become easier to visualize after distention when cracking and mucosal bleeding become evident 2

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, proceed with targeted treatment. 2, 3

• Perform fulguration (with laser or electrocautery) and/or injection of triamcinolone to provide significant symptom relief 2, 3

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these interventions for patients who have failed all other treatments. 3, 4

Sacral Neuromodulation

• Has Grade C evidence with limited sample sizes and lack of durable follow-up 3, 4
• Not FDA-approved for IC/BPS 3, 4

Cyclosporine A

• For refractory cases with Grade C evidence 3, 4
• Not FDA-approved for IC/BPS 3, 4

Intradetrusor Botulinum Toxin A

• Has Grade C evidence and is not FDA-approved for IC/BPS 3, 4
• Counsel patients on the possibility of requiring intermittent self-catheterization post-treatment 3, 4

Pain Management Throughout Treatment

Implement multimodal pain management approaches throughout all treatment phases, with non-opioid alternatives 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
• Due to the global opioid crisis, use chronic opioids judiciously and only after informed shared decision-making with periodic follow-ups to assess efficacy, adverse events, compliance, and potential for abuse 1
• If pain management is inadequate, refer to pain specialists 2

Treatments That Should NOT Be Offered

Long-Term Oral Antibiotics

• Grade B evidence against: no significant benefit over placebo with risk of antibiotic resistance and adverse events 3

Intravesical BCG

• Grade B evidence against: no efficacy compared to placebo with potentially life-threatening adverse events 3

Intravesical Resiniferatoxin

• Grade A evidence against: no statistically significant benefit with high adverse event rates 3

High-Pressure, Long-Duration Hydrodistension

• Grade C recommendation against: increased risk of bladder rupture and sepsis without consistent benefit 3

Systemic Long-Term Glucocorticoids

• Grade C recommendation against: serious adverse events outweigh minimal benefits 3

Critical Pitfalls to Avoid

• Do not prescribe pelvic floor strengthening exercises—only relaxation techniques should be used 1, 2
• Document baseline symptoms using validated tools such as the Genitourinary Pain Index (GUPI) or Interstitial Cystitis Symptom Index (ICSI) to measure treatment effects 2
• Educate patients that IC/BPS is a chronic disorder requiring continual and dynamic management with typical course involving symptom exacerbations and remissions 1, 4
• Inform patients that no single treatment has been found effective for the majority of patients and acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) 1, 4
• Ensure ophthalmologic examinations for patients on pentosan polysulfate 2, 4
• Consider a multidisciplinary approach and refer appropriately when symptoms are not adequately controlled 1