What are the treatment options for interstitial cystitis?

Treatment of 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, treatment of Hunner lesions if present, and reserve advanced interventions only for refractory cases that have failed all other treatments. 1, 2

First-Line Treatment: Behavioral Modifications (Required for All Patients)

Dietary Management:

• Eliminate coffee, citrus fruits, tomatoes, carbonated beverages, alcoholic drinks, spicy foods, artificial sweeteners, and vitamin C from the diet 1, 2, 3
• Implement an elimination diet to identify personal trigger foods that reproducibly worsen symptoms 1, 2
• Consider using calcium glycerophosphate (Prelief) or sodium bicarbonate before consuming potential trigger foods to reduce sensitivity 3

Fluid and Symptom Management:

• Alter urine concentration strategically through fluid restriction or additional hydration to dilute urinary irritants 1, 2
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 1, 2
• Practice stress management techniques including meditation and imagery to manage symptom flares 1, 2

Pelvic Floor Management:

• Perform pelvic floor muscle relaxation exercises only—never strengthening exercises, as these can worsen symptoms 1, 2
• Consider referral for manual physical therapy techniques 1

Critical Documentation:

• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) or Genitourinary Pain Index (GUPI) to measure treatment effects 1, 4

Second-Line Treatment: Oral Medications

When first-line behavioral modifications prove insufficient, advance to pharmacologic therapy. 2

Amitriptyline (Grade B Evidence):

• Start at 10 mg daily and titrate up to 100 mg per day as tolerated 5, 1, 2
• Superior to placebo for symptom improvement, though adverse events (sedation, drowsiness, nausea) are common 5

Pentosan Polysulfate Sodium (Elmiron):

• The only FDA-approved oral medication for IC/BPS at 100 mg three times daily 1, 2
• Mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity 1, 2
• Ensure baseline and periodic eye examinations including slit lamp examinations 2

Alternative Second-Line Oral Options:

• Cimetidine and hydroxyzine are equally appropriate alternatives with Grade B or C evidence 1
• No hierarchy exists among second-line oral medications—selection depends on patient-specific factors and adverse event profiles 1

Second-Line Treatment: Intravesical Therapies

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

Dimethyl Sulfoxide (DMSO/RIMSO-50):

• FDA-approved for symptomatic relief of interstitial cystitis 6
• Patients will experience a garlic-like taste within minutes that may last several hours, with breath and skin odor persisting up to 72 hours 6
• May change effectiveness of concurrent medications—review all current medications before instillation 6
• Eye evaluations including slit lamp examinations should be performed prior to and periodically during treatment 6

Heparin:

• Repairs the damaged glycosaminoglycan layer of the bladder and provides clinically significant symptom improvement 1, 2

Lidocaine:

• Provides rapid onset temporary relief of bladder pain 1, 2

Third-Line Treatment: Cystoscopy with Hydrodistension

Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction. 1, 2

Critical Safety Consideration:

• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 1, 2

Fourth-Line Treatment: Hunner Lesions

If Hunner lesions are identified on cystoscopy, perform fulguration and/or injection of triamcinolone to provide significant symptom relief. 1, 2

Fifth-Line Treatment: Advanced Interventions for Refractory Cases

Reserve these interventions only for patients who have failed all other treatments. 2

Sacral Neuromodulation:

• May be considered with Grade C evidence, though it is not FDA-approved for IC/BPS and has limited sample sizes with lack of durable follow-up 2

Cyclosporine A:

• May be administered orally for refractory cases with Grade C evidence, not FDA-approved for IC/BPS 1, 2

Intradetrusor Botulinum Toxin A:

• May be beneficial with Grade C evidence, but patients must accept the possibility of needing intermittent self-catheterization 1, 2

Pain Management Throughout All Treatment Phases

Initiate multimodal pain management approaches and maintain them throughout treatment, with non-opioid alternatives strongly 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 5, 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 5

Treatments That Should NOT Be Offered

Do not offer the following due to lack of efficacy or increased risk of adverse events: 2

• Long-term oral antibiotics 2
• Intravesical BCG 2
• Intravesical resiniferatoxin 2
• High-pressure long-duration hydrodistension 2
• Systemic long-term glucocorticoids 2

Critical Patient Education

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

• 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, 2
• Adequate symptom control is achievable but may require trials of multiple therapeutic options including combination therapy 5, 1