What is the recommended treatment for interstitial cystitis?

Treatment for Interstitial Cystitis/Bladder Pain Syndrome

Begin all patients with dietary elimination of bladder irritants (coffee, citrus, spicy foods) and pelvic floor relaxation exercises, then escalate systematically through oral amitriptyline or pentosan polysulfate, followed by intravesical therapies (heparin, lidocaine, or DMSO), reserving cystoscopy and advanced interventions only for refractory cases. 1, 2, 3

Initial Conservative Management

All patients should start with behavioral modifications before any pharmacologic intervention. 1, 2, 3

• Eliminate coffee, citrus products, and spicy foods from the diet, then implement a systematic elimination diet to identify personal trigger foods 2, 3
• Manage fluid intake strategically to dilute urinary irritants and alter urine concentration 2, 3
• Apply local heat or cold over the bladder or perineum for symptomatic pain relief 2, 3
• Practice stress management techniques including meditation and imagery to reduce symptom flares 2, 3
• Perform pelvic floor muscle relaxation exercises only—never strengthening exercises—and consider referral for manual physical therapy 2, 3

Common pitfall: Prescribing pelvic floor strengthening exercises will worsen symptoms; only relaxation techniques should be used. 2, 3

Second-Line: Oral Medications

When conservative measures prove insufficient after an adequate trial (typically 6 weeks), advance to oral pharmacotherapy. 1, 2

Amitriptyline (Preferred First Oral Agent)

• Start at 10 mg daily at bedtime and titrate up to 100 mg per day as tolerated 2, 3
• Has Grade B evidence showing superior symptom improvement compared to placebo 2
• Side effects include sedation, dry mouth, and constipation 2

Pentosan Polysulfate Sodium (Elmiron)

• Dose: 100 mg three times daily 2, 3
• The only FDA-approved oral medication specifically for IC/BPS 2, 3
• Mandatory ophthalmologic monitoring is required due to risk of macular damage and ocular toxicity 2, 3
• Critical pitfall: Many patients will choose not to start or will discontinue this medication due to the concerning risk of pigmented maculopathy with chronic use 4

Alternative Second-Line Oral Options

• Hydroxyzine: effective antihistamine option with minor adverse events and Grade B/C evidence 3, 5
• Cimetidine: H2-blocker alternative 3

Second-Line: Intravesical Therapies

Intravesical treatments can be used concurrently with or following oral medications. 2, 3

Dimethyl Sulfoxide (DMSO/RIMSO-50)

• Instill 50 mL directly into the bladder via catheter, retain for 15 minutes, then expel by spontaneous voiding 6
• Repeat every two weeks until maximum symptomatic relief is obtained, then increase intervals appropriately 6
• Apply lidocaine jelly to the urethra prior to catheter insertion to avoid spasm 6
• Consider oral analgesics or belladonna/opium suppositories prior to instillation to reduce bladder spasm 6
• In patients with very sensitive bladders, perform initial treatments under anesthesia (saddle block suggested) 6

Heparin

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

Lidocaine

• Provides rapid onset temporary relief of bladder pain 2, 3
• Can be combined with other intravesical agents 2

Third-Line: Cystoscopy with Hydrodistension

Perform cystoscopy when second-line treatments fail to determine anatomic bladder capacity and identify fibrosis-related capacity reduction. 2, 3

• Avoid high-pressure and long-duration hydrodistension to minimize risk of bladder rupture and sepsis 2
• Most patients with IC/BPS may tolerate office flexible cystoscopy without hydrodistension 1
• Some patients may prefer cystoscopy under general anesthesia 1

Fourth-Line: Treatment of Hunner Lesions

If Hunner lesions are identified on cystoscopy, perform fulguration and/or injection of triamcinolone immediately—these patients do not need to fail other treatments first. 1, 2, 3

• Hunner lesions are the only consistent cystoscopic finding diagnostic for IC/BPS 1
• Early diagnosis by cystoscopy is recommended in patients suspected to have these lesions 1
• Most patients with Hunner lesions will respond to treatment 1

Fifth-Line: Advanced Interventions for Refractory Cases

Reserve these interventions only for patients who have failed all other treatments. 2, 3

Sacral Neuromodulation

• Has Grade C evidence with limited sample sizes and lack of durable follow-up 2
• Not FDA-approved for IC/BPS 2
• Consider only if other treatments have not provided adequate symptom control 3

Cyclosporine A

• Oral immunosuppressive therapy for refractory cases 3, 5
• Has Grade C evidence and is not FDA-approved for IC/BPS 2

Intradetrusor Botulinum Toxin A

• May be beneficial but patients must accept the possibility of needing intermittent self-catheterization 3
• Has Grade C evidence and is not FDA-approved for IC/BPS 2

Pain Management Throughout Treatment

Initiate multimodal pain management approaches early and maintain throughout treatment, strongly preferring non-opioid alternatives due to the chronic nature of the condition. 2, 3

• Pain management alone does not constitute sufficient treatment—underlying bladder symptoms must also be addressed 2, 3
• Consider chronic opioid therapy only after shared decision-making, limited to select patients, with regular follow-up to assess efficacy, adverse events, compliance, and abuse risk 2
• Pain and nocturia are the symptoms most likely to impair overall physical quality of life 7

Treatments That Should NOT Be Offered

Do not offer long-term oral antibiotics, intravesical BCG, intravesical resiniferatoxin, high-pressure long-duration hydrodistension, or systemic long-term glucocorticoids due to lack of efficacy or increased risk of adverse events. 2

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 3
• Educate patients that IC/BPS is a chronic condition with periods of flares and remissions requiring long-term management 3
• Set realistic expectations: treatment efficacy is unpredictable, and multiple therapeutic options may need to be tried before adequate symptom control is achieved 2, 3
• Adequate symptom control is often achievable but typically requires trials of multiple therapeutic options, including combination regimens 2