What is interstitial cystitis (IC), also known as bladder pain syndrome?

From the Guidelines

Interstitial cystitis (IC) patients should be educated about normal bladder function and the benefits versus risks of available treatment alternatives, and a multimodal approach including lifestyle modifications and oral medications should be considered for symptom management. Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition causing bladder pressure, bladder pain, and sometimes pelvic pain. Treatment typically involves a multimodal approach, as no single treatment has been found effective for the majority of patients 1. First-line treatments include lifestyle modifications such as avoiding trigger foods (caffeine, alcohol, spicy foods, artificial sweeteners), stress management, and bladder training techniques, as well as behavioral modification strategies like altering the concentration and/or volume of urine, avoidance of certain foods, and use of an elimination diet to determine which foods or fluids may contribute to symptoms 1.

Key Considerations

• Oral medications often include amitriptyline (10-75 mg at bedtime), pentosan polysulfate sodium (Elmiron, 100 mg three times daily), antihistamines like hydroxyzine (25-75 mg daily), or pain medications such as gabapentin (300-900 mg three times daily) 1.
• Bladder instillations may be recommended, typically using dimethyl sulfoxide (DMSO), heparin, or lidocaine solutions administered directly into the bladder weekly for 6-8 weeks.
• For severe cases, more invasive options include hydrodistention during cystoscopy, Botox injections into the bladder wall, or sacral neuromodulation.
• Physical therapy focusing on pelvic floor relaxation can also be beneficial, as well as techniques applied to trigger points and areas of hypersensitivity, and strategies to manage IC/BPS flare-ups (eg, meditation, imagery) 1.

Patient Education

• Patients should be educated about what is known and not known about IC/BPS, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved 1.
• Patients should become aware of and avoid specific behaviors that worsen symptoms, such as certain types of exercise, sexual intercourse, wearing of tight-fitting clothing, and constipation 1.

From the Research

Definition and Symptoms of Interstitial Cystitis

• Interstitial cystitis (IC) is characterized by symptoms of urinary frequency and urgency, dysuria, and chronic pelvic pain 2
• The debilitating pelvic pain associated with IC is most difficult to control, and its pathophysiology is poorly understood, involving nociceptive, visceral, and neuropathic components 2

Treatment Options for Interstitial Cystitis

• Oral treatments are frequently used, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentin, and pentosan polysulfate, which have shown varying degrees of efficacy 2
• Intravesical and surgical options are also available for treating IC pain 2
• Pharmacotherapies used to treat IC/BPS include oral and intravesical agents, such as amitriptyline, hydroxyzine, cyclosporine A, and pentosan polysulfate sodium (PPS) 3

Pentosan Polysulfate Sodium (PPS) as a Treatment Option

• PPS is used to manage bladder pain and discomfort in adults with interstitial cystitis (IC) and has been shown to repair damaged glycosaminoglycan (GAG) layers lining the urothelium 4
• PPS has beneficial effects in a proportion of patients with IC, improving overall condition and relieving pain, and is generally well-tolerated 4
• Systematic reviews and meta-analyses have confirmed the efficacy of PPS in treating IC/BPS symptoms, including bladder pain, urinary urgency, and frequency of micturition 5
• However, recent findings have raised concerns about the potential correlation between prolonged high-dose therapy with PPS and a special kind of maculopathy, leading to recommendations for ophthalmologic examinations before and during treatment with PPS 6

Efficacy and Safety of PPS

• PPS has a US and European approval for the therapy of IC characterized by glomerulations or a Hunner lesion detected by endoscopy and bladder distension 6
• Side-effects of PPS include mild haemodilution, nausea, and loss of hair, and its efficacy should be re-evaluated after a treatment period of six months 6
• Despite ongoing litigation and concerns about maculopathy, PPS remains an important option in the treatment of patients with IC/BPS, being the only causally acting compound in the therapy of IC/BPS 6