Treatment of Bladder Lesions in Women with IC and Painful Bladder Syndrome

Diagnostic Assessment and Treatment Algorithm

The American Urological Association recommends cystoscopy with hydrodistension to identify Hunner lesions, which if present, should be treated with fulguration and/or triamcinolone injection as the next step in management 1, 2
Cystoscopy with hydrodistension serves multiple purposes: identifying Hunner lesions, assessing bladder capacity, and potentially providing therapeutic benefit 1, 3
Document baseline symptoms using validated tools such as the genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), or visual analog scale (VAS) to measure treatment effects 3
Assess the impact on quality of life, as IC/BPS causes significant psychological distress, sexual dysfunction, and reduced quality of life compared to other urological conditions 4
Fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed as the primary treatment for Hunner lesions 1, 5
Hunner lesions can be easier to identify after distention when cracking and mucosal bleeding become evident 1
The AUA guidelines consider fulguration and/or triamcinolone injection a third-line treatment, but it is the most effective intervention for this specific subtype of IC/BPS 1, 2

Implement multimodal pain management approaches including pharmacological options, stress management, and manual therapy 3, 5, 6
Pain management should be continually assessed for effectiveness due to its importance to quality of life 6
Consider referral to pain specialists if pain control is inadequate with standard approaches 6

Sacral neuromodulation may be considered if intravesical treatments fail 1
Cyclosporine A may be considered if other treatments have failed 1
Intradetrusor botulinum toxin A injections may be beneficial 1
Substitution cystoplasty or urinary diversion with or without cystectomy may be considered for patients with severe, unremitting symptoms that have failed all other treatment options 1, 2, 7

Treatments that should NOT be offered include long-term oral antibiotic administration and intravesical BCG 1
IC/BPS is a chronic condition with periods of flares and remissions; patients should be educated about the long-term nature of management 2
Ineffective treatments should be discontinued after an appropriate trial period 3
Sexual dysfunction is common and significantly impacts quality of life; successful treatment of IC/BPS symptoms can improve sexual function 4