Treatment for Interstitial Cystitis

Introduction to Treatment Guidelines

The American Urological Association recommends beginning with behavioral modifications and self-care practices for all patients, then escalating systematically through oral medications, intravesical therapies, and finally advanced interventions for refractory cases 1, 2

Dietary modifications, such as eliminating known bladder irritants, can help alleviate symptoms in patients with interstitial cystitis 1, 2
Fluid management, including altering urine concentration through strategic fluid intake, can help dilute urinary irritants in patients with interstitial cystitis 1, 2
Physical interventions, such as applying local heat or cold over the bladder or perineum, can provide symptomatic pain relief in patients with interstitial cystitis 1, 2
Stress management techniques, including meditation and imagery, can help reduce symptoms in patients with interstitial cystitis 1, 2
Pelvic floor therapy, focusing on muscle relaxation techniques, can help manage symptoms in patients with interstitial cystitis 1, 2
Bladder training, including urge suppression techniques, can help manage frequency in patients with interstitial cystitis 1, 2

Amitriptyline is a preferred initial oral agent, with dosing starting at 10 mg daily and titrating up to 100 mg per day as tolerated, and has Grade B evidence for symptom improvement 1
Pentosan polysulfate sodium is an FDA-approved oral medication, with dosing at 100 mg three times daily, and requires mandatory ophthalmologic monitoring due to the risk of ocular toxicity 1

Heparin has a mechanism of repairing the damaged glycosaminoglycan layer of the bladder and provides clinically significant symptom improvement in patients with interstitial cystitis 1
Lidocaine provides rapid onset temporary relief of bladder pain in patients with interstitial cystitis 1

Cystoscopy can determine anatomic bladder capacity and identify fibrosis-related capacity reduction in patients with interstitial cystitis 3
Hydrodistension should avoid high-pressure and long-duration procedures to minimize the risk of bladder rupture and sepsis 4

Fulguration and/or triamcinolone injection can provide significant symptom relief in patients with Hunner lesions 3, 1

Sacral neuromodulation can be considered for patients who have failed all other treatments, with Grade C evidence and limited by small sample sizes and lack of durable follow-up 3, 1
Cyclosporine A can be used for refractory cases, but has Grade C evidence and is not FDA-approved for interstitial cystitis 3, 1
Intradetrusor botulinum toxin A can be used for refractory cases, but has Grade C evidence and is not FDA-approved for interstitial cystitis, and requires patient counseling on the possibility of requiring intermittent self-catheterization post-treatment 3, 1

Long-term oral antibiotics have no significant benefit over placebo and risk antibiotic resistance and adverse events, with Grade B evidence against 4, 3
Intravesical BCG has no efficacy compared to placebo and potentially life-threatening adverse events, with Grade B evidence against 4, 3
Intravesical resiniferatoxin has no statistically significant benefit and high adverse event rates, with Grade A evidence against 4, 3
High-pressure, long-duration hydrodistension increases the risk of bladder rupture and sepsis without consistent benefit, with Grade C recommendation against 4, 3
Systemic long-term glucocorticoids have serious adverse events and outweigh minimal benefits, with Grade C recommendation against 4