Interstitial Cystitis/Bladder Pain Syndrome Treatment

Introduction

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes, as defined by the American Urological Association (AUA) 1, 2
The hallmark symptom of IC/BPS is pain (including pressure and discomfort) perceived to be related to the bladder, which may be felt throughout the pelvis and in other locations like the lower abdomen and back, as noted by the American Urological Association 2

Diagnosis should be confirmed by symptoms present for at least 6 weeks, documented negative urine cultures, bladder/pelvic pain, pressure, or discomfort, urinary frequency and urgency, and exclusion of other conditions that could cause similar symptoms, with an evidence strength of Grade A 3, 2, 1
Diagnostic steps for IC/BPS include excluding other conditions with similar symptoms 2
Rule out infection with urinalysis and urine culture in patients with bladder spasms and pain, according to the American Urological Association 4, 2
Consider cystoscopy if hematuria is present, Hunner lesions are suspected, or symptoms are refractory to initial treatment, as suggested by the American Urological Association 2, 3
Flank pain in IC/BPS patients should always trigger a thorough evaluation of the upper urinary tract, as this symptom is not typically part of the classic IC/BPS presentation and may indicate a complication or comorbid condition requiring specific management 1

The AUA recommends a stepwise, tiered approach to treating IC/BPS, starting with conservative therapies and progressing to more invasive options only when earlier treatments fail, with surgical interventions reserved as a last resort except for Hunner's lesions 1
Treatment should be individualized, with concurrent, multi-modal therapies often being more effective than single-modality approaches, as emphasized by the AUA guidelines 3
A multimodal approach combining pharmacologic agents with other therapies is likely most effective, and patients should be treated for underlying bladder-related symptoms in addition to pain management, with an evidence strength of Grade B 3, 2

Patient education about normal bladder function, self-care practices, including stress management, dietary modifications, bladder training techniques, fluid management, and pelvic floor relaxation, are recommended as initial treatments 1
Stress management practices, bladder training, and dietary modifications are recommended to improve coping techniques and identify trigger foods, with an evidence strength of Grade C for dietary modifications 3
Fluid management, including modifying concentration/volume of urine through fluid restriction or hydration, is recommended to reduce bladder spasms and pain, as suggested by the American Urological Association 4
Reduce caffeine intake to decrease voiding frequency in patients with bladder spasms and pain, as recommended by the American Urological Association 4
Physical therapy, including manual physical therapy techniques for pelvic floor tenderness, is recommended with Grade A evidence 1

Amitriptyline is recommended as a first-line pharmacologic agent for IC/BPS treatment, with a starting dose of 10mg and gradual titration to 75-100mg as tolerated, although the specific details of this recommendation are not provided in the citation, according to the AUA guidelines 3
Amitriptyline has shown clinically significant improvement in IC/BPS symptoms, pain, and nocturia, with minimal reported adverse effects, and is superior to placebo for symptom improvement, with Grade B evidence 3, 1, 2
Pentosan polysulfate sodium (Elmiron) is an FDA-approved medication for IC/BPS, with clinical trials showing 38% of patients had >50% improvement in bladder pain vs 18% with placebo 2, 3
Anticholinergics, such as darifenacin, fesoterodine, solifenacin, tolterodine, or trospium, are recommended for overactive bladder symptoms in patients with bladder spasms and pain, according to the American Urological Association 4
Non-steroidal anti-inflammatory drugs are recommended for pain relief in patients with interstitial cystitis/bladder pain syndrome, as suggested by the Military Medical Research 5
Cimetidine, hydroxyzine, and cyclosporine A may be considered for pain management, with varying evidence strengths and potential side effects 2, 3, 1

Dimethyl Sulfoxide (DMSO), an FDA-approved intravesical therapy for IC/BPS, administered via bladder instillation, with anti-inflammatory and analgesic properties, and a treatment frequency of every two weeks until maximum relief is obtained 2
Heparin, lidocaine, and other intravesical therapies may be considered for pain management, with varying evidence strengths and potential side effects 2, 3
Botulinum toxin A (BTX-A) injections into the bladder may be considered as a treatment option 1

Cystoscopy with fulguration/resection of lesions is recommended for treating Hunner's lesions at any point in the algorithm 1
Diversion with or without cystectomy, substitution cystoplasty, and pain management referral may be considered as last resort options 1
Hydrodistention of the bladder is recommended for interstitial cystitis/bladder pain syndrome with Hunner lesions, as suggested by the American Urological Association 3

Treatment efficacy should be assessed every 4-12 weeks using validated symptom scores, with ineffective treatments discontinued and therapy adjusted based on symptom response and side effects, with an evidence strength of Grade B 3, 1
Regular upper tract imaging, such as periodic ultrasound, is recommended to monitor for hydronephrosis or other complications 1
Follow-up within 1-2 weeks to assess symptom resolution, and if pain persists beyond 2 weeks, consider urine culture to rule out infection, cystoscopy to evaluate for other pathology, and referral to urology if symptoms persist, as suggested by the National Comprehensive Cancer Network, with an evidence strength of Grade A 6