Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

nonulcerative interstitial cystitis

1st line – lifestyle changes + noninvasive therapies

Back
ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
1st line – 

lifestyle changes + noninvasive therapies

Patients should avoid foods that have been noted to exacerbate symptoms (a food diary can help identify them).[1][15]

Pelvic-floor physical therapy, biofeedback, and/or bladder training programs are considered excellent initial interventions, but consistency is key to achieving long-term improvement.

Other noninvasive therapies include stress reduction, hypnosis, or acupuncture. For patients who have an established psychiatric history, working with the psychiatrist can benefit the physician and the patient.

Plus – supportive therapies

Back
ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis. Chronic pain is a significant life stressor and must be recognized in the context of long-term lifestyle changes. The known associations of IC/BPS with physical and psychological abuse, sexual dysfunction, and depression necessitate a close working relationship with psychiatric or psychological counseling services.

Physical and emotional support are also important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

Consider – pharmacologic therapy

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ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
Consider – 

pharmacologic therapy

Treatment recommended for SOME patients in selected patient group

Some patients may choose to try noninvasive therapies alone initially, while others may benefit from concurrent pharmacologic or intravesical therapy.[1]​ Treatment choice should be guided by shared decision-making, individual patient factors, and clinical judgment.[1]

Initial therapies include antihistamines (e.g., hydroxyzine), pentosan polysulfate sodium, and mild analgesics such as ibuprofen or acetaminophen. Combinations of these medications may be used.

Pentosan polysulfate sodium is the only FDA-approved medication for IC/BPS but in some countries its use in IC/BPS is not recommended.[20] The proposed mechanism of action is the replacement of the deficient inner lining of the bladder wall and inhibition of mast cell degranulation.[46] Bioavailability is poor and the cost of the medication can be prohibitive. Symptom improvement may take up to 6 months. Modest efficacy has been demonstrated in several studies.[46][47]​ However, a randomized trial was halted early, showing no benefit of pentosan polysulfate sodium over placebo.[48] Studies have shown an association between prolonged pentosan polysulfate sodium use and the development of a unique retinal pigmentary maculopathy causing difficulty reading, slow adjustment to low or reduced light environments, and blurred vision. Patients need to be counseled regarding this risk and a retinal examination prior to initiating therapy in those with pre-existing ophthalmologic conditions and within 6 months of initiation for all patients is recommended.[1]​ An open-label study of hydroxyzine demonstrated a 40% improvement in symptom scores from baseline, while symptom scores improved an additional 55% in study patients with concomitant seasonal allergies.[50] However, a pilot study found hydroxyzine to be no more effective than placebo in improving quality of life or number of voids.[51]

If these drugs fail, tricyclic antidepressants (e.g., amitriptyline) or gabapentin may be tried.

Anticholinergic medications (e.g., oxybutynin, trospium) or newer beta-3 agonists (e.g., mirabegron) may be beneficial for those symptoms of urgency and frequency, but not for pain. There are no data to support one particular anticholinergic over another. Factors to consider are cost, side effects of dry mouth and constipation, and dosing frequency.

Many physicians reserve opioid analgesics for recalcitrant patients, but these drugs should be prescribed under specialist guidance.

Primary options

pentosan polysulfate sodium: 100 mg orally three times daily

OR

hydroxyzine: 10-100 mg orally once daily

OR

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day

OR

oxybutynin: 5 mg orally three times daily

OR

trospium: 20 mg orally (immediate-release) twice daily

OR

mirabegron: 25-50 mg orally once daily

Secondary options

amitriptyline: 10-100 mg orally once daily at night

OR

gabapentin: 300-1200 mg orally three times daily

Tertiary options

hydrocodone/acetaminophen: 2.5 to 10 mg orally every 4-6 hours when required, maximum 60 mg/day (hydrocodone) or 4000 mg/day (acetaminophen)

More

OR

oxycodone: 5 mg orally (immediate-release) every 6 hours when required

Consider – intravesical therapy

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ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
Consider – 

intravesical therapy

Treatment recommended for SOME patients in selected patient group

Recommended as a bridging therapy, given adjunctively when oral drugs are initiated, as some medications may take 1 to 3 weeks before a response is seen. Also recommended in patients who show no response to oral pharmacologic therapy and have predominant bladder-centered pain, and no pelvic floor dysfunction.

Drugs are instilled in the bladder through a catheter, where the solution is held for a specific time (usually 10-15 minutes) before being emptied.

Dimethyl sulfoxide (DMSO) is the most commonly used drug for this type of therapy. It is thought to decrease inflammation in the bladder and prevent muscle contractions.

A 2016 meta-analysis showed good treatment efficacy and cost-effectiveness with use of sodium hyaluronate (hyaluronic acid).[60]

Various other cocktails of heparinoids, sodium bicarbonate, and lidocaine have been described in the literature.[61][62]​ Heparin has also been used on its own, but data are limited.[3]​ Lidocaine is usually used in combination with sodium bicarbonate, as alkalinization improves urothelial penetration.[1]​ The limitation of all drugs instilled is their relatively short duration of action; frequent redosing may be required for lasting relief.

Intravesical injection of onabotulinumtoxinA has also been evaluated for patients with IC/BPS. This treatment is thought to work on blocking the afferent pathway, reducing pain and urgency. It also blocks acetylcholine release, which leads to bladder muscle relaxation. A single injection can give a short-term (3-9 months) improvement in 67% to 85% of patients, but a recent randomized study showed that repeat injections are necessary to maintain long-term outcomes.[63][64][65]

Selected patients may self-administer bladder instillation treatment at home.

Consult an expert for guidance on intravesical combinations; these formulations need to be made by a pharmacist and should only be used under specialist supervision.

Consider – intradetrusor botulinum toxin injection or neuromodulation

Back
ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
Consider – 

intradetrusor botulinum toxin injection or neuromodulation

Treatment recommended for SOME patients in selected patient group

Patients with primary urgency and frequency symptoms not relieved by medication may be considered for more invasive treatments.

Neuromodulation is indicated for patients with severe urgency and frequency symptoms. It is not FDA approved for pelvic pain. Select patients have shown improvements in pain symptoms after implantation. Office-based percutaneous trial or staged operative procedures may be performed. Implantation rates do not differ between these approaches.

For patients with urgency and frequency, sacral neuromodulation (InterStim) is a viable and efficacious treatment. A less invasive form of neuromodulation, posterior tibial nerve stimulation (PTNS), has also been used for patients with IC/BPS. Initially described for urinary frequency, PTNS has been shown to improve patient quality of life and pain scores for those with chronic pelvic pain.

Chemical neuromodulation with botulinum toxin has become a standard treatment for patients with medication resistant urinary urgency and frequency. Currently, onabotulinumtoxinA is FDA approved for neurogenic and non-neurogenic urinary frequency.

OnabotulinumtoxinA injected in the ambulatory setting allows for symptom relief and minimizes risk for acute urinary retention requiring self-catheterization.

Primary options

onabotulinumtoxinA: consult specialist for guidance on dose

Consider – cystoscopy plus hydrodistention

Back
ONGOING
|
nonulcerative interstitial cystitis
|
on diagnosis: no myofascial trigger points no levator spasms
Consider – 

cystoscopy plus hydrodistention

Treatment recommended for SOME patients in selected patient group

Some patients with bladder-centered pain and no myofascial trigger points will respond to bladder distention under anesthesia.

Up to 50% may see improvement, though this may be short-lived.[66]​ The American Urological Association recommends short-duration, low-pressure hydrodistention as a treatment option, but the European Association of Urology states that its role in treatment is limited due to lack of evidence.[1][3]

The bladder is distended to 80 cm with water for 2 minutes and repeated. Avoid prolonged distention to avoid bladder necrosis and perforation.

Treatments may be repeated as pain and urgency recur, though usually not more than every 3 to 6 months.

1st line – pelvic physical therapy

Back
ONGOING
|
nonulcerative interstitial cystitis
|
with myofascial trigger points and levator spasms
1st line – 

pelvic physical therapy

Pelvic-floor rehabilitation by a trained pelvic rehabilitation specialist is critical for treatment of patients with myofascial trigger points and pelvic floor dysfunction.

Biofeedback and/or bladder retraining programs are considered excellent initial interventions aimed at dyspareunia and urgency/frequency symptoms but consistency is the key to achieving long-term improvement.

Bladder retraining is a method where patients are instructed to retain their urine a little longer each time (e.g., goal to urinate every hour at first, then every 2 hours, etc). Patience is necessary because this method may take a few months to reduce frequency.

Patients are instructed to learn self-guided exercises and massage between rehabilitation specialist visits. Internal manipulators or vaginal dilators are helpful for patients with severe pelvic floor dysfunction and spasm.

Plus – myofascial trigger point injection

Back
ONGOING
|
nonulcerative interstitial cystitis
|
with myofascial trigger points and levator spasms
Plus – 

myofascial trigger point injection

Treatment recommended for ALL patients in selected patient group

For patients with myofascial trigger points and levator spasms, periodic transvaginal trigger point injections can provide substantial symptom relief.

Patients with pelvic pain and palpable myofascial tenderness on exam should be offered injections to relieve muscle spasm. This should be offered in conjunction with pelvic-floor physical therapy to continue to focus on relaxing these muscle groups.

A combination of a local anesthetic and corticosteroid (e.g., ropivacaine and triamcinolone) allows for immediate relief with potential for long-term improvement. Multiple injections separated by several weeks may be necessary. The combination is injected transvaginally into levator muscle complexes at tender trigger points.

Monitor vital signs and visual analog scale (VAS) pain scores pre- and post-procedure.

An emerging use of onabotulinumtoxinA has been for patients who respond to trigger-point injections but do not have long-term relief. The pelvic floor may be injected in a similar manner, though onabotulinumtoxinA is injected directly into the levator complex. This serves to break the spasm-pain-spasm cycle. The patient should be counseled about the risks of lower extremity weakness or urinary incontinence following injections.[32]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

and

ropivacaine: consult specialist for guidance on dose

Secondary options

onabotulinumtoxinA: consult specialist for guidance on dose

Plus – supportive therapies

Back
ONGOING
|
nonulcerative interstitial cystitis
|
with myofascial trigger points and levator spasms
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis.

Physical and emotional support are important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

2nd line – neuromodulation

Back
ONGOING
|
nonulcerative interstitial cystitis
|
with myofascial trigger points and levator spasms
2nd line – 

neuromodulation

Neuromodulation is indicated for patients with severe urgency and frequency symptoms. It is not FDA approved for pelvic pain. Select patients have shown improvements in pain symptoms after implantation. Office-based percutaneous trial or staged operative procedures may be performed. Implantation rates do not differ between these approaches.

For patients with urgency and frequency, sacral neuromodulation (InterStim) is a viable and efficacious treatment. A less invasive form of neuromodulation, posterior tibial nerve stimulation (PTNS), has also been used for patients with IC/BPS. Initially described for urinary frequency, PTNS has shown to improve patient quality of life and pain scores for those with chronic pelvic pain.

1st line – diversion and cystectomy

Back
ONGOING
|
nonulcerative interstitial cystitis
|
treatment failure
1st line – 

diversion and cystectomy

Extirpative surgery should only be considered if all other treatments have failed and the pain is severe. The presence of ulcers should alert the clinician to the possibility of fulguration and/or resection under anesthesia.

Cystectomy (bladder removal) and urostomy may be considered at any time for patients with small, fibrotic bladders. Persistence of pain is a risk and patients should be counseled appropriately.

It should be noted that even after radical surgery, symptoms may persist, and the risks and benefits of procedures should be discussed with the patient before a surgical approach is decided. In one systematic review, 77.2% of patients experienced symptom improvement after surgery for treatment-refractory IC/BPS, but the rate of complications was 26.5%.[73]

Plus – supportive therapies

Back
ONGOING
|
nonulcerative interstitial cystitis
|
treatment failure
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis.

Physical and emotional support are important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

ulcerative interstitial cystitis

1st line – lifestyle changes + noninvasive therapies

Back
ONGOING
|
ulcerative interstitial cystitis
1st line – 

lifestyle changes + noninvasive therapies

Patients should avoid foods that have been noted to exacerbate symptoms (a food diary can help identify them).

Pelvic-floor physical therapy, biofeedback, and/or bladder training programs are considered excellent initial interventions, but consistency is key to achieving long-term improvement.

Other noninvasive therapies include stress reduction, hypnosis, or acupuncture. For patients who have an established psychiatric history, working with the psychiatrist can benefit the physician and the patient.

Plus – supportive therapies

Back
ONGOING
|
ulcerative interstitial cystitis
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis.

Physical and emotional support are important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

2nd line – cystoscopy and ulcer fulguration

Back
ONGOING
|
ulcerative interstitial cystitis
2nd line – 

cystoscopy and ulcer fulguration

Patients with active ulcers respond well to fulguration and resection. First-time procedures should include biopsy to rule out malignancy.

Assessment of maximum anesthesia bladder capacity is important.

Consider – cyclosporine or prednisone

Back
ONGOING
|
ulcerative interstitial cystitis
Consider – 

cyclosporine or prednisone

Treatment recommended for SOME patients in selected patient group

Cyclosporine is used following cystoscopy and ulcer fulguration for ulcer recurrences. Patients need to be free of active infections and undergo routine complete blood counts after starting therapy. Blood pressure should also be routinely monitored. Substantial improvement in bladder capacity and decreased frequency after treatment was reported in patients taking the drug for 1 year or more.[57]

Oral prednisone is sometimes used for the short-term to manage symptom flares in patients with ulcerative IC, but there is a lack of evidence for its use.[1][3]​ Nonsteroidal treatments are preferred and corticosteroids should not be used for long-term treatment.

Primary options

cyclosporine non-modified: consult specialist for guidance on dose

Secondary options

prednisone: consult specialist for guidance on dose

Plus – supportive therapies

Back
ONGOING
|
ulcerative interstitial cystitis
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis.

Physical and emotional support are important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

3rd line – diversion and cystectomy

Back
ONGOING
|
ulcerative interstitial cystitis
3rd line – 

diversion and cystectomy

Extirpative surgery should only be considered if all other treatments have failed and the pain is severe. The presence of ulcers should alert the clinician to the possibility of fulguration and/or resection under anesthesia.

Cystectomy (bladder removal) and urostomy may be considered at any time for patients with small, fibrotic bladders. Persistence of pain is a risk and patients should be counseled appropriately.

It should be noted that even after radical surgery, symptoms may persist, and the risks and benefits of procedures should be discussed with the patient before a surgical approach is decided.

Plus – supportive therapies

Back
ONGOING
|
ulcerative interstitial cystitis
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be educated as to the chronic nature of their condition and must have a clear understanding of their prognosis.

Physical and emotional support are important because patients must often try various treatment options over time, as immediate, complete response to individual therapies is rare.

Referral to a support group or to the Interstitial Cystitis Association website can be helpful. Interstitial Cystitis Association Opens in new window

Referral to a specialist pain clinic is recommended.

Comorbid conditions should be treated appropriately.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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