Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Publication Date: May 10, 2022
Last Updated: May 11, 2022

Diagnosis of IC/BPS

The basic assessment should include a careful history, physical examination, and laboratory examination to document symptoms and signs that characterize IC/BPS and exclude other disorders that could be the cause of the patient's symptoms. (Clinical Principle, )
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Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects. (Clinical Principle, )
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Cystoscopy and/or urodynamics should be considered when the diagnosis is in doubt; these tests are not necessary for making the diagnosis in uncomplicated presentations. (Expert Opinion, )
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Cystoscopy should be performed in patients for whom Hunner lesions are suspected. (Expert Opinion, )
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Management Approach to IC/BPS

Treatment decisions should be made after shared decision-making, with the patient informed of the risks, potential benefits, and alternatives. Except for patients with Hunner lesions, initial treatment should typically be nonsurgical. (Expert Opinion, )
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Efficacy of treatment should be periodically reassessed, and ineffective treatments should be stopped. (Clinical Principle, )
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Multimodal pain management approaches (e.g., pharmacological, stress management, manual therapy if available) should be initiated. Pain management should be continually assessed for effectiveness because of its importance to quality of life. If pain management is inadequate, then consideration should be given to a multidisciplinary approach and the patient referred appropriately. (Clinical Principle, )
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The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. (Clinical Principle, )
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Behavioral/Non-pharmacologic Treatments

Patients should be educated about normal bladder function, what is known and not known about IC/BPS, the benefits versus risks/burdens of the available treatment alternatives, the fact that no single treatment has been found effective for the majority of patients, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved. (Clinical Principle, )
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Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible. (Clinical Principle, )
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Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. (Clinical Principle, )
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Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. (Standard, A)
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Clinicians may prescribe pharmacologic pain management agents (e.g., urinary analgesics, acetaminophen, NSAIDs, opioid/non-opioid medications) after counseling patients on the risks and benefits. Pharmacological pain management principles for IC/BPS should be similar to those for management of other chronic pain conditions. (Clinical Principle, )
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Oral Medications

The following oral medications may be administered (listed in alphabetical order; no hierarchy is implied):
Amitriptyline: Amitriptyline has been shown to be superior to placebo to improve symptoms of IC/BPS; however, AEs are common and, although not lifethreatening, have substantial potential to compromise QoL (e.g., sedation, drowsiness, nausea). Available data suggest that beginning at low doses (e.g., 10 mg) and titrating gradually to 75-100 mg if tolerated is an acceptable dosing regimen. (Option, B)
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Cimetidine: Cimetidine has been reported to have clinically significant improvement of IC/BPS symptoms, pain, and nocturia with no AEs reported. (Option, B)
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Hydroxyzine: Oral hydroxyzine has been shown to result in clinically significant improvement compared to placebo.10 Some studies indicate that patients who report clinically significant improvement have systemic allergies; this patient population may be more likely to respond to hydroxyzine. AEs were common and generally not serious (e.g., short-term sedation, weakness). (Option, C)
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Pentosan polysulfate: Pentosan polysulfate (PPS) is the only FDA-approved oral agent for the treatment of IC/BPS and is by far the most-studied oral medication in use for IC/BPS. Results on the effectiveness of PPS have been contradictory; some trials report no differences in symptom improvement,12 10 while others show that PPS patients improved compared to those on placebo. Overall, it is the opinion of the Panel that the benefits and risks of PPS should be discussed with the patient before initiating or continuing treatment. (Option, B)
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Clinicians should counsel patients who are considering pentosan polysulfate on the potential risk for macular damage and vision-related injuries. (Clinical Principle, )
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Oral cyclosporine A may be offered to patients with Hunner lesions refractory to fulguration and/or triamcinolone. (Option, C)
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Intravesical Instillations

DMSO, heparin, and/or lidocaine may be administered as intravesical treatments (listed in alphabetical order; no hierarchy is implied).
DMSO: DMSO instillation has been shown to be efficacious in improving urodynamic and voiding parameters as compared to placebo, to bacillus Calmette-Guerin (BCG), and in observational studies. DMSO is rapidly absorbed into the bladder wall and longer periods of holding are associated with significant pain, therefore if DMSO is used, then the panel suggests limiting instillation dwell time to 15-20 minutes. DMSO is often administered as a part of a "cocktail" that may include heparin, hydrocortisone, sodium bicarbonate, a local steroid, a lidocaine preparation, bupivacaine, and/or triamcinolone. If a clinician chooses to administer a "cocktail" preparation, then he or she should be aware that DMSO potentially enhances absorption of other substances, creating the possibility for toxicity from drugs such as lidocaine. (Option, C)
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Heparin: Observational studies of intravesical heparin and clinical trials of patients randomized heparin in combination with alkalized lidocaine report clinically significant improvement in symptom relief compared to patients who were given placebo. (Option, C)
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Lidocaine: Lidocaine has been shown to significantly improve symptoms in the short-term (i.e., less than two weeks) compared to placebo. Alkalinization increases urothelial penetration of lidocaine and therefore is expected to improve efficacy, but it also can increase systemic absorption and potential toxicity. No published studies have directly compared lidocaine with and without alkalinization. Patients who are given lidocaine in combination with heparin or PPS32 have been show to exhibit relief of symptoms and a significant reduction of bladder pain and urgency compared to lidocaine alone. (Option, B)
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Procedures

Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken as a treatment option. (Option, C)
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If Hunner lesions are present, then fulguration (with electrocautery) and/or injection of triamcinolone should be performed. (Conditional, C)
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Intradetrusor onabotulinumtoxin A may be administered if other treatments have not provided adequate improvement in symptoms and quality of life. Patients must be willing to accept the possibility that intermittent self-catheterization may be necessary. (Option, C)
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A trial of neuromodulation may be performed if other treatments have not provided adequate symptom control and quality of life improvement. If a trial of nerve stimulation is successful, then the permanent neurostimulation device may be implanted. (Option, C)
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Major Surgery

Major surgery (substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients with bladder-centric symptoms, or in the rare instance when there is an end-stage small fibrotic bladder, for whom all other therapies have failed to provide adequate symptom control and quality of life improvement. (Option, C)
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Treatments That Should Not Be Offered

Long-term oral antibiotic administration should not be offered. (Standard, B)
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Intravesical instillation of bacillus Calmette-Guerin should not be offered outside of investigational study settings. (Standard, B)
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High-pressure, long-duration hydrodistension should not be offered. (Conditional, C)
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Systemic (oral) long-term glucocorticoid administration should not be offered. (Conditional, C)
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Recommendation Grading

Overview

Title

Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Authoring Organization

Publication Month/Year

May 10, 2022

Last Updated Month/Year

August 10, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline provides direction to clinicians and patients regarding how to recognize interstitial cystitis/bladder pain syndrome (IC/BPS), conduct a valid diagnostic process, and approach treatment with the goals of maximizing symptom control and patient quality of life while minimizing adverse events and patient burden. 

IC/BPS is a heterogeneous clinical syndrome. Even though patients present with similar symptoms of bladder/pelvic pain and pressure/discomfort associated with urinary frequency and strong urge to urinate, there are subgroups or phenotypes within IC/BPS. Except for patients with Hunner lesions, initial treatment should typically be nonsurgical. Concurrent, multi-modal therapies may be offered.

Target Patient Population

Patients with IC/BPS

Target Provider Population

Urologists and other providers caring for patients with IC/BPS

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D018856 - Cystitis, Interstitial, D003556 - Cystitis

Keywords

Interstitial Cystitis, bladder pain, IC/BPS

Source Citation

Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. J Urol. 2022 Jul;208(1):34-42. doi: 10.1097/JU.0000000000002756. Epub 2022 May 10. PMID: 35536143.

Methodology

Number of Source Documents
271
Literature Search Start Date
January 1, 1983
Literature Search End Date
January 1, 2021