Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome

Publication Date: May 1, 2015
Last Updated: March 14, 2022

Guideline Statements


The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize IC/BPS and rule out other confusable disorders (see text for details). (Clinical Principle)
Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
Cystoscopy and/or urodynamics should be considered as an aid to diagnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations.


Treatment strategies should proceed using more conservative therapies first, with less conservative therapies employed if symptom control is inadequate for acceptable quality of life; because of their irreversibility, surgical treatments (other than fulguration of Hunner's lesions) are appropriate only after other treatment alternatives have been exhausted, or at any time in the rare instance when an end-stage small, fibrotic bladder has been confirmed and the patient's quality of life suggests a positive risk-benefit ratio for major surgery. (Clinical Principle)
Initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences; appropriate entry points into the treatment portion of the algorithm depend on these factors. (Clinical Principle)
Multiple, simultaneous treatments may be considered if it is in the best interests of the patient; baseline symptom assessment and regular symptom level reassessment are essential to document efficacy of single and combined treatments. (Clinical Principle)
Ineffective treatments should be stopped once a clinically meaningful interval has elapsed. (Clinical Principle)
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)
The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. (Clinical Principle, )
Treatments that may be offered: Treatments that may be offered are divided into first-, second-, third-, fourth-, fifth-, and sixth-line groups based on the balance between potential benefits to the patient, potential severity of adverse events (AEs) and the reversibility of the treatment. See body of guideline for protocols, study details, and rationales.

First-Line Treatments (should be performed on all patients)

Patients should be educated about normal bladder function, what is known and not known about IC/ BPS, the benefits v. 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.
Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible. (Clinical Principle)

Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations.

(Clinical Principle)

Second-Line treatments

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. (Strong, A)
Multimodal pain management approaches (e.g., pharmacological, stress management, manual therapy if available) should be initiated. (Expert Opinion)
Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as second-line oral medications (listed in alphabetical order; no hierarchy is implied). (Conditional, )
(Evidence Strength Grades B, B, C, and B)

Third-Line treatments

Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken if first- and second-line treatments have not provided acceptable symptom control and quality of life or if the patient's presenting symptoms suggest a more invasive approach is appropriate. (Conditional, C)
If Hunner's lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed. (Moderate, C)

Fourth-Line treatment

Intradetrusor botulinum toxin A (BTX-A) may be administered if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. Patients must be willing to accept the possibility that post-treatment intermittent self- catheterization may be necessary. (Conditional, C)
A trial of neurostimulation may be performed and, if successful, implantation of permanent neurostimulation devices may be undertaken if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. (Conditional, C)

Fifth-Line treatments

Cyclosporine A may be administered as an oral medication if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. (Conditional, C)

Sixth-Line treatment

Major surgery (e.g., substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients for whom all other therapies have failed to provide adequate symptom control and quality of life. (Conditional, C)

Treatments that Should Not be Offered

The treatments below appear to lack efficacy and/or appear to be accompanied by unacceptable AE profiles. See body of guideline for study details and rationales.
Long-term oral antibiotic administration should not be offered. (Strong, B)
Intravesical instillation of bacillus Calmette-Guerin (BCG) should not be offered outside of investigational study settings. (Strong, B)
High-pressure, long-duration hydrodistension should not be offered. (Moderate, C)
Systemic (oral) long-term glucocorticoid administration should not be offered. (Moderate, C)

Recommendation Grading




Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome

Authoring Organization

Publication Month/Year

May 1, 2015

Last Updated Month/Year

May 31, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

The purpose of this amendment is to provide an updated clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome based upon data received since the publication of original guideline in 2011.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D018856 - Cystitis, Interstitial, D003556 - Cystitis


cystitis, urinary bladder disease, pelvic pain


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