Diagnosis and Management of Interstitial Cystitis/Painful Bladder Syndrome – Treatment

(Published May 2008)

Treatment with Cystoscopy, Intravesical Therapy, or Surgery

Approach to therapy

• The preferred approach to first-line therapy varies among clinicians, making construction of treatment algorithms for IC/PBS a challenge.
• Most clinicians knowledgeable about IC/PBS focus on self-care and oral therapy, adding intravesical therapy as needed.
• Surgery is an option of last resort for patients whose symptoms are unresponsive to other forms of treatment, and is rarely performed.

Cystoscopy with Hydrodistention Under General Anesthesia

• A procedure often used to better identify bladder abnormalities commonly associated with IC/PBS.
• Can have short-term therapeutic benefit in up to 50 percent of patients.¹
• For a complete description of the procedure, see Diagnosis.

Intravesical Therapy

Uses for intravesical therapy

• As a second-line treatment.
• In conjunction with oral therapy or other types of conservative therapies.

Agents used for intravesical therapy

• Dimethylsulfoxide (DMSO; RIMSO^®-50)
  • The only intravesical therapy with FDA approval for use in IC/PBS (1978).
  • Appears to have anti-inflammatory, analgesic, and muscle-relaxant effects.
  • Often administered in the form of a “cocktail.”
  • Instilled in the bladder via catheter and for 15 minutes.
  • Treatment is repeated weekly for 6 to 8 weeks.
  • Randomized controlled trials showed intravesical DMSO to have a 70 percent efficacy rate in reducing the symptoms of IC/PBS.^2,3
  • Patients who respond often experience improvement for several months, perhaps as long as a year.
  • Side effects include a garlic taste and body odor and discomfort caused by catheterization.
• Intravesical cocktail:
  • Randomized controlled data are not available for any cocktails.
  • Examples of typical cocktails:
    • Heparin, lidocaine, and sodium bicarbonate—demonstrated immediate and statistically significant symptom relief in an open study (n= 82).⁴
    • DMSO, a methylprednisolone, and heparin sulfate—demonstrated initial remission of symptoms in 92 percent of patients in an open study (n=25).

How intravesical therapy is performed

• The therapeutic agent is introduced slowly into the bladder via urinary catheter.
• The agent is held in bladder for varying duration (usually 20 to 30 minutes), then voided.

Surgery

Indications for surgery

• Treatment of last resort, reserved for patients with severe symptoms that are unresponsive to other therapy.
• Some patients continue to experience pelvic pain even after the bladder is removed, possibly due to pelvic floor spasm or central nervous system-mediated pain.
• Goal is to increase the functional capacity of the bladder or to divert the urine stream.⁶

Surgical options

• Cystoscopic treatments: usually performed for the rare patient with the “classical” form of IC/PBS, which is associated with specific inflammatory lesions on the bladder wall.^7,8
  • Bladder wall resection.
  • Laser therapy ablation.
• Implantable nerve stimulators
  • Interstim is approved by the FDA for urinary frequency and urgency.
  • Less helpful for IC/PBS patients whose primary symptom is pain.
  • Two open, noncomparative studies found that a majority of IC/PBS patients whose condition was refractory to other treatment experienced at least 50 percent improvement in symptoms with implantation of the device.^9,10
• Radical surgery options
  • Urinary diversion with or without cystectomy (removal of bladder).
  • Augmentation cystoplasty, in which a portion of bowel is added to the bladder to increase bladder capacity.

References

1. Hanno PM. Painful bladder syndrome/interstitial cystitis and related disorders. In: Wein AJ, editor. Campbell-Walsh Urology. 9th edition. Philadelphia: Saunders; 2007. p. 330-70.
2. Perez-Merrero R. A controlled study of dimethylsulfoxide in interstitial cystitis. J Urol. 1988;140:36-9.
3. Peeker R. Intravesical BCG and DMSO for treatment of classic ulcer and non-ulcer interstitial cystitis: a prospective, double blind, randomized study. J Urol. 2000;164:1912-15.
4. Parsons CL. Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis. Urol. 2005;65(1):45-8.
5. Ghoniem GM, McBride D, Sood OP, Lewis V. Clinical experience with multiagent intravesical therapy in interstitial cystitis patients unresponsive to single-agent therapy. World J Urol. 1993;11(3):178-82.
6. Hanno PM. Painful bladder syndrome (interstitial cystitis). In: Hanno PM, Wein AJ, Malkowicz SB, editors. Penn Clinical Manual of Urology. Philadelphia: Saunders; 2007. p. 217-34.
7. Rofeim O, Hom D, Freid RM, Moldwin RM. Use of the neodymium:YAG laser for interstitial cystitis: a prospective study. J Urol. 2001 Jul;166(1):134-6.
8. Peeker R, Aldenborg F, Fall M. Complete transurethral resection of ulcers in classic interstitial cystitis. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11:290–5.
9. Peters KM. Neuromodulation for the treatment of refractory interstitial cystitis. Rev Urol. 2002;4(Suppl.1):S36-S43.
10. Comiter CV. Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol. 2003;169:1369-73.