Interstitial Cystitis/Painful Bladder Syndrome - Mount Sinai Hospital

Interstitial Cystitis/Painful Bladder Syndrome:
What are the treatment options?
Dr. Kathryn Rutherford
Introduction
Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) is defined as urinary
frequency, urgency, and pelvic pain without any identifiable cause. Once diagnosed, it
may take weeks to months to achieve symptom relief. At present, there is no cure. 1
The impact of IC/PBS is significant: increased stress, loss of sleep, decreased
quality of life, work limitations and lost wages, and higher medical costs to the sufferer
and the health care system. 2
There are several theories about the causes of IC/PBS. Most involve some form
of inflammation or damage to the bladder lining, making the bladder irritated by urine as
it fills and stretches. 1,3
The main goals of treatment are to increase daily functioning and improve quality
of life. 3 New guidelines, developed by the American Urological Association, outline the
steps in managing IC/PBS based on current research.4 Most of the suggested
treatment options are discussed below.
Treatment Options
Stress management:
Identification and treatment of depression and anxiety disorders reduce the
impact of IC/PBS. Stress reduction strategies may include relaxation tapes, sitz baths,
biofeedback (learning how to control breathing, pulse, and blood pressure), exercise,
and Cognitive Behavioral Therapy. 3
Bladder training:
The concept of bladder training is to hold urine for a reasonable length of time,
and gradually increase this time period. For example, one might begin by urinating
every hour or two. Each week, the length of time can be increased by 15 minutes so
that after a month the interval may have reached 2-3 hours. This could have a
significant impact on social functioning. 5
Bladder irritants:

Certain foods and beverages, (plus smoking!) have been found to increase
bladder irritation. These include: alcohol, caffeine, acidic foods (citrus, tomatoes), spicy
foods, artificial sweeteners (diet pop), foods rich in potassium, and MSG. Bladderfriendly
diets have been developed, and individuals may discover that certain foods
cause them more bladder pain or urinary frequency. An elimination diet can be used to
find out what an individual’s food triggers are. 1,3,6
Pelvic physical therapy:
Pelvic physical therapy is done by a specially trained physiotherapist. Therapy
includes stretching exercises (both internal and external), massage, home exercises,
and biofeedback to learn how to control relaxation of the pelvic floor muscles. 1,3
Oral medications:
Many medications have been tried for the treatment for IC/PBS, but few of them
have proven effective. The only oral medication currently approved by the FDA for
treatment of IC/PBS is pentosan polysulphate sodium (PPS; brand name: Elmiron). It
works by coating the bladder, preventing irritation from urine against the bladder lining.
It may take from 4 weeks up to 6 months for full effect. 3,6
Anti-histamine medications, such as cimetidine and hydroxyzine, decrease
inflammation in the bladder. 4 Anticholinergic medications like oxybutinin (Ditropan)
decrease muscle spasms in the bladder wall. 7 Amitriptyline is an anti-depressant
medication, commonly used to treat neuropathic pain. Whether any these medications
are effective for IC/PBS is still in debate. 3,6,8,9
Intravesicular medications:
Intravesicular medications are put directly into the bladder for a short period of
time using a urinary catheter. Many medications have been studied for this use, but
there continues to be debate surrounding their effectiveness. Dimethylsulfoxide (DMSO)
is the only intravesicular therapy currently approved by the FDA for IC/PBS, although
little is known about how it works. 6,7 Lidocaine is a local analgesic, often mixed with
bicarbonate before instillation. 7,10 Heparin belongs to a class of compounds called
glycosaminoglycans (GAGs). Other GAGs include chondroitin and hyaluronan. These
medications coat the bladder lining and prevent irritation from urine. 3,11,12 PPS,
described above, can be used both as an oral and intravesicular medication.
Intravesicular PPS is helpful during the beginning of oral PPS treatment, and can be
discontinued once symptoms are under control. 13
Hydrodistension:

Hydrodistension involves filling the bladder with enough water to stretch the
bladder wall. It is thought to be more effective when used in combination with bladder
training, as described above. 5,14
TENS/Neuromodulation:
Transcutaneous Electrical Nerve Stimulation (TENS) uses electric current across
the skin to stimulate the nerves that produce and that mask pain, theoretically blocking
the pain signal. 3 Sacral neuromodulation is like an implanted version of TENS. After a 4-
7 day trial with a temporary device, a permanent implant is placed into the upper buttock
area. 15,16
Botox:
Botox-A injections, directly into the muscle of the bladder wall, cause relaxation
of the muscle and may help people who fail other therapies. 6,17
Surgery:
Surgery is the last resort. This can include enlarging the bladder using intestine,
cutting the nerves to the bladder, or complete removal of the bladder. 6,3 The most
common complication is urinary retention (resulting in the need for selfcatheterization).
18
Summary:
IC/PBS is a painful and potentially disabling condition with significant physical,
emotional, and financial costs. There is no single agreed-upon approach to treatment,
nor does it seem that one treatment fits all. It is helpful to keep in mind that the goals of
treatment are pain management, function, and quality of life. An individualised
combination of the treatments described above can give people the best chance to feel
better and improve their quality of life.
References
1. Dell JR. Interstitial Cystitis / Painful Bladder Syndrome: Appropriate Diagnosis and
Management. Journal of Women’s Health 2007; 16(8):1181-1187.
2. Stanford EJ, Chen A, Wan GJ, et al. Treatment modalities, health care resource
utilization, and costs in patients diagnosed with interstitial cystitis. Am J Obstet
Gynecol 2008; 199:71.e1-71.e10.
3. Banerjee S. Patient education and self-advocacy: Questions and responses on pain
management. “Interstitial Cystitis”. Journal of Pain & Palliative Care Pharmacotherapy
2011; 25:72-75.
4. Hanno PM, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, FitzGerald MP,
Forrest JB, Gordon B, Gray M, Mayer RD, Newman D, Nyberg L Jr., Payne CK,

Wesselmann U, Faraday MM. AUA guideline for the diagnosis and treatment of
interstitial cystitis/bladder pain syndrome. The Journal of Urology, 2011; 185:2162-
2170.
5. Hsieh C-H, Chang S-T, Hsieh C-J, Hsu C-S, Kuo T-C, Chang H-C, Lin Y-H.
Treatment of interstitial cystitis with hydrodistention and bladder training. Int.
Urogynecol J, 2008; 19:1379-1384.
6. Hanno P, Nordling J, Fall M. Bladder Pain Syndrome. Med Clin N Am 2011; 95:55-
73.
7. Dawson TE, Jamison J. Intravesical treatments for painful bladder
syndrome/interstitial cystitis (Review). Cochrane Database of Systematic Reviews
2007, Issue 4. Art. No.: CD006113.
8. Dimitrakov J, Kroenke K, Steers WD, Berde C, Zurakowski D, Freeman MR, Jackson
JL. Pharmacologic Management of Painful Bladder Syndrome/Interstitial Cystitis. Arc
Intern Med. 2007; 167(18):1922-1929.
9. Foster HE, Hanno PM, Nickel JC, Payne CK, Mayer RD, Burks DA, Yang CC, Chai
TC, Kreder KJ, Peters KM, Lukacz ES, FitzGerald MP, Cen L, Landis JR, Propert KJ,
Yang W, Kusek JW, Nyberg LM and the Interstitial Cystitis Collaborative Research
Network. Effect of Amitriptyline on Symptoms in Treatment Naive Patients With
Interstitial Cystitis/Painful Bladder Syndrome. The Journal of Urology, 2010; 183:1853-
1858.
10. Nickel JC, Moldwin R, Lee S, Davis EL, Henry RA, Wyllie MG. Intravesical
alkalinized llidocaine (PSD597) offers sustained relief from symptoms of interstitial
cystitis and painful bladder syndrome. BJUI, 2008; 103:910-918.
11. Nickel JC, Egerdle RB, Steinhoff G, Palmer B, Hanno P. A multicenter, randomized,
double-blind parallel group pilot evaluation of the efficacy and safety of intravesical
sodium chondroitin sulfate versus vehicle control in patients with interstitial
cystitis/painful bladder syndrome. Urology, 2010; 76(4):804-809.
12. Engelhardt PF, Morakis N, Daha LK, Esterbauer B, Riedl CR. Long-term results of
intravesical hyaluronan therapy in bladder pain syndrome/interstitial cystitis. Int.
Urogynecol J, 2011; 22:401-405.
13. Davis EL, El Khoudary SR, Talbott EO, Davis J and Regan LJ. Safety and efficacy
of the use of intravesical and oral pentosan polysulfate sodium for interstitial cystitis: A
randomized double-blind clinical trial. The Journal of Urology, 2008; 179:177-185.
14. Aihara K, Hirayama A, Tanaka N, Fujimoto K, Yoshida K, Hirao Y. Hydrodistension
under local anesthesia for patients with suspected painful bladder syndrome/interstitial
cystitis: Safety, diagnostic potential and therapeutic efficacy. International Journal of
Urology, 2009; 16:947-952.
15. Ghazwani YQ, Elkelini MS, Hassouna MM. Efficacy of sacral neuromodulation in
treatment of bladder pain syndrome: long-term follow-up. Neurourology and
Urodynamics, 2011; 30:1271-1275.
16. Marinkovic SP, Gillen LM, Marinkovic CM. Minimum 6-year outcomes for interstitial
cystitis treated with sacral neuromodulation. Int Urogynecol J, 2011; 22:407-412.
17. Tirumuru S, Al-Kurdi D, Latthe P. Intravesical botulinum toxin A injections in the
treatment of painful bladder syndrome/interstitial cystitis: a systematic review. Int
Urogynecol J, 2010; 21:1285-1300.

18. Rossberger J, Fall M, Jonsson O, Peeker R. Long-term results of reconstructive
surgery in patients with bladder pain syndrome/interstitial cystitis: subtyping is
imperative. Urology, 2007; 70:638-642.
Bio
Dr. Kathryn Rutherford is a resident in family medicine at Queen’s University in
Kingston, Ontario. She completed her medical degree at Queen’s University and has a
Bachelor of Science with Honours from the University of Ottawa. She is interested in the
management of chronic pain from a generalist perspective, including the integration of
diet, exercise, and stress management into comprehensive pain management
strategies. Her other interests include community health, addiction medicine, and the
issues surrounding management of chronic pain in the acute care setting.