Treatments are directed toward a patient's primary symptoms (pain, urinary urgency, urinary frequency) with minimally invasive options recommended before more complex, invasive therapies. Treatment is escalated until the patient gets relief from symptoms.
Though interstitial cystitis isn't curable, changes in behavior can help minimize and manage some symptoms. Dietary changes, stress management and behavioral modification (like bladder training techniques) can be used to help. Foods such as alcohol, coffee, vinegar, tomatoes, chocolate, spicy foods and certain fruits and vegetables have been known to worsen symptoms of interstitial cystitis. Patients who fill out a food diary can sometimes draw a direct link between specific foods and beverages and increased symptoms of interstitial cystitis.
Pelvic floor rehabilitation, or bladder retraining
Pelvic floor rehabilitation with physical therapists that are specifically trained to manage pelvic floor spasm can be very beneficial in managing the muscle spasm often associated with interstitial cystitis symptoms. This includes both external and internal myofascial release. Patients are often taught to do home stretching exercises.
Bladder retraining programs are also excellent treatment options aimed at helping lessen symptoms of urinary urgency, urinary frequency and painful intercourse. Bladder retraining is a method where you hold your urine a little longer each time (urinating every hour at first, then every two hours, etc.) to gradually decrease urinary frequency.
Medications used to treat symptoms of interstitial cystitis include pentosan polysulfate sodium, antihistamines (including hydroxyzine) and mild analgesics such as ibuprofen or acetaminophen. Combinations of these medications may be required to treat certain cases.
Pentosan polysulfate sodium
Pentosan polysulfate sodium is the only FDA-approved oral medication for interstitial cystitis. The drug binds to the walls of the bladder, helping replace and repair the lining. Symptom improvement can take up to six months, but several studies have shown moderately positive results.
Antihistamines target histamine release, which is involved in your body's inflammatory response to harmful things like bacteria and other pathogens. One study of hydroxyzine demonstrated a 40 percent improvement in symptom scores from baseline, while symptom scores improved an additional 55 percent in patients who also had seasonal allergies.
Tricyclic antidepressants like amitriptyline have also been proposed for patients with pelvic pain. Studies have shown positive results as long as treatment is continued. Amitriptyline, Prednisone and gabapentin have all shown be useful in managing painful symptoms of interstitial cystitis.
Minimally Invasive Therapies
Intravesical therapy is recommended in patients who show no response to medications and have bladder-centered pain and no pelvic floor dysfunction. Intravesical therapy may also be used as a bridging therapy, given at the same time as medication is prescribed.
In intravesical therapy, drugs used to decrease inflammation are injected into the bladder through a catheter, where the solution is held for a 10 to 15 minutes before being emptied. Once comfortable with the procedure, patients can self-administer treatment at home.
Pelvic floor trigger-point injections
For patients with tender areas and muscle spasms, periodic trans-vaginal trigger point injections can provide substantial relief of symptoms. A long-acting anesthetic mixed with an anti-inflammatory relaxes the muscles and relieves pain associated with symptoms of interstitial cystitis. Multiple injections over the course of several months may be necessary to significantly relieve symptoms. If symptom improvement is not sustained, botox can be injected into the pelvic floor to provide more sustained muscle relaxation.
Some patients with bladder-centered pain and no specific tender areas may respond to bladder distention under anesthesia. In a hydrodistention procedure, the bladder is distended with water for two minutes and repeated. Treatments can be repeated as pain and urgency recur, though usually not more than every three to six months. Up to 50 percent of patients can see improvement, though it may be short lived.
Interstim® is one form of sacral neuromodulation therapy designed for patients with severe symptoms of urinary urgency and urinary frequency. Interstim involves the placement of a pacemaker-like device next to the sacral nerve and a power generator implanted in the upper part of the buttock. The generator is connected to the device and produces a small electrical pulse that stimulates the sacral nerve, helping you control the bladder and pelvic floor. Reports show decrease in urinary urgency and urinary frequency, as well as decreased need for medications. Although not approved for pelvic pain, there are many publications including our own from Beaumont demonstrating improvement in interstitial cystitis and pelvic pain symptoms.
Beaumont urologists helped developed pudendal neuromodulation. This technique is used for patients who did not respond to sacral neuromodulation and has been shown to be effective in the management of pelvic pain and pudendal neuropathy.
A less invasive form of neuromodulation at the posterior tibial nerve (PTNS) can also been used for patients with overactive bladder symptoms. A thin needle is placed at the posterior tibial nerve and stimulated weekly for 12 weeks, then treatments are spaced further apart for maintenance. Unlike sacral neuromodulation, this treatment is intermittent and does not require invasive surgery or costly implants.
Chemical neuromodulation has become a standard treatment for patients with medication-resistant urinary urgency and frequency. Currently, Onabotulinum Toxin A (Botox®) is FDA approved to treat urinary frequency.
Cauterization or laser surgery
Cautery or laser ablation has been used successfully to treat Hunner's ulcers, which are found in ulcerative interstitial cystitis patients. This surgery destroys the ulcerative layer of tissue in the bladder using an electrical current or laser beam, leaving new tissue behind. This treatment may provide relief of symptoms caused by these ulcers, however, symptoms can recur over time, requiring additional surgery.
Resection of ulcers
Similar to laser surgery, resection involves cutting around and removing the ulcers in the bladder to leave new tissue behind. Resection is generally used in milder forms of ulcerative interstitial cystitis.
Radical surgery - cystectomy and urinary division
Radical surgery should only be considered in select patients with interstitial cystitis. Patients with 'end stage' bladders have very low bladder volumes, recurrent ulcers and often severe, localized pain in the bladder. Their storage symptoms are extreme and these patients have usually endured years of other therapies. This select group may be considered for cystectomy with urinary diversion
Urinary diversion eliminates urinary frequency, but may not always result in elimination of pain. There are several options when performing a urinary diversion. The bladder may be removed or left in place, and any number of methods to help you store and void your bladder can be fashioned. One version of the surgery diverts urine through an opening in the abdomen, allowing it drain continually into an external collection bag. Another option constructs an internal pouch from a segment of your bowel and places it inside the abdomen. Urine is then emptied from the pouch by self-catheterization four to six times each day.
Several case studies support these treatments with reasonable outcomes. In one study of patients undergoing cystectomy with diversion, eight of nine would undergo the surgery again and all had improved quality of life and pain. Because these treatments are very risky, they should not be offered to patients unwilling to accept the complications.
You should know about the chronic nature of your condition and have a clear understanding of your diagnosis. Physical and emotional support is important because symptoms of interstitial cystitis often take time and several treatments before they get better. Patients often try various treatment options over time, and the lack of success can often be discouraging.
The Women's Urology Center offers a Women's Coping Support Group run by a psychologist who specializes in women's health, including issues related to urinary problems, pelvic pain and interstitial cystitis. Other support groups can be found at the Interstitial Cystitis Network website .
An early study showed that significantly more patients treated with lidocaine injected directly into the bladder through a catheter had noticeable improvement in symptom relief and reported continued relief from long-term symptoms. Lidocaine therapy is considered safe, though long-term studies are still needed. A Beaumont clinical trial using a removable implant retained in the bladder for two weeks that secretes lidocaine 24/7 is currently in phase II trials.