Interstitial cystitis/bladder pain

Question 1

Diagnosis

Answer 1

• 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.
• 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.

Question 2

General treatment

Answer 2

General Treatment

• 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.
• 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.
• Multiple, simultaneous treatments may be considered if it is in the best interests of the patient; baseline symptom assessment and regular symptom level re-assessment are essential to document efficacy of single and combined treatments.
• Ineffective treatments should be stopped once a clinically meaningful interval has elapsed.
• 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.
• The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches.

Question 3

First-Line Treatment(Should be performed on all patients)

Answer 3

First-Line Treatment(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 vs. 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.
• Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations

Question 4

Second-Line Treatments

Answer 4

• 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.
• Multimodal pain management approaches (e.g., pharmacological, stress management, manual therapy if available) should be initiated.
• Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as second-line oral medications (listed in alphabetical order; no hierarchy is implied).
• DMSO, heparin, or lidocaine may be administered as second-line intravesical treatments (listed in alphabetical order; no hierarchy is implied).

Question 5

Third line treatments

Answer 5

• 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.
• If Hunner’s lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed

Question 6

Fourth line treatments

Answer 6

• 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.
• 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.

Question 7

Fifth-line treatments

Answer 7

• 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.

Question 8

Sixth Line treatments

Answer 8

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

Question 9

Treatments that should not be offered

Answer 9

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.
• Intravesical instillation of bacillus Calmette-Guerin (BCG) should not be offered outside of investigational study settings.
• High-pressure, long-duration hydrodistension should not be offered.
• Systemic (oral) long-term glucocorticoid administration should not be offered.