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Diagnosis and Management of Interstitial Cystitis/Painful Bladder Syndrome
(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.
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.
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
- 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.
- 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.
- Perez-Merrero R. A controlled study of dimethylsulfoxide in interstitial cystitis. J Urol. 1988;140:36-9.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Peters KM. Neuromodulation for the treatment of refractory interstitial cystitis. Rev Urol. 2002;4(Suppl.1):S36-S43.
- Comiter CV. Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol. 2003;169:1369-73.