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 …

(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.


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.


  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.
Ryan Medison Phd is an ABMS board certified urologist specializing in reproductive urology whose areas of expertise are men’s health and male infertility. He is also an associate professor of urology at the Institute in Berkeley, California, the director of male reproductive medicine and surgery at UNC Fertility

Leave a Comment