AUA guidelines on diagnosis and treatment of interstitial cystitis/bladder pain syndrome

GUIDELINE STATEMENTS

Diagnosis

• The basic assessment should include a careful history, physical examination, and laboratory examination to document symptoms and signs that characterize IC/BPS and exclude other disorders that could be the cause of the patient's symptoms.
• Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
• Cystoscopy and/or urodynamics should be considered when the diagnosis is in doubt; these tests are not necessary for making the diagnosis in uncomplicated presentations.
• Cystoscopy should be performed in patients in whom Hunner lesions are suspected.

Management Approach

• Treatment decisions should typically be made after shared decision-making, with the patient informed of the risks, potential benefits, and alternatives. Except for patients with Hunner lesions (Statement 19), initial treatment should be nonsurgical.
• Efficacy of treatment should be periodically reassessed and ineffective treatments should be stopped.
• Multimodal pain management approaches (e.g., pharmacological, stress management, manual physical therapy if available) should be initiated. 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.

Treatment categories for IC/BPS

Behavioral/Non-pharmacologic treatments

• Patients should be educated about normal bladder function, what is known and not known about IC/ BPS, the benefits versus 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.
• 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.

Oral medications

• Clinicians may prescribe pharmacologic pain management agents (e.g., urinary analgesics, acetaminophen, NSAIDs, opioid/non-opioid medications) after counseling patients on the risks and benefits. Pharmacological pain management principles for IC/BPS should be similar to those for management of other chronic pain conditions.
• Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as oral medications (listed in alphabetical order; no hierarchy is implied).
• Clinicians should counsel patients who are considering pentosan polysulfate about the potential risk for macular damage and vision-related injuries.
• Oral cyclosporine A may be offered particularly for patients with Hunner lesions refractory to fulguration and/or triamcinolone.

Intravesical instillations

• DMSO, heparin, and/or lidocaine may be administered as intravesical treatments (listed in alphabetical order; no hierarchy is implied).

Procedures

• Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken as a treatment option.
• If Hunner lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed.
• Intradetrusor onabotulinumtoxin A may be administered if other treatments have not provided adequate improvement in symptoms and quality of life. Patients must be willing to accept the possibility that post-treatment intermittent self-catheterization may be necessary.
• A trial of neuromodulation may be performed if other treatments have not provided adequate symptom control and quality of life improvement. If a trial of nerve stimulation is successful, then a permanent neurostimulation device may be implanted.

Major surgery

• Major surgery (e.g., substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients with bladder-centric symptoms, or in the rare instance when there is an end-stage small fibrotic bladder, for whom all other therapies have failed to provide adequate symptom control and quality of life improvement.

Treatments that should not be offered

The treatments below appear to lack efficacy and/or appear to be accompanied by unacceptable adverse event profiles.

• Long-term oral antibiotic administration should not be offered.
• Intravesical instillation of bacillus Calmette-Guerin 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.

Reference:

Clemens JQ, Erickson DR, Varela NP et al: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2022; https://doi.org/10.1097/JU.0000000000002756.