Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome: AUA Guideline

The bladder disease complex includes a large group of patients with bladder and/or urethral and/or pelvic pain, lower urinary tract symptoms, and sterile urine cultures. IC/BPS comprises a part of this complex. The Panel used the IC/BPS definition agreed upon by the Society for Urodynamics and Female Urology (SUFU): "An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes."2 This definition was selected because it allows treatment to begin after a relatively short symptomatic period, preventing treatment withholding that could occur with definitions that require longer symptom durations (i.e., six months). Definitions used in research or clinical trials should be avoided in clinical practice; many patients may be misdiagnosed or have delays in diagnosis and treatment if these criteria are employed.3

American Urological Association (AUA) has released guidelines titled Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome on (2022). The purpose of this clinical guideline is to provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS), including a discussion of treatments that should and should not be offered.

Following are its major recommendations:

1. 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. . Clinical Principle

2. Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects. Clinical Principle

3. 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. Expert Opinion

4. Cystoscopy should be performed in patients in whom Hunner lesions are suspected. Expert Opinion

5. 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. Expert Opinion

6. Efficacy of treatment should be periodically reassessed and ineffective treatments should be stopped. Clinical Principle

7. 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. Clinical Principle

8. The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. Clinical Principle

9. 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. Clinical Principle

10. Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible. Clinical Principle

11. Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. Clinical Principle

12. 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. Standard (Evidence Strength: Grade A)

13. 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. Clinical Principle

14.; Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as oral medications (listed in alphabetical order; no hierarchy is implied) Option (Evidence Strength: Grades B, B, C, and B)

15. Clinicians should counsel patients who are considering pentosan polysulfate about the potential risk for macular damage and vision-related injuries. Clinical Principle

16. Oral cyclosporine A may be offered particularly for patients with Hunner lesions refractory to fulguration and/or triamcinolone. Option (Evidence Strength: Grade C)

17. DMSO, heparin, and/or lidocaine may be administered as intravesical treatments (listed in alphabetical order; no hierarchy is implied). Option (Evidence Strength: Grades C, C, and B)

18. Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken as a treatment option. Option (Evidence Strength: Grade C)

19. If Hunner lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed. Recommendation (Evidence Strength: Grade C)

20. 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. Option (Evidence Strength: Grade C)

21. 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. Option (Evidence Strength: Grade C)

22. 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. Option (Evidence Strength: Grade C)

23. Long-term oral antibiotic administration should not be offered. Standard (Evidence Strength: Grade B)

24. Intravesical instillation of bacillus Calmette-Guerin should not be offered outside of investigational study settings. Standard (Evidence Strength: Grade B)

25. High-pressure, long-duration hydrodistension should not be offered. Recommendation (Evidence Strength: Grade C)

26. Systemic (oral) long-term glucocorticoid administration should not be offered. Recommendation (Evidence Strength: Grade C)

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.