Interstitial Cystitis Guidelines

Updated: Aug 19, 2022
  • Author: Eric S Rovner, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines

Guidelines Summary

Guidelines of the diagnosis and management of interstitial cystitis/bladder pain syndrome (IC/BPS) have been issued by the following organizations:

  • American Urological Association (AUA)
  • Canadian Urological Association (CUA)

The AUA evidence-based guidelines were initially published in 2011 and updated in 2014 and 2022. [3] The CUA issued its evidenced-based guideline in 2016. [4]

Diagnosis

Tha AUA recommendations for diagnosis are as follows [3] :

  • A basic assessment that includes history, physical examination, and laboratory testing should be conducted both to confirm the presence of symptoms characteristic of IC/BPS and to rule out other conditions
  • Baseline voiding symptoms and pain levels should be documented, for use in assessment of response to treatment
  • Cystoscopy and/or urodynamics should not be used routinely but should be considered for complex presentations
  • Cystoscopy should be performed when Hunner lesions are suspected

The CUA recommendations are in agreement with AUA that all evauations should begin with history, physical examination, and laboratory testing and that baseline voiding and pain levels should be used to track response to treatment. However, the CUA recommends that cystoscopy be performed for most patients, to do the following [4] :

  • Rule out bladder cancer/carcinoma in situ
  • Identify Hunner lesions
  • Determine the effect of bladder filling and emptying on pelvic pain
  • Evaluate functional bladder capacity
  • Facilitate pelvic examination
  • Reassure the patient

The CUA considers cystoscopy optional only for young women with symptoms of IC/BPS but no risk factors for bladder cancer or other pelvic conditions. [4]

Additional CUA recommendations include the following [4] :

  • Ultrasound and/or other pelvic imaging is optional to rule out alternative clinical disorders, required for patients with hematuria
  • Optional intravesical anesthetic bladder challenge testing after cystoscopy to provide both relief to the patient, as well as provide diagnostic information and guide future therapy
  • Hydrodistension in select patients such as women unable to tolerate cystoscopy under local anesthesia

The AUA and CUA guidelines agree that urodynamics and bladder biopsy should not be used in routine care. Both guidelines recommend against potassium sensitivity diagnostic testing. [3, 4]

Treatment

The CUA guidelines offer a treatment algorithm that begin with conservative management and progress to less conservative therapies if symptoms are not adquately controlled. [4]  In the 2022 amended AUA guidelines the algorithm has been replaced with the recommendation of an individualized clinical approach based on the patient's specific symptoms. [3]

Overall management

Key AUA guideline recommendations for disease management include the following [3] :

  • Treatment decisions should be made after the patient is informed of the risks, potential benefits, and alternatives.
  • Except for patients with Hunner lesions, initial treatment should be nonsurgical. 
  • Treatments that fail to demonstrate efficacy should be stopped once a clinically meaningful interval has elapsed
  • Multimodal pain management approaches (eg, pharmacologic, stress management, manual physical therapy if available) should be initiated.
  • Pain management should be continually assessed because of its importance to quality of life; if pain management is inadequate, 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

Treatments that may be offered

The AUA guidelines divides treatments into behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures and major surgery. [3]  

Behavioral/non-pharmacologic treatments

Both AUA and CUA guidelines are in agreement that recommended behavioral treatments include the following:

  • Patient education 
  • Self-care practices and behavioral modifications that can improve symptoms should be implemented as feasible.
  • Stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. 
  • Appropriate manual physical therapy techniques should be offered, if trained clinicians are available; however, pelvic floor strengthening exercises (eg, Kegel exercises) should be avoided.

CUA guidelines recommend pelvic floor physiotherapy for patients with pelvic floor muscle dysfunction (PFD). Massage, acupuncture, and trigger point injections are optional for patients with pelvic floor tenderness. In addition, the CUA recommends dietary restrictions of common food triggers for a period of 1 week to 3 months, with re-introduction of one item at a time and a waiting period of 3 days to identify potential offenders. [4]

Oral medications

According to AUA guidelines, pharmacologic pain management agents (e.g., urinary analgesics, acetaminophen, NSAIDs, opioid/non-opioid medications) may be prescribed after counseling patients on the risks and benefits. Pharmacologic pain management principles for IC/BPS should be similar to those for management of other chronic pain conditions. [3]

The AUA recommends amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate (PPS) (listed in alphabetical order; no hierarchy is implied). Clinicians should counsel patients who are considering PPS about the potential risk for macular damage and vision-related injuries [3]

The CUA recommends amitriptyline, cimetidine, hydroxyzine, or PPS as options after conservative therapies have failed, but notes that there is conflicting evidence of the effectiveness of PPS and expected benefits may be marginal in the majority of patients. In addition, CUA recommends gabapentin and quercetin, although evidence is weak. [4]

Cyclosporine is recommended by AUA for patients with Hunner lesions refractory to fulguration and/or triamcinolone. [3] CUA guidelines note that due to its adverse side effects, cyclosporine should be considered a last resort in patients with inflammation and refractory disease. Close monitoring, including measurement of blood pressure, creatinine, and cyclosporine levels, is required. [4]

Intravesical instillations

AUA and CUA guidelines recommend cimethyl sulfoxide (DMSO), heparin, or lidocaine as intravesical treatments (listed in alphabetical order; no hierarchy is implied). [3, 4]

Procedures

The following procedures are recommended treatment options [3]

  • Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension 
  • If Hunner lesions are present, fulguration (electrocautery) and/or injection of triamcinolone 

If other treatments have not provided adequate symptom control and quality of life improvement, these treatments are recommended [3] :

  • Intradetrusor botulinum toxin A (BTX-A); post-treatment intermittent self-catheterization may be required
  • A trial of neurostimulation may be performed, if successful, implantation of permanent neurostimulation devices 

Overall, CUA guidelines concur with the AUA  recommendations. The guidelines do note that sacral neuromodulation (SNM) is not yet approved by Health Canada or the US Food and Drug Administration (FDA) for the treatment of IC/BPS, but is indicated for urgency frequency syndrome and urgency urinary incontinence. [4]

Major surgery

According to AUA, major surgery (eg, substitution cystoplasty, urinary diversion with or without cystectomy) should be considered for carefully selected patients for whom all other therapies have failed to provide adequate symptom control and quality of life. [3]  After weighing the invasiveness of surgery, the benign nature of IC/BPS, and multiple other treatment options available, the CUA concluded that major surgery should only be considered as an absolute last resort. [4]  

Treatments that should not be offered

The AUA recommends against the following treatments, due to a lack of evidence of efficacy, unacceptable adverse event profiles, or both [3] :

  • Long-term oral antibiotic administration 
  • Intravesical instillation of bacillus Calmette-Guerin (BCG) outside of clinical studies
  • High-pressure, long-duration hydrodistension 
  • Systemic long-term glucocorticoid administration