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Treatment Guidelines
 
The need for standardized guidelines for diagnosing and treating IC has become very apparent over the past few years—and has generated many heated debates. The good news is that several countries and professional medical associations are now in the process of developing their own IC Guidelines.

  • The Japanese Urological Association’s new IC Guidelines were recently published in the International Journal of Urology. Japanese Guidelines for Diagnosis and Treatment of Interstitial Cystitis by Homma, Ueda, Ito, Takei, and Tomoe is a very detailed, comprehensive document that you can access for free online.  Read a short article about the Japanese IC Guidelines. 
  • The American Urological Association (AUA) is currently working on IC guidelines for the United States with the goal of 2010 launch. ICA Executive Director Barbara Gordon and several of the ICA’s Medical Advisory Board are members of the AUA steering committee. We are hopeful that these various guidelines from different countries and professional associations will eventually lead to an international concensus regarding IC Guidelines.

ICA Treatment Guidelines

For many patients combination of treatments, referred to as a multi-modal approach, is needed. For example, an individualized treatment plan might include diet modification, combined with the regular use of a low-dose tricyclic antidepressant, Elmiron, and an opioid analgesic for breakthrough pain. 

  • Self-Help
  • Physical Therapy
  • Oral Medicines
  • Bladder Instillations
  • Other Treatments

Self-Help:  Non-invasive techniques, such as diet modification and self-help measures, may be used in combination with other, more traditional medical therapies, and are considered a first step in relieving IC symptoms. Response to treatment is individual. A diet low in acidic foods and beverages, such as coffee and most teas, and avoiding carbonated and alcoholic drinks, may be helpful in reducing IC symptoms. Some over-the-counter dietary supplements may also be helpful to people with IC.

Physical Therapy: The goal of physical therapy for IC patients is to relax the pelvic floor muscles and avoid overly stressing them. Many people with IC have problems with this group of muscles and develop a condition called pelvic floor dysfunction (PFD). Treatment usually combines physical therapy, home exercise, medication, and self-care.

Oral Medicines:  Pentosan Polysulfate Sodium (Elmiron) is the only oral medicine FDA-approved specifically for us in IC. Elmiron is thought to work by restoring a damaged, thin, or "leaky" bladder surface. Elmiron eases the pain and discomfort of IC in many patients. Tricyclic antidepressants, antihistamines, and pain medicines may be added if more relief is needed.

  • Tricyclic Antidepressants: Used for their anti-pain properties, and prescribed in low dosages. Benefits include:
    • Helping decrease urinary frequency (anticholinergic effects)
    • Sedative effects
    • Blockage or reuptake of certain neurotransmitters that cause the brain to misinterpret or ignore pain impulse
    • The most common tricyclic antidepressants used to treat IC are:
      • Amitriptyline (formerly Elavil, now generic)
      • Desipramine (Norpramin)
      • Nortriptyline (Pamelor)
      • Doxepin (Sinequan)
      • Imipramine (Tofranil)
      • Serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil)
      • Selective serotonin and norepinephrine reuptake inhibitors (SSNRIs), such as duloxetine
  • Antihistamines: Especially useful for IC patients with allergies. The most widely used antihistamine to treat IC is hydroxyzine, which affects mast cell degranulation (thought to play a part in causing some IC symptoms). It also has sedative and anxiety reducing effects.
  • Pain Medicines: Anticonvulsants such as gabapentin (Neurontin) and clonazepam (Klonopin) are being used to treat chronic pain, as are muscle relaxants such as Valium and Flexeril. Short-acting opioid analgesics such as Vicodin and Percocet may be used to treat moderate, intermittent IC pain. OxyContin, MS-Contin, and Duragesic are long-acting analgesics that are useful in treating chronic, severe IC pain.
  • Additional medicines: Given the range of IC symptoms, additional medications may include:
    • Anticholinergics (Detrol, Ditropan XL, and Levsin)
    • H2 blockers (Tagamet and Zantac)
    • Urinary alkalinizing agents (Bicitra and Polycitra-K)
    • Adrenergic blockers (Cardura, Flomax, and Hytrin)
    • Leukotriene inhibitors such as (montelukast, Singulair)
    • Combination urinary tract medications such as those that contain an antispasmodic, analgesic, and anti-infective.

Bladder Instillations: The following bladder instillations may be added to the treatment protocol, as necessary. Also review bladder cocktail recipes used by IC experts, who are also members of the ICA Medical Advisory Board.

  • DMSO (dimethyl sulfoxide), Rimso-50: Instilled directly into the bladder. Believed to work as an anti-inflammatory agent. DMSO can be combined with steroids, heparin, and/or local anesthetics to form a bladder “cocktail.”
  • Heparin: Has both anti-inflammatory and surface protective actions. Heparin may mimic the activity of the bladder's mucous lining, temporarily "repairing" the glycosaminoglycan (GAG) layer. Heparin is also a commonly used component of bladder “cocktails.”
  • Cystistat: This medication is approved for use in Canada and Europe. It is not FDA-approved for use in IC in the US. It is thought to work by replacing the defective lining of the bladder.

Neuromodulation Devices: Products approved for the treatment of urgency, frequency, urge incontinence, and retention may be considered as a potential IC treatment when other more conservative therapies have failed. Small, surgically implanted neuromodulation devices send mild electrical pulses to nerves located in the lower back (just above the tailbone). By influencing the bladder and surrounding muscles that manage urinary function, neuromodulation devices can help relieve symptoms. Nonsurgical devices are also available. Worn externally, these devices use electrical current to treat symptoms of IC, PFD, vulvodynia, etc.

Surgery: Laser surgery has been successfully used to treat Hunner's ulcers (or patches), present in 5 to 10 percent of IC patients. No other uses for treating IC with lasers have been clinically proven, therefore laser surgery should be reserved for the ulcerative form of IC only. Other surgeries are considered only as a last resort. Several types of surgeries have been used to treat IC, including bladder augmentation, urinary diversion, and construction of an internal pouch. Serious complications can result from surgery, and pain may persist after the procedure.

Experimental Treatments: The following treatments are currently under investigation for treatment of IC and have not approved by the US Food & Drug Administration for use in IC.

  • Acupuncture
  • Botulinum Toxin (Botox)
  • Uracyst (chondroitin sulfate)
  • URG-101 (bladder instillation)

For more information on these and other IC research studies, visit current clinical trials and the literature reviews.


Revised January 28, 2009
 
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