First- and second-line treatments
AUA guidelines and algorithms for the diagnosis and treatment of IC, as well as information available online from the ICA and the IC Network, are useful references for both providers and patients. These online references can be shared with patients at their initial visits. A downloadable information sheet used at Scripps Clinic is also available (see Resources).
Multimodal therapy is a key to successful treatment of patients with IC. Monotherapy can be frustrating because it works slowly, if at all.16,17 Encouraging patients to commit to an initial 6- to 8-week course of multimodal therapy will improve symptoms quickly and build confidence that the problem can be managed successfully. Initial multimodal therapy regimens should include a combination of first- and second-line treatments from the AUA IC therapy algorithm. Suggested initial therapy is outlined in Table 3. The majority of patients respond well to a combination of these therapies.
Dietary factors, lifestyle modifications, physical therapy
Dietary triggers have been identified in up to 90% of patients diagnosed with IC. Citrus, tomatoes, artificial sweeteners, coffee, tea, chocolate, alcohol, and spicy food can exacerbate symptoms, although this varies significantly among patients.18 Patients should be encouraged to explore how diet modification might help control their symptoms. Additional lifestyle modifications for IC management include relaxation techniques and optimization of stress management, low-impact exercises, pain management techniques (ie, warm sitz baths), wearing nonrestrictive clothing, bladder retraining, and controlled fluid intake.
For patients with findings suggestive of significant musculoskeletal pain or muscle spasm identified on exam, physical therapy (and/or nerve blocks) targeted to the abdominal wall and pelvic floor musculature can provide significant relief.19
Several oral therapies are used in the treatment of IC. These are selected based on symptomatology and associated comorbidities such as IBS, migraines, and allergies, among others. Sample initial therapy is outlined in Table 3. Pentosan polysulfate is the only oral FDA-approved medication for the treatment of IC. The mechanism of action of this medication is unknown, but it is believed to be from either rebuilding the GAG layer, mast cell stabilization, or by neutralizing toxic substances within the urine.20 An adjunct oral medication is typically used in combination with it, including either an antihistamine (hydroxyzine 10-25 mg/d) or a tricyclic antidepressant (amitriptyline 10-25 mg/d). Patients with IC have an increased concentration and activation of mast cells, which leads to release of histamine and other inflammatory mediators.8 Amitriptyline is believed to exhibit analgesic properties and has been widely used for other chronic pain syndromes.21 For patients with severe symptoms, consider using all 3 of these medications for initial therapy. Urinary analgesics such as phenazopyridine or the combination drug hyoscyamine/methenamine/methylene blue/phenyl salicylate/sodium phosphate can also be helpful for symptom flares.