Many experts recommend an initial series of approximately 9 bladder instillations in the first 6 to 8 weeks of therapy. These are performed along with diet modification and oral therapy. This initial series of treatments usually results in rapid improvement in symptoms and acts as a “jump start” to therapy.17
A premixed, compounded bladder instillation of alkalinized lidocaine and heparin is now available for the treatment of interstitial cystitis. It can be purchased directly by patients for home use or by physicians for use in the office. Kits come with a choice of catheters and are stable for storage for at least 6 months.
Patients with symptom flares while on oral therapy can return for additional bladder instillations on an as-needed basis, but the urine should first be evaluated for infection and treated appropriately.
Bladder instillations can be administered by an LVN or RN. These visits can also be used for patient education. Billing for these services performed by nursing staff is often appropriate. Coding and billing for evaluation and treatment are shown in Table 1.
Additional therapy options
Patients with severe IC may require additional therapies. If first- and second-line therapies are not providing sufficient relief or are not tolerated, additional treatments (or referral) may be considered using the previously noted AUA guidelines including: cystoscopy under anesthesia with low-pressure hydrodistension and/or fulguration of Hunner’s ulcer; sacral nerve stimulation; percutaneous tibial nerve stimulation (PTNS); or intradetrusor botulinum toxin injections. These therapies do not need to be performed in a specific order. Cyclosporin A and urinary diversion with or without cystectomy are rarely indicated.
Although cystoscopy with hydrodistention under general anesthesia is no longer required for the diagnosis of IC, it continues to have a role in treatment. It can reduce pain and discomfort in some IC patients for up to 6 months. Not everyone benefits from this procedure, however, and it may take up to several weeks to notice any symptom improvement. For patients undergoing surgical treatment for endometriosis, performing cystoscopy with hydrodistention should be considered at that time. It is an easy procedure for any surgeon with basic cystoscopic privileges to learn.
Follow-up and long-term care
Following initial multimodal therapy, a follow-up visit should be scheduled to discuss continuing therapy. Most patients do not require ongoing intravesical therapy, although flares of symptoms can often be treated with a short course of 1 to 3 instillations. Continuing diet modification and oral therapy allows for continued downregulation and desensitization of pelvic nerves. Follow-up visits at 4- to 6-month intervals for 1 to 2 years to evaluate ongoing medications are appropriate.
A few patients with severe symptoms will benefit from ongoing intravesical therapy. These patients, and those who have difficulty traveling to the office, should be encouraged to perform self bladder instillations at home. Such patients should schedule a nursing visit dedicated to learning how to prepare and perform home instillations.
We now know that IC is a visceral pain syndrome and many patients have overlapping symptoms of other chronic pain syndromes. The ABC or bladder instillation is a helpful tool for diagnosis as well as therapy. Importantly, most providers can successfully care for patients with IC, and the majority of patients do not need to be referred to a specialist.
When caring for patients with IC, it is important to help them learn what works for them. IC is a disorder that exists on a spectrum, and each patient will require individually tailored therapy. Helping patients take charge of the management of their disease is the most effective strategy, and this will make patients grateful for the care you have provided.
1. Berry SH, Elliott MN, Suttorp M, et al. Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. J Urol. 2011;186(2):540–544.
2. McLennan MT. Interstitial cystitis: epidemiology, pathophysiology, and clinical presentation. Obstet Gynecol Clin North Am. 2014;41(3):385–395
3. Parsons JK, Parsons CL. The historical origins of interstitial cystitis. J Urol. 2004;171(1):20–22.
4. Hanno P, Dmochowski R. Status of international consensus on interstitial cystitis/bladder pain syndrome/painful bladder syndrome:2008 snapshot. Neurourol Urodyn. 2009;28(4):274–286.
5. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol. 2002;187(1):116–126.
6. Lilly JD, Parsons CL. Bladder surface glycosaminoglycans is a human epithelial permeability barrier. Surg Gynecol Obstet. 1990;171(6):493–496.
7. Parsons CL. The role of the urinary epithelium in the pathogenesis of interstitial cystitis/prostatitis/urethritis. Urology. 2007;69(4 suppl):9–16.
8. Theoharides TC, Kempuraj D, Sant GR. Mast cell involvement in interstitial cystitis: a review of human and experimental evidence. Urology. 2001;57(6 suppl 1):47–55.
9. Rodriguez MA, Afari N, Buchwald DS; National Institute of Diabetes and Digestive and Kidney Diseases Working Group on Urological Chronic Pelvic Pain. Evidence for overlap between urological and nonurological unexplained clinical conditions. J Urol. 2009;182(5):2123–2131.
10. Evans RJ, Sant GR. Current diagnosis of interstitial cystitis: an evolving paradigm. Urology. 2007;69(4 suppl):64–72.
11. Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology. 2002;60(4):573–578.
12. Rosenberg MT, Hazzard M. Prevalence of interstitial cystitis symptoms in women: a population based study in the primary care office. J Urol. 2005;174(6):2231–2234.
13. Kahn BS, Tatro C, Parsons CL, Willems JJ. Prevalence of interstitial cystitis in vulvodynia patients detected by bladder potassium sensitivity. J Sex Med. 2010;7(2 pt 2):996–1002.
14. Sant GR. Etiology, pathogenesis, and diagnosis of interstitial cystitis. Rev Urol. 2002;4 suppl 1:S9–S15.
15. Hanno P. Is the potassium sensitivity test a valid and useful test for the diagnosis of interstitial cystitis? Against. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):428–429.
16. Rosenberg MT, Moldwin RM, Stanford EJ. Early diagnosis and management of interstitial cystitis: what primary care clinicians should know. Womens Health Primary Care. 2004;7(9):456–463.
17. Dell JR, Parsons CL. Multimodal therapy for interstitial cystitis. J Reprod Med. 2004;49(3 suppl):243–252.
18. Shorter BL, Lesser M, Moldwin RM, Kushner L. Effect of comestibles on symptoms of interstitial cystitis. J Urol. 2007;178(1):145–152.
19. Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166(6):2226–2231.
20. Chiang G, Patra P, Letourneau R, et al. Pentosanpolysulfate inhibits mast cell histamine secretion and intracellular calcium on levels: an alternative explanation of its beneficial effect in interstitialcystitis. J Urol. 2000;164(6):2119–2125.
21. McQuay HJ, Carroll D, Glynn CJ. Dose-response for analgesic effect of amitriptyline in chronic pain. Anaesthesia.1993;48(4):281–285.
22. Moore KN, Fader M, Getliffe K. Long-term bladder management by intermittent catheterization in adults and children. Cochrane Database Syst Rev. 2007;(4):CD006008.