“When you’re at the end of your rope, tie a knot and hold on.” — Theodore Roosevelt
Interstitial Cystitis (IC) can have a significant impact on quality of life. While symptoms are similar to urinary infections, IC occurs in the absence of infections with urinanalysis and urine cultures negative. Symptom flare-ups are common.
There is no cure for Interstitial Cystitis, but many treatments offer some relief, either on their own or in combination.
Treatment is aimed at relieving pain and reducing inflammation. The two main approaches are oral medications and bladder instillations. Below are some of the medications and treatments available.
Due to the sensitivity of the bladder in IC to acidic substances, urinary alkalinization with baking soda (a glass of water mixed with ½ tsp of baking soda [maximum 3 glasses/day]) or potassium citrate (Urocit-K®, twice a day) can be effective. Prelief, an OTC medication with calcium glycerophosphate, reduces acids in foods and has also been shown effective.
CystoProtek is a multi-agent dietary supplement formulated from glucosamine sulfate (120 mg), chondroitin sulfate (150 mg), hyaluronate sodium (10 mg), quercitin dehydrate (150 mg), rutin (20 mg), and olive kernel extract (45%). Isoflavinoids are present to decrease bladder inflammation and multiple mucopolysaccharides to replenish the bladder lining. CystoProtek contains multiple components similar to bladder surface glycosaminoglycans (GAGs) to help reduce bladder wall dysfunction and inflammation. It is thought that the mucopolysaccharide GAG bladder surface layer is composed primarily of chondroitin sulfate and sodium hyaluronate, with glucosamine sulfate serving as the synthetic building block. In one study, patients aged 18 to 69 years with IC who had failed other treatment options took two capsules of CystoProtek twice a day with food. In the 252 patients who participated in this study, about 50% had an overall positive response to CystoProtek.
Pentosan polysulfate sodium (Elmiron)
Pentosan polysulfate sodium (Elmiron) is the only oral medicine that is FDA approved for treating the pain and discomfort of interstitial cystitis (IC). In clinical trials, 38-61 percent of patients treated with Elmiron for three months reported improvement of their IC symptoms. Elmiron is thought to work by restoring a damaged, thin, or “leaky” bladder surface. This surface (glycosaminoglycans, or GAG layer) is composed of a coating of mucus, which protects the bladder wall from bacteria and irritating substances in urine. It is believed that Elmiron functions as a synthetic GAG layer, but the drug’s mechanical action in IC is unknown.
While some patients report symptom improvement in 3-4 weeks, others may take up to six months to see improvement. Patients are encouraged to continue Elmiron for at least six months before discontinuing treatment. Pain subsides first, but a decrease in urinary frequency may take six to nine months.
The side effects of Elmiron include minor gastrointestinal disturbances. Some patients have also experienced hair loss that is reversible upon discontinuing the drug. Elmiron has few if any negative interactions with any other medicines and is usually well tolerated.
The usual dosage for IC patients is 100 mg. of Elmiron three times a day, for a total of 300 mg/day.
Antidepressants such as Elavil (amitryptiline) and Savella (milnacaprin) can be effective for the pain associated with IC. As noted elsewhere in the management of neuropathic pain, the analgesic benefit of the antidepressants is not related to the presence of depression as they are effective regardless of the presence or absence of depression.
Gabapentinoids (Gabapentin [Neurontin] and Pregabalin [Lyrica])
Neuromodulating medications such as gabapentin (Neurontin) and pregablin (Lyrica) can also be effective for the pain associated with IC, as well as contributing to the reduction of central sensitization.
Mirabegron (Myrbetriq®) and trospium (Sanctura) relaxe the detrusor smooth muscle around the bladder during the storage phase of the urinary bladder fill-void cycle, thereby increasing bladder capacity and reducung voiding frequency, urge urinary incontinence, urgency and frequency.
Mirabegron was evaluated in three 12-week, studies of patients with overactive bladder and symptoms of urge urinary incontinence, urgency and urinary frequency. Results from all three studies demonstrated statistically significant improvements in incontinence episodes and micturitions/24 hours across all doses of mirabegron (25, 50 and 100 mg) compared to placebo.
Medications Instilled into the Bladder
A few medications have been shown to be effective when instilled directly into the bladder, including dimethyl sulfoxide (DMSO, lidocaine, heparine and botulinum toxin A (Botox). One potential complication of the use of Botox, however, is that it can sometimes reduce bladder muscle activity so effectively that a reduced ability to void occurs, requiring the patient self-catheterize themselves until the effects of the Botox wear down or off, possibly requiring 3 months or more.