Intravesical “Cocktail” Therapy for Interstitial Cystitis for Pain
Intravesical therapy, bladder instillations or bladder cocktails are mixtures of medicines put directly into the bladder.
Pain Management
Most patients do not respond to a single agent/drug, and a complex multidisciplinary option with expert guidance under a pain specialist or clinic should be sought. Treatment should be introduced slowly, with the lowest possible dose and a minimal number of drugs used as possible, in line with the WHO (World Health Organization) pain ladder. Non-opioid treatments are much preferred over opioid therapy. This post is about the different “bladder cocktail” formulas for intervesical instillation (medicine installed in the bladder using a catherer). [https://www.ncbi.nlm.nih.gov/books/NBK570588/]
Bladder Cocktail Formulas for Intravesical InstillatiON LIST
Alkalinized Lidocaine Cocktail
- Gentamicin 80 mg in 5 mL
- Heparin 10,000 IU in 10 mL
- Lidocaine 2% solution: 25 mL
- Sodium Bicarbonate 8.4%: 5 to 10 mL
- Schedule:
- Weekly as needed in office/clinic.
- Should be mixed immediately before intravesical instillation to avoid precipitation.
- Increase the interval between instillations as symptoms improve.
DMSO (Dimethylsulfoxide) Cocktail
- Gentamicin 80 mg in 5 mL
- Heparin 10,000 to 20,000 IU
- Rimso-50 (DMSO) 50 mL
- Sodium Bicarbonate 8.4%: 10 mL
- Triamcinolone 40 mg
- Schedule:
- Weekly as needed in the office/clinic.
- Increase the interval between instillations as symptoms improve.
Robert Moldwin, MD—Smith Institute for Urology & Long Island Jewish Medical Center
- Bupivacaine (Marcaine) 0.5% and Lidocaine jelly 2% in a 1:1 mixture: Total of 30 to 40 mL.
- Heparin 10,000 to 20,000 IU
- Gentamicin 80 mg
- Triamcinolone 40 mg (Increase to 80 mg in patients with documented Hunner’s ulcer.)
- Schedule:
- Weekly instillations in the office/clinic.
- May also be self-administered by patients at home up to three times weekly.
- Increase the interval between instillations as symptoms improve.
- Maximum symptom improvement is expected by twelve weeks.
- If no longer effective, switch to “DMSO Cocktail.” May resume the above bupivacaine combination cocktail later if symptoms return.
Christopher Payne, MD “Payne Cocktail 1”
- Bupivacaine (Marcaine) 0.5%: 10 mL
- Heparin 10,000 IU
- Schedule:
- Weekly instillations in the office/clinic.
- May also be self-administered by patients at home as often as daily.
- Increase the interval between instillations as symptoms improve.
Christopher Payne, MD “Payne Cocktail 2”
- Bupivacaine (Marcaine) 0.5%: 10 mL
- Heparin 10,000 IU (Optional. May be reserved as separate instillation treatment.)
- Hydrocortisone (Solu-Cortef) 100 mg
- Rimso-50 (DMSO): 50 mL
- Sodium Bicarbonate 8.4%: 5 mL
- Schedule:
- Weekly instillations of 30 to 50 mL for six to eight weeks.
- Increase the interval between instillations as symptoms improve.
- Use B&O suppositories if patients are unable to hold the solution for at least 30 minutes.
Kristene Whitmore, MD—Drexel University College of Medicine
- Bupivacaine (Marcaine) 0.5%: 20 mL
- Gentamicin 80 mg: 5 mL of Normal Saline. (Add for patients with a documented UTI within three months.)
- Heparin 10,000 IU in 10 mL
- Hydrocortisone 100 mg: 5 mL of Normal Saline
- Sodium Bicarbonate 8.4%: 40 to 50 mL
- Schedule:
- Six weekly instillations. Should be administered during a premenstrual flare when possible.
- Appropriate for patients who are able to self-catheterize and administer at home.
TREATING INTERSTITIAL CYSTITIS 