Page 10 - Diagnosis and treatment of interstitial cystitis/bladder pain syndrome

iC/BPS guideline

Unfortunately, the study was halted prematurely, but the Two RCTs compared DMSO to Bacillus Calmette-Guerin
interim results on 56 patients showed no difference in (BCG), one favouring DMSO (30% response rate compared
111
response between treatment and placebo groups (15% vs. to 10% for BCG, p<0.05) and one concluding no benefit
16%, p=0.67). 100 with either regimen. Finally, two other RCTs compared
112
Guideline: Based on Level 3 evidence, CyA may be consid- DMSO to chondroitin sulfate (CS), or to CS plus hyaluronic
ered a treatment option for IC/BPS. Close patient moni- acid, with significantly better performances of CS groups
toring, including blood pressure, Cr and CyA levels are over DMSO for both objective and subjective outcomes
necessary. Due to the potential for serious side effects, CyA (14‒53 % for DMSO against 73% for GAG, p<0.05). 113,114
should be reserved for severe patients refractory to other Other observational studies have described use of DMSO in
treatment options. combination with corticoids, bicarbonate, or heparin. 52,115-117
Overall, DMSO has a favourable safety profile. Typical
6. Gabapentinoids (OPTION in patients with neuropathic pain, Grade C) side effects include halitosis (garlic-like breath, as it is elim-
inated through the lungs) and potential flare-up after the first
Based on success in treating other neuropathic pain condi- instillation, which usually improves after the second one.
118
tions, gabapentin has been used for the treatment of IC/BPS. It is administered as a 50 mL solution of 50% DMSO with
Only two case reports 101,102 and three small observational a dwell time of 30‒60 minutes, once weekly for six weeks.
trials exist 103-105 The only trial that used gabapentin alone Monthly maintenance doses may be considered. 119
found a 48% improvement in pelvic pain. 105 Guideline: Based on Level 2 evidence, DMSO is a thera-
Guideline: Based on scarce Level 3 evidence, gabapentin peutic option for IC/BPS.
may be an option in the treatment of IC/BPS refractory to
conservative therapies. 2. Heparin (RECOMMENDED in select patients, Grade C)

7. Quercetin (OPTION, Grade C) Heparin, as a GAG analogue, may be instilled intravesically
with virtually no systemic absorption. It may be used alone
Quercetin has been used to treat male chronic pelvic pain by mixing 20 000 to 40 000 IU of heparin diluted in 10 mL
syndrome with success. One small observational trial has NS on a weekly basis for four to six weeks and retained for
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106
found a symptomatic improvement in 19/22 patients with 30‒60 minutes. From two prospective, uncontrolled studies,
IC/BPS after four weeks of Cysta-Q complex (equivalent to
quercetin 500 mg orally twice daily).
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Guideline: Based on scarce Level 3 evidence, quercetin may Table 3. Intravesical cocktails for IC/BPS
be an option in the treatment of IC/BPS. Ingredients References
20 mL 0.5% bupivacaine, 20 mL 2% lidocaine jelly,
C2. Intravesical therapies 40 mg triamcinolone, 10–20 000 IU heparin, 80 mg Moldwin 217
gentamicin
8 mL 2% lidocaine, 4 mL 8.4% NaHCO3, 20 000 IU Welk and
Multiple agents have been studied, alone or in combination, heparin Teichman 123
for instillation into the bladder for treatment of IC/BPS. Table 50 mL 0.5% bupivacaine, 50 mL 8.4% NaHCO3
3 summarizes various cocktails described in the literature. (8.4%), 100 mg hydrocortisone, 10 000 IU heparin, Lukban et
al.
218
Treatments may be administered in the clinic setting or at 80 mg gentamicin
home in some cases. Common side effects include tem- 40 mL 0.5% bupivacaine, 10 000 IU heparin, 2 mL Mishra 219
porary discomfort, hematuria, and UTI. The use of an 8 Fr dexamethasone, 20 mL NaHCO3
pediatric feeding tube combined with intraurethral lidocaine 50 mL DMSO, 44 mEq (1 amp) NaHCO3, 10 mg Hanno 220
triamcinolone, 20 000 IU heparin
may help to improve tolerance to the procedure. 108
300 mg pentosan polysulfate sodium, 10 mL
2% lidocaine, 10 mL 4.2% NaHCO3; add to this
1. Dimethylsulfoxide (DMSO) (RECOMMENDED in select patients, Grade B) sufficient NaCl 0.9% to reach a total volume of 60 Bade 219
mL
DMSO is an organic solvent with anti-inflammatory and 40 000 IU heparin, 8 mL 1% (80 mg) or 2%
analgesic properties. Theoretically, it may cause dissolution lidocaine (160 mg), 3 mL 8.4% NaHCO3 suspended Parsons 120
of collagen that could potentially cause bladder fibrosis if in a volume of 15 mL total fluid
used on a long-term basis. The strongest data supporting 50 mL DMSO, 100 mg hydrocortisone, 10 mL 0.5% Payne 219
109
bupivacaine, 5 mL NaHCO3 (Optional: add heparin)
its use come from five small RCTs. Perez-Marrero et al com- Nickel et
pared DMSO to normal saline (NS) and showed a 93% 5 mL 4% lidocaine followed by 5 mL 8.4% NaHCO3 al. 150
objective improvement and 53% subjective improvement Adapted from Erickson DR; 221 DMSO: dimethysulfoxide; IC/BPS: interstitial cystitis/ bladder
compared to 35% and 18%, respectively, in controls. 110 pain syndrome; NaCl: sodium chloride; NaHCO : sodium bicarbonate.
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CUAJ • May-June 2016 • Volume 10, Issues 5-6 E145