Tricyclic antidepressants are commonly used in patients with pain. A trial by the Interstitial Cystitis Collaborative Research Network found that amitriptyline plus education and behavioral modification did not significantly improve symptoms in the treatment of naive patients with bladder pain syndrome, but the network did suggest that it may be beneficial in those patients who could tolerate a daily dose of 50 mg or greater (158).
Pentosan polysulfate (Elmiron) is an FDA-approved oral agent with heparin-like activity that attempts to replace the glycosaminoglycan sulfate layer that is believed deficient in these patients. The FDA-recommended oral dosage of pentosan polysulfate is 100 mg, three times a day. Patients may not feel relief from pain for the first 2 to 4 months, and it may take up to 6 months for a decrease in urinary frequency to occur.
It is theorized that bladder pain may result from increased histamine release, and some patients benefit from medications that block these inﬂammatory mediators, such as diphenhydramine hydrochloride, 25 to 50 mg orally three times per day, in combination with 300 mg of cimetidine three times per day. Tricyclic antidepressants help some women by modulating sensory nerve pain.
Transcutaneous electrical nerve stimulation (TENS), through wires placed on the lower back or just above the symphysis, may help some women, though the mechanism of action is unclear. Ongoing preliminary research suggests that some women with severe bladder pain syndrome may find relief following sacral neuromodulation (InterStim), acupuncture, or intravesical Botox injection associated with hydrodistension.
1.
DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713–1723.
2.
Wall LL, Helms M, Peattie AB, et al. Bladder neck mobility and the outcome of surgery for genuine stress urinary incontinence: a logistic regression analysis of lateral bead-chain cystourethrograms. J Reprod Med 1994;39:429–435.
3.
Sand PK, Bowen LD, Panganiban R, et al. The low pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol 1987; 69:399–402.
4.
Stay K, Dwyer PL, Rosamilia L, et al. Risk factors of treatment failure of midurethral sling procedures for women with urinary stress incontinence. Urogynecol J Pelvic Floor Dysfunct 2010;21:149–155.
5.
Burnstock G. Nervous control of smooth muscle by transmitters, cotransmitters and modulators. Experientia 1985;41:869–874.
6.
Burnstock G. The changing face of autonomic neurotransmission. Acta Physiol Scand 1986;126:67–91.
7.
Daniel EE, Cowan W, Daniel VP. Structural bases of neural and myogenic control of human detrusor muscle. Can J Physiol Pharmacol 1983;61:67–91.
8.
Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic ﬂoor dysfunction. Neurourol Urodyn 2010;29:4–20.
9.