Guideline sources The following summarized guidelines for the evaluation and management of interstitial cystitis/bladder pain syndrome (IC/BPS) are prepared by our editorial team based on guidelines from the American Urological Association (AUA 2022), the European Association of Urology (EAU 2022), and the Royal College of Obstetricians and Gynaecologists (RCOG 2017). 1 2 3 CalculatorESSIC diagnostic criteria for bla Guidelines https://web.pathway.md/diseases/recxmEROtXvbKBbfu 1/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway 1. Screening and diagnosis Diagnosis: As per EAU 2022 guidelines, diagnose patients with symptoms according to the European Association of Urology definition, after primary exclusion of specific diseases, with primary bladder pain syndrome by subtype and phenotype. A As per RCOG 2017 guidelines, exclude other conditions presenting with bladder pain, as bladder pain syndrome is a diagnosis of exclusion. B 2. Classification and risk stratification Severity assessment: As per EAU 2022 guidelines, use a validated symptom and quality of life scoring instrument for initial assessment and follow-up. A As per RCOG 2017 guidelines: Use a validated symptom score to assess baseline severity of bladder pain syndrome and response to treatment. B Consider using VAS for pain to assess severity of pain in patients with bladder pain syndrome. C 3. Diagnostic investigations Initial assessment: As per AUA 2022 guidelines: Elicit a careful history, perform a physical examination, and obtain laboratory tests to document symptoms and signs characterizing IC/BPS, and rule out other disorders. B Elicit baseline voiding symptoms and pain levels to assess subsequent treatment effects. B As per EAU 2022 guidelines: Assess for negative cognitive, behavioral, sexual and emotional consequences associated with primary bladder pain syndrome. A Assess for non-bladder diseases associated with primary bladder pain syndrome. A As per RCOG 2017 guidelines, elicit a thorough medical history, perform a physical examination, and obtain urinalysis in patients with suspected IC/BPS. B Show 3 more Urodynamic testing: As per AUA 2022 guidelines, consider obtaining urodynamic testing when the diagnosis is in doubt, but not necessarily for making the diagnosis in uncomplicated presentations. E As per RCOG 2017 guidelines, consider obtaining urodynamic testing in patients in whom there is coexisting overactive bladder (and/or stress urinary incontinence and/or voiding dysfunction) https://web.pathway.md/diseases/recxmEROtXvbKBbfu 2/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway not responsive to treatment. C 4. Diagnostic procedures Cystoscopy: As per AUA 2022 guidelines: Consider performing cystoscopy when the diagnosis is in doubt, but not necessarily for making the diagnosis in uncomplicated presentations. E Perform cystoscopy in patients with suspected Hunner lesions. E As per EAU 2022 guidelines, perform rigid cystoscopy under general anesthesia in patients with bladder pain, in order to exclude other diseases, and to classify IC/BPS into subtypes. A As per RCOG 2017 guidelines, perform cystoscopy to diagnose/exclude other conditions mimicking bladder pain syndrome. Recognize that cystoscopy does not confirm or exclude the diagnosis of bladder pain syndrome. B Bladder biopsy: do not perform bladder biopsy for the diagnosis of bladder pain syndrome. D 5. Medical management General principles: As per AUA 2022 guidelines: Make treatment decisions after shared decision-making with the patient informed of the risks, potential benefits, and alternatives. Offer nonsurgical options as initial treatment, except for patients with Hunner lesions. E As per EAU 2022 guidelines, offer subtype and phenotype-oriented therapy for the treatment of primary bladder pain syndrome. A As per RCOG 2017 guidelines, refer patients failed to respond to conservative treatment to secondary care. B Show 2 more Pain management: As per AUA 2022 guidelines, offer multimodal pain management approaches (such as pharmacological, stress management, and manual physical therapy if available) in patients with IC/BPS. B Show 2 more As per RCOG 2017 guidelines: Administer analgesia for symptomatic relief of pelvic or bladder pain. B Apply established principles of chronic pain pain management in patients with bladder pain syndrome, as it is a chronic pain syndrome. B Pharmacotherapy: https://web.pathway.md/diseases/recxmEROtXvbKBbfu 3/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway As per AUA 2022 guidelines, consider initiating any of the following oral agents in patients with IC/BPS: amitriptyline C cimetidine C hydroxyzine C pentosan polysulfate. C Show 4 more As per EAU 2022 guidelines, offer amitriptyline for the treatment of patients with primary bladder pain syndrome. A Show 3 more As per RCOG 2017 guidelines, consider initiating oral amitriptyline or cimetidine for the treatment of patients with IC/BPS, if first-line conservative treatments have failed. Consider initiating cimetidine only by a clinician specialized to treat bladder pain syndrome, as it is not licensed to treat this condition. C Show 3 more 6. Nonpharmacologic interventions Self-care and behavioral modifications: As per AUA 2022 guidelines, discuss and implement self-care practices and behavioral modifications as feasible to improve symptoms in patients with IC/BPS. B As per EAU 2022 guidelines, consider offering multimodal behavioral, physical and psychological techniques in combination with oral or more invasive treatments for primary bladder pain syndrome. B As per RCOG 2017 guidelines, consider referring patients with refractory bladder pain syndrome for psychological support or counseling if it is impacting on their quality of life or the patient requests a referral. C Stress management: As per AUA 2022 guidelines, encourage stress management practices to improve coping techniques and manage stress-induced symptom exacerbations in patients with IC/BPS. B As per RCOG 2017 guidelines, consider advising stress management techniques and regular exercice in patients with IC/BPS. C Dietary modifications: As per EAU 2022 guidelines, provide dietary advice in patients with IC/BPS. B As per RCOG 2017 guidelines, consider advising dietary modifications and avoidance of caffeine, alcohol, and acidic foods and drinks. C Physical therapy: As per AUA 2022 guidelines: https://web.pathway.md/diseases/recxmEROtXvbKBbfu 4/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway Offer appropriate manual physical therapy techniques (such as maneuvers resolving pelvic, abdominal and/or hip muscular trigger points, lengthening muscle contractures and releasing painful scars and other connective tissue restrictions), if appropriately trained clinicians are available, in patients presenting with pelvic floor tenderness. A Advise avoiding pelvic floor strengthening exercises, such as Kegel exercises. A As per EAU 2022 guidelines, consider offering physical therapy in combination with oral or more invasive treatments for primary bladder pain syndrome. B As per RCOG 2017 guidelines, consider referring patients with bladder pain syndrome symptoms to a physiotherapist for physical therapy. C Acupuncture: insufficient evidence to recommend acupuncture in patients with IC/BPS. I 7. Therapeutic procedures Bladder hydrodistention: As per AUA 2022 guidelines: Consider performing cystoscopy under anesthesia with short-duration, low-pressure hydrodistension as a treatment option in patients with IC/BPS. C Do not perform high-pressure, long-duration hydrodistension in patients with IC/BPS. D As per EAU 2022 guidelines: Consider performing hydrodistension with submucosal botulinum toxin type A administration, if intravesical instillation therapies have failed. B Do not perform bladder distension alone for the treatment of primary bladder pain syndrome. D As per RCOG 2017 guidelines: Consider performing bladder hydrodistension if conservative and oral treatments have failed. C Do not perform high-pressure long-duration bladder hydrodistension in patients with bladder pain syndrome. D Intravesical instillations: As per AUA 2022 guidelines: Consider administering intravesical instillations of any of the following agents in patients with IC/BPS: dimethyl sulfoxide C heparin C lidocaine. C Do not use intravesical instillation of BCG for the treatment of IC/BPS outside of a clinical trial. D As per EAU 2022 guidelines, offer intravesical instillation of the following agents before attempting more invasive interventions: https://web.pathway.md/diseases/recxmEROtXvbKBbfu 5/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway hyaluronic acid chondroitin sulfate lidocaine plus sodium bicarbonate heparin, alone or in combination. B As per RCOG 2017 guidelines: Consider administering the following intravesical instillations if conservative and oral treatments have been unsuccessful, using an individualized approach depending on the experience and expertise of the clinical team involved: lidocaine C hyaluronic acid C botulinum toxin A C dimethyl sulfoxide C heparin C chondroitin sulfate. C Do not administer intravesical resiniferatoxin or BCG in patients with bladder pain syndrome. D Intradetrusor botulinum toxin injection: As per AUA 2022 guidelines, consider administering intradetrusor botulinum toxin A injection if other treatments have not provided adequate symptom control and quality of life. Ensure that patients accept the possibility that post-treatment intermittent self-catheterization may be necessary. C As per EAU 2022 guidelines, consider performing injection of botulinum toxin type A into the submucosal bladder wall and trigone, in combination with hydrodistension, if intravesical instillation therapies have failed. B Submucosal triamcinolone: perform submucosal injection of triamcinolone and/or fulguration with electrocautery in patients presenting with Hunner's lesions. B Neurostimulation: As per AUA 2022 guidelines, consider offering a trial of neurostimulation if other treatments have not provided adequate symptom control and quality of life. Consider implanting a permanent neurostimulation device in case of a successful trial. C As per EAU 2022 guidelines, offer neuromodulation before attempting more invasive interventions. B As per RCOG 2017 guidelines: Consider offering neuromodulation (nerve stimulation) in the form of posterior tibial or sacral neuromodulation after conservative, oral and/or intravesical treatments have failed in a multidisciplinary setting. C Refer patients likely to benefit from neuromodulation to a multidisciplinary team before treatment is commenced. B https://web.pathway.md/diseases/recxmEROtXvbKBbfu 6/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway 8. Surgical interventions Transurethral fulguration and resection: As per AUA 2022 guidelines, perform fulguration with electrocautery and/or submucosal injection of triamcinolone in patients presenting with Hunner's lesions. B As per EAU 2022 guidelines, perform transurethral resection (or coagulation or laser) of bladder lesions only in patients with primary bladder pain syndrome type 3C, i.e. Hunner's lesions with inflammation on biopsy. A As per RCOG 2017 guidelines, consider performing cystoscopic fulguration and laser treatment, and transurethral resection of Hunner's lesions, if identified at cystoscopy. C Indications for major surgery: As per AUA 2022 guidelines, consider performing a major surgery (such as substitution cystoplasty, or urinary diversion with or without cystectomy) in carefully selected patients with bladder-centric symptoms, or in the rare case where there is an end-stage small fibrotic bladder, if all other therapies have failed to provide adequate symptom control and quality of life improvement. C As per EAU 2022 guidelines, perform ablative and/or reconstructive surgery only as after all other therapeutic options have been exhausted, and only if it can be performed by knowledgeable surgeons, following a multidisciplinary assessment including pain management. A As per RCOG 2017 guidelines, consider performing major surgery as last-line treatment in refractory bladder pain syndrome. C 9. Specific circumstances Pregnant patients: counsel female patients that the effect of pregnancy on the severity of bladder pain syndrome symptoms can be variable. B Show 2 more 10. Patient education General counseling: As per AUA 2022 guidelines, educate patients with IC/BPS regarding: normal bladder function what is known and not known about IC/BPS relative risks and benefits of available treatments the fact that no single treatment has been found effective for the majority of patients the fact that acceptable symptom control may require trials of multiple therapeutic options, including combination therapy. B https://web.pathway.md/diseases/recxmEROtXvbKBbfu 7/8 6/24/23, 2:34 PM Interstitial cystitis/bladder pain syndrome Pathway As per RCOG 2017 guidelines, provide patients with IC/BPS with written information about patient organizations providing evidence-based information. B 11. Follow-up and surveillance Assessment of treatment response: As per AUA 2022 guidelines: Reassess the efficacy of treatment periodically and discontinue ineffective treatments. B Reconsider the diagnosis of IC/BPS if no improvement occurs after multiple treatment approaches. B As per EAU 2022 guidelines, use a validated symptom and quality of life scoring instrument for follow-up assessment. A As per RCOG 2017 guidelines: Follow-up patients in secondary care with consideration for shared care between the pain team and urogynecology until symptoms become controlled and then consider monitoring in primary care if required. B Use a validated symptom score to assess response to treatment. B References 1. No authors listed. Management of Bladder Pain Syndrome: Green-top Guideline No. 70. BJOG. 2017 Jan;124 2):e46-e72. Open 2. J Quentin Clemens, Deborah R Erickson, Norma P Varela et al. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. J Urol. 2022 Jul;208 1 34 42. Open 3. D. Engeler, A.P. Baranowski, B. Berghmans et al. EAU Guidelines on Chronic Pelvic Pain. EAU. 2022. Open 4. Joop P van de Merwe, J rgen Nordling, Pierre Bouchelouche et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol. 2008 Jan;53 1 60 7. Open https://web.pathway.md/diseases/recxmEROtXvbKBbfu 8/8