Staged treatment policy- The biggest drawback of IC management is that we do not know which treatment will suit which patient. Multiple treatment options are available. We try one treatment after the other and hope that one of the treatments will give relief to the patient. We can not guarantee that patient will be free of symptoms. In our experience around 80- 90% of patients improve with this protocol.

1st stage- cystoscopy hydrodistension with oral therapy
2nd stage- intravesical therapy
3rd stage- intravesical botox injection
4th stage- neuromodulation
5th stage- surgery

STAGE ONE-All the patients are subjected to  diagnostic cystoscopy and therapeutic hydrodistension  after their urine culture, and sonography  are normal. On cystoscopy under anasthesia  if patient has less than 150 ml capacity he is advised for surgical therapy.All other  patients with normal bladder capacity  are put on triple drug therapy including amytrptaline, hydroxyzine and PPS  for 3 months. PPS is now available  in India by the trade name COMFORA. All over the world PPS is known as ELMIRON. It is important to note that the routine analgesics do not act on such patients and should not be prescribed alone. Antibiotics also do not work so they should also be avoided.

STAGE TWO-If the patient does not respond or there is flare-up during oral therapy, the patient is treated with intravesical rescue solution. The rescue solution is prepared by mixing an anaesthetic agent with steroid and heparin and sodium bicarbonate is added to facilitate absorption. The solution is usually kept in the bladder for 30 minutes and 6 treatments are given at intervals of 2 weeks. My favourite rescue solution consists of 40 ml sensorcaine 0.5%, 2cc dexamethasone and 25000 unit of heparin. If the patient does not improve with one rescue solution then other therapies like DMSO and hyaluronic acid are tried  intravesically depending on the availability.

STAGE THREE-Some patients do not respond and continue to suffer. These patients are offered intravesical Botulinum toxin injections or neuromodulation. 200 units of botulinum toxin is injected in the bladder cystoscopically  at 20 sites (10 units per injection site) using a specially designed needle. Botulinum toxin improves the symptoms in around half of the patients with intractable IC, but the effect is temporary and lasts for 6 to 12 months, making re-injection necessary. If pain is main symptom then botulinum toxin does not work. It is o good for the patient who has frequency and urgency as main symptom.

STAGE FOUR-Neuromodulation is found effective in around one third of patients with intractable IC when sacral stimulation is used. First a test stimulation is carried out for a period of 7 days. If the patient improves, a permanent generator is implanted to stimulate the S3 nerve root. Although both these modalities are effective in some patients, they should only be attempted if patients do not improve with routine treatment.

STAGE FIVE-Surgery is offered as a last resort and various procedures are available with varying success rates. It includes augmentation cystoplasty, substitution cystoplasty, neobladder with or without cystectomy. Bladder lesions are ablated with Laser. Surgery is offered to those patients who have a miserable life and have failed all other therapies.

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