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 with hydrodistension
2nd stage- oral therapy
3rd stage- intravesical therapy
4th stage- intravesical botox injection
5th stage- neuromodulation
6th stage- surgery.
STAGE ONE-. All the patients are subjected to cystoscopy and therapeutic hydrodistension after their urine culture, urine routine and sonography are normal. Around 40% patients inprove with hydrodistension and do not need further therapy. Hydrodistension is a very controversial modality of treatment but gives immediate relief in most of the patients. A few patients also enjoy long-lasting benefit. If a patient remains symptom-free after hydrodistension for more than a year, it can be repeated when the symptoms develop again.
On cystoscopy under anasthesia if patient has less than 150 ml capacity he is advised for surgical therapy .
STAGE TWO-If patients do not improve after hydrodistension then they are put on triple drug therapy including amytrptaline, hydroxyzine and gabapantin for 3 months. PPS is not available in India. 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 THREE-If the patient does not respond or there is flare-up during oral therapy, the patient is treated with intravesical rescue solutions. The rescue solutions are 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 6treatments are given at intervals of 2 weeks. My favourite rescue solution consists of 40 ml sensorcaine 0.5%, 20 ml sodabicarb , 2cc dexamethasone and 25000 unit of heparin.
STAGE FOUR-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.
STAGE FIVE-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 SIX-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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