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Interstitial cystitis/bladder pain syndrome

What's new

The Canadian Urological Association (CUA) has published a new guideline for selected interventions in interstitial cystitis/bladder pain syndrome. Intradetrusor onabotulinumtoxinA (± hydrodistension) is suggested for cases refractory to other treatments. For Hunner's lesions, treatment options include lesion fulguration, intralesional triamcinolone injection, and intradetrusor onabotulinumtoxinA (± hydrodistension). Oral pentosan polysulfate should be avoided, and cyclosporin A is not recommended due to lack of evidence. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of interstitial cystitis/bladder pain syndrome are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2025), the European Association of Urology (EAU 2025), the American Urological Association (AUA 2022), and the Royal College of Obstetricians and Gynaecologists (RCOG 2017).
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Screening and diagnosis

Diagnosis: as per EAU 2025 guidelines, diagnose patients with symptoms according to the EAU definition, after primary exclusion of specific diseases, with primary BPS by subtype and phenotype.
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Classification and risk stratification

Severity assessment: as per EAU 2025 guidelines, use a validated symptom and QoL scoring instrument for initial assessment and follow-up.
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Diagnostic investigations

Initial assessment
As per EAU 2025 guidelines:
Assess for negative cognitive, behavioral, sexual and emotional consequences associated with primary BPS.
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Assess for non-bladder diseases associated with primary BPS.
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  • Urodynamic testing

Diagnostic procedures

Cystoscopy: as per EAU 2025 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.
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  • Bladder biopsy

Medical management

General principles: as per EAU 2025 guidelines, offer subtype and phenotype-oriented therapy for the treatment of primary BPS.
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  • Pain management

  • Pharmacotherapy

Nonpharmacologic interventions

Self-care and behavioral modifications: as per EAU 2025 guidelines, consider offering multimodal behavioral, physical and psychological techniques in combination with oral or more invasive treatments for primary BPS.
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  • Stress management

  • Dietary modifications

  • Physical therapy

  • Acupuncture

Therapeutic procedures

Bladder hydrodistention: as per CUA 2025 guidelines, consider performing hydrodistension with intradetrusor onabotulinumtoxinA injections in patients with IC/BPS refractory to other treatments or with Hunner's lesions.
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  • Intravesical instillations

  • Intradetrusor botulinum toxin injection

  • Intradetrusor triamcinolone injection

  • Intradetrusor triamcinolon injection

  • Neurostimulation

Surgical interventions

Transurethral fulguration and resection: as per CUA 2025 guidelines, consider performing fulguration as a treatment option for Hunner's lesions.
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  • Indications for major surgery

Specific circumstances

Pregnant patients: as per RCOG 2017 guidelines, counsel female patients that the effect of pregnancy on the severity of BPS symptoms can be variable.
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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.
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Follow-up and surveillance

Assessment of treatment response: as per EAU 2025 guidelines, use a validated symptom and QoL scoring instrument for follow-up assessment.
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