In 2011, the American Urological Association released consensus-based guideline for the diagnosis and treatment of<unk> . They include treatments ranging from conservative to more invasive: # First-line treatments — education, self care (diet modification), stress management # Second-line treatments — physical therapy, oral medications (amitriptyline, cimetidine or hydroxyzine, pentosan polysulfate), bladder instillations (DMSO, heparin, or lidocaine) # Third-line treatments — treatment of Hunner's lesions (laser, fulguration or triamcinolone injection), hydrodistention (low pressure, short duration) # Fourth-line treatments — neuromodulation (sacral or pudendal nerve) # Fifth-line treatments — cyclosporine A, botulinum toxin (BTX-A) # Sixth-line treatments — surgical intervention (urinary diversion, augmentation, cystectomy) The American Urological Association guidelines also listed several discontinued treatments, including long-term oral antibiotics, intravesical bacillus Calmette Guerin, intravesical resiniferatoxin), high-pressure and long-duration hydrodistention, and systemic glucocorticoids. Bladder distension Bladder distension while under general anesthesia, also known as hydrodistention (a procedure which stretches the bladder capacity), has shown some success in reducing urinary frequency and giving short-term pain relief to those with<unk> . However, it is unknown exactly how this procedure causes pain relief. Recent studies show pressure on pelvic trigger points can relieve symptoms. The relief achieved by bladder distensions is only temporary (weeks or months), so is not viable as a long-term treatment for<unk> /BPS. The proportion of people with<unk> /BPS who experience relief from hydrodistention is currently unknown and evidence for this modality is limited by a lack of properly controlled studies. Bladder rupture and sepsis may be associated with prolonged, high-pressure hydrodistention. Bladder instillations Bladder instillation of medication is one of the main forms of treatment of<unk> , but evidence for its effectiveness is currently limited. Advantages of this treatment approach include direct contact of the medication with the bladder and low systemic side effects due to poor absorption of the medication. Single medications or a mixture of medications are commonly used in bladder instillation preparations. Dimethyl sulfoxide (DMSO) is the only approved bladder instillation for<unk> /BPS yet it is much less frequently used in urology clinics. A 50% solution of DMSO had the potential to create irreversible muscle contraction. However, a lesser solution of 25% was found to be reversible. Long-term use of DMSO is questionable, as its mechanism of action is not fully understood though DMSO is thought to inhibit mast cells and may have anti-inflammatory, muscle-relaxing, and analgesic effects. Other agents used for bladder instillations to treat<unk>  include: heparin, lidocaine, chondroitin sulfate, hyaluronic acid, pentosan polysulfate, oxybutynin, and botulinum toxin A. Preliminary evidence suggests these agents are efficacious in reducing symptoms of<unk> , but further study with larger, randomized, controlled clinical trials is needed. Diet Diet modification is often recommended as a first-line method of self-treatment for<unk> , though rigorous controlled studies examining the impact diet has on<unk>  signs and symptoms are currently lacking. An increase in fiber intake may alleviate symptoms. Individuals with<unk>  often experience an increase in symptoms when they consume certain foods and beverages. Avoidance of these potential trigger foods and beverages such as caffeine-containing beverages including coffee, tea, and soda, alcoholic beverages, chocolate, citrus fruits, hot peppers, and artificial sweeteners may be helpful in alleviating symptoms. Diet triggers vary between individuals with<unk> ; the best way for a person to discover his or her own triggers is to use an elimination diet. Sensitivity to trigger foods may be reduced if calcium glycerophosphate and/or sodium bicarbonate is consumed. The foundation of therapy is a modification of diet to help people avoid those foods which can further irritate the damaged bladder wall. The mechanism by which dietary modification benefits people with<unk>  is unclear. Integration of neural signals from pelvic organs may mediate the effects of diet on symptoms of<unk> . Medications The antihistamine hydroxyzine failed to demonstrate superiority over placebo in treatment of people with<unk>  in a randomized, controlled, clinical trial. Amitriptyline has been shown to be effective in reducing symptoms such as chronic pelvic pain and nocturia in many people with<unk> /BPS with a median dose of 75 mg daily. In one study, the antidepressant duloxetine was found to be ineffective as a treatment, although a patent exists for use of duloxetine in the context of<unk> , and is known to relieve neuropathic pain. The calcineurin inhibitor cyclosporine A has been studied as a treatment for<unk>  due to its immunosuppressive properties. A prospective randomized study found cyclosporine A to be more effective at treating<unk>  symptoms than pentosan polysulfate, but also had more adverse effects. Oral pentosan polysulfate is believed to repair the protective glycosaminoglycan coating of the bladder, but studies have encountered mixed results when attempting to determine if the effect is statistically significant compared to placebo. Pelvic floor treatments Urologic pelvic pain syndromes, such as<unk> /BPS and CP/CPPS, are characterized by pelvic muscle tenderness, and symptoms may be reduced with pelvic myofascial physical therapy. This may leave the pelvic area in a sensitized condition, resulting in a loop of muscle tension and heightened neurological feedback (neural wind-up), a form of myofascial pain syndrome. Current protocols, such as the Wise–Anderson Protocol, largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress. Pelvic floor dysfunction is a fairly new area of specialty for physical therapists worldwide. The goal of therapy is to relax and lengthen the pelvic floor muscles, rather than to tighten and/or strengthen them as is the goal of therapy for people with urinary incontinence. Thus, traditional exercises such as Kegel exercises, which are used to strengthen pelvic muscles, can provoke pain and additional muscle tension. A specially trained physical therapist can provide direct, hands on evaluation of the muscles, both externally and internally. A therapeutic wand can also be used to perform pelvic floor muscle myofascial release to provide relief. Surgery Surgery is rarely used for<unk> /BPS. Surgical intervention is very unpredictable, and is considered a treatment of last resort for severe refractory cases of<unk> . Some people who opt for surgical intervention continue to experience pain after surgery. Typical surgical interventions for refractory cases of<unk> /BPS include: bladder augmentation, urinary diversion, transurethral fulguration and resection of ulcers, and bladder removal (cystectomy). Neuromodulation can be successful in treating<unk> /BPS symptoms, including pain. One electronic pain-killing option is TENS. Percutaneous tibial nerve stimulation stimulators have also been used, with varying degrees of success. Percutaneous sacral nerve root stimulation was able to produce statistically significant improvements in several parameters, including pain. Alternative medicine There is little evidence looking at the effects of alternative medicine though their use is common. There is tentative evidence that acupuncture may help pain associated with<unk> /BPS as part of other treatments. Despite a scarcity of controlled studies on alternative medicine and<unk> /BPS, "rather good results have been obtained" when acupuncture is combined with other treatments. Biofeedback, a relaxation technique aimed at helping people control functions of the autonomic nervous system, has shown some benefit in controlling pain associated with<unk> /BPS as part of a multimodal approach that may also include medication or hydrodistention of the bladder.
Interstitial cystitis
Bladder cancer
Hemorrhagic cystitis
Endometriosis
Eosinophilic cystitis
Urinary tract infection
Emphysematous cystitis
Prostatitis