Treatment Options

THERE IS NO PUBLISHED TREATMENT PROTOCOL FOR COVID ASSOCIATED CYSTITIS. 

The closest comparison we have are the AUA guidelines for overactive bladder and/or interstitial cystitis/bladder pain syndrome. Suggestions from the OAB Guidelines are labelled (OAB) and suggestions from the IC Guidelines are labelled (IC/BPS) 

The suggestions below are for educational purposes only and we encourage you to talk these over with your medical care provider. 

STEP ONE - SELF HELP 

A. Water Intake (IC,OAB)

Cystitis patients often reduce water intake to reduce their trips to the restroom. If you are not drinking water, your urine becomes darker, concentrated and more irritating to our sensitive bladder wall. Thus a normal amount of water throughout the day (i.e. 6 to 8 glasses) is vital. Urine should be a clear, pale yellow. If it’s dark and cloudy, you may not be drinking enough water. If your urine is clear without any yellow tone, you may be drinking too much water. If you have any questions about your water intake, please talk with your doctor. However, it is important not to drink so much water that it is keeping you up and night. 

B. Diet Modification (IC,OAB)

Diet modification is the single most important self-help strategy that patients must try. You must avoid foods that trigger bladder irritation. Several research studies have proven that certain foods, particularly those high in acid and/or caffeine, can irritate the bladder and trigger IC and prostatitis symptoms.Avoid foods that are high in acid and caffeine, such as coffees, teas, sodas, citrus and tomato products. For more info, visit IC Network Diet Page. 

C. Heat or Cold Therapy (IC)

The use of a heating or cold pad may help reduce symptoms. Heat is often helpful to reduce muscle tension while cold may help reduce nerve sensitivity. Follow manufacturers instructions carefully. Neither heat nor cold should be applied for long periods of time. Care must be taken to avoid burns. Ice should not be applied directly to skin. It should be placed within a towel. The MamaStrut gel packs are ideal! 

D. OTC Supplements (IC)

The AUA encourages the use of OTC supplements which have fewer side effects than the medications suggested in Step Two. A variety of products are commonly suggested including:  

• Calcium glycerophosphate (aka Prelief) to reduce the acid in food. 
• Phenazopyridine (Azo Bladder Pain Relief Tablets / Pyridium) for mild pain relief. 
• Bladder Rest™, BLADDER BUILDER™, Cystoprotek®, CystoMend®, AloePath and Cysto Renew® 
• Palmitoylethanolamide (PEAORA®) has one study released in 2019 which showed remarkable success in reducing pain in patients with IC/BPS.

E. Meditation, Anxiety and Stress Management (OAB,IC)

Stress and anxiety are well known triggering and/or intensifying bladder symptom flares. Patients should consider trying some basic mind-body medicine techniques (Eye Spy, Tapping) that can reduce "fight or flight", as well as learning some new, effective anxiety and stress management techniques. Seriously, we're all stressed during COVID. This is the time to learn some new skills, right? 

F. Bladder Training  (OAB,IC) 

Bladder training, aka timed voiding, is used to help retrain the bladder in patients who struggle with frequency and urgency. Essentially, patients are given a timed voiding schedule that is slowly increased over a long period of time to help improve bladder capacity. Bladder training is not usually recommended for patients struggling with pain because it can exacerbate chronic pain symptoms and neurological dysfunction.

STEP TWO - ORAL MEDICATIONS

Mirabegron, Oxybutynin, Tolteradine, Fesoterodine, Solifenacin (OAB)

Some medications are effective at reducing the symptoms of urinary frequency and urgency but they can have a variety of side effects, including dry mouth, constipation, dry eyes, blurred vision and used for long periods of time, impaired cognitive dysfunction. These may be available as an extended release medication, as well as a patch or gel. (Mirabegron is often the first choice because it does not pose the risk of cognitive decline though it can be more expensive. )

Amitriptyline/ Elavil® (IC)   

Amitryptiline is a tricyclic antidepressant, has several studies reporting success in reducing IC symptoms. One study demonstrated a 63% significant improvement at four months. (R). Two observational long term studies reported 50% to 64% improvement.(R) Unfortunately, adverse events are extremely common making this medication more difficult to tolerate, including: dry mouth, drowsiness, cardiac arrhythmias (irregular heart rate), tachycardia (rapid heart rate) and, more recently, has been linked to cognitive decline. 

Cimetidine (aka Tagamet) (IC) 

Some medications are effective at reducing the symptoms of urinary frequency and urgency but they can have a variety of side effects, including dry mouth, constipation, dry eyes, blurred vision and used for long periods of time, impaired cognitive dysfunction. These may be available as an extended release medication, as well as a patch or gel. (Mirabegron is often the first choice because it does not pose the risk of cognitive decline though it can be more expensive.) 

Hydroxyzine (aka Vistaril, Atarax)  (IC)

An antihistamine, hydroxyzine acts to reduce histaminic activity in the bladder wall. It has mixed research studies, one of which reported that 92% of patients experienced improvement yet those participating patients also had systemic allergies.(R) Other studies found much more modest effectiveness (i.e. 23%).(R) Adverse events were common and generally not serious. 

Bladder Instillations (IC) 

Bladder instillations are a second-line treatment option in the AUA Guidelines for IC/BPS when treatments such as diet modifications, stress management, and over the counter products are not enough. During a bladder instillation (aka intravesical instillation or treatment), the bladder is filled with medication via a catheter. The solution is held for varying periods of time, from a few seconds to 20 minutes (known as “dwell time”), before being drained or voided.  Some treatments are thought to coat and protect the bladder, while others are thought to suppress inflammation. Many physicians instill combinations of ingredients (“bladder cocktails”) that they believe work better than a single agent. The advantage of bladder intravesical therapy is that a high concentration of medication can be delivered to the bladder without increasing systemic concentrations. Thus, there is less risk of systemic side effects. That said,  bladder instillations may cause bladder and/or urethral discomfort of varying degrees. (Learn more!)

STEP THREE - PTNS & NEUROMODULATION

These therapies are usually reserved for both IC and OAB patients who have long-term chronic symptoms. 

Botulinum Toxin (IC, OAB)

Botulinum toxin (aka Botox) is neurotoxin produced by the bacterium Clostridium Botulinum. When found in contaminated meat, it can cause botulism, a potentially deadly disease in humans and animals. In 1928, researchers also discovered that it can block nerve transmissions. In the 1980’s, it was first used to treat some eye problems, including strabismus (crossed eyes) and uncontrollable blinking (belpharospasm). It has since been used to treat spasm of the lower esophageal sphincter, frown lines, TMJ, migraines, dystonia and patients with upper motor neuron syndrome, such as cerebral palsy. When injected into a tight muscle, botox can relax the contraction thus allowing for better movement and so forth.  In the bladder and/or pelvis, Botox has been studied with tight pelvic floor muscles (vaginismus), incontinence and IC/BPS. In the bladder, it is injected into the bladder wall in multiple sites during a hydrodistention procedure. Research studies have shown modest success. (Learn more)

Neuromodulation (IC,OAB)

Neuromodulation uses a mild electrical impulse on various nerves to help maintain nerve function. Two different forms of neuromodulation are available, Urgent PC® (Uroplasty) and Interstim® (Medtronic). Both devices are approved for urinary frequency, urgency, incontinence and overactive bladder. 

Post Tibial Nerve Stimulation  

In general, patients start with the least invasive form of neuromodulation known as post tibial nerve stimulation (PTNS). Invented by Dr. Marshall Stoller (UCSF) in the early 1990’s, it uses an acupuncture needle inserted carefully at the SP6 point above the ankle bone. A nerve stimulation device (aka TENS unit) is then attached to the needle where it delivers a mild, electronic pulse to the nerve. The original protocol required that it be done for just 30 minutes, one day per week for up to ten weeks. When Dr. Stoller’s device lost funding, Uroplasty (now Cogentix Medical) stepped forward with a similar device (Urgent PC) which is now available throughout the USA. Uroplasty offers a Find A Provider Service on their website.  

Post tibial nerve stimulation offers several benefits:  

• No surgery is required. 
• Risk of adverse event is minimal with only two adverse events filed with the US FDA MAUDE database 
• The cost of Urgent PC is substantially less than the cost of a surgically implanted device. 
• If found ineffective, treatment can be terminated without requiring an additional surgery to remove the device.

Sacral or Pudendal Nerve Stimulation

If post tibial nerve stimulation is ineffective, a more aggressive, surgical approach can be considered. Known as Interstim®, many physicians around the country have been trained to do this procedure. It requires an initial trial procedure inwhich a lead is surgically implanted on either the sacral or pudendal nerve. A wire then extends through the skin where it is attached to a portable nerve stimulation device. For the following two weeks, patients keep a pain and voiding diary. If their symptoms improve during the trial, a permanent surgical implantation is then performed with the stimulator implanted near the hip or upper buttock.  (Learn More)