Discontinued and Outdated Treatments
The AUA Guidelines specifically discourage the use of several therapies due to poor results and/or the risk of adverse events. In addition, several older, out-dated therapies were not discussed and/or recommended.
Long Term Antibiotic Therapy
Research studies have not found significant improvement in IC symptoms when treated with long term-antibiotics.(1) Adverse events, on the otherhand, were profound including GI disturbances, vaginal infections, nausea and dizziness (2)(3). The risk of fostering antibiotic resistant infections must also be considered. As a result, the AUA panel judged that antibiotic treatment is contraindicated in the treatment of IC in patients who have a negative urine culture and who have been treated previously. They do NOT, however, want to discourage the use of antibiotics in patients using prophylactic antibiotics to treat recurrent bladder infection.
Bacillus Calmette Guerin (BCG)
Bacillus Calmette Guerin is a therapy used for the treatment of bladder cancer. Four studies found BCG to be no more effective than placebo for the treatment of IC thus the AUA now specifically discourages its use other than in a research setting.(3,4,5,6) Side effects can be severe, including fatality.(7)
Resiniferatoxin is another investigational medication that had little success with studies showing no difference from placebo.(8) Patients also reported severe pain after treatment. As a result, the AUA does not recommend this therapy.
High Pressure, Long Duration Hydrodistention
High -pressure (e.g., greater than 80 to 100 cm H20), long-duration (e.g., greater than 10 min) hydrodistension is associated with increased frequency of serious adverse events (e.g., bladder rupture, sepsis) without a consistent increase in benefit.(9-10) As a result, the AUA strongly discourages their use.
Long-term Glucocorticoid therapy
Two studies found marginal success and serious adverse events when glucocorticoids were used as a long-term therapy for IC.(11,12) Of particular concern were reports severe side effects including: new diabetes onset, exacerbation of diabetes, pneumonia with septic shock and increased blood pressure. The AUA believes that the risks of this treatment clearly outweigh any potential benefit. Short term use may be considered for flares, however.
Silver Nitrate, Clorpactin & Agyrol
Not even mentioned in the AUA Guidelines is the use of Silver Nitrate and Clorpactin, commonly used from the 1950’s through the 1990’s. Patients may occasionally encounter physicians who use them today however the AUA does not suggest nor recommended them. They have been replaced with the far more effective bladder instillations, such as a rescue instillation. A key concern for both silver nitrate and clorpactin is their caustic effect. Both can cause severe damage to the bladder wall and underlying nerves.
Argyrol (“mild silver protein solution”) was used, at one point, as a bladder instillation. Less caustic that silver nitrate, it was believed to provide an antiseptic effect to the bladder wall. There is no evidence showing any effect in the treatment of IC.
- Warren JW, Horne LM, Hebel JR et al: Pilot study of sequential oral antibiotics for the treatment of interstitial cystitis. J Urol 2000; 163: 1685.
- Parziani S, Costantini E, Petroni PA et al: Urethral syndrome: clinical results with antibiotics alone or combined with estrogen. Eur Urol 1994; 26: 115.
- Weinstock LB, Klutke CG and Lin HC: Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms. Dig Dis Sci 2008; 53: 1246.
- Peters K, Diokno A, Steinert B et al: The efficacy of intravesical Tice strain bacillus Calmette-Guerin in the treatment of interstitial cystitis: a doubleblind, prospective, placebo controlled trial. J Urol 1997; 157: 2090.
- Mayer R, Propert KJ, Peters KM et al: A randomized controlled trial of intravesical bacillus calmette-guerin for treatment refractory interstitial cystitis. J Urol 2005; 173: 1186.
- Propert KJ, Mayer R, Nickel JC et al: Did patients with interstitial cystitis who failed to respond to initial treatment with bacillus Calmette-Guerin or placebo in a randomized clinical trial benefit from a second course of open label bacillus Calmette-Guerin? J Urol 2007; 178: 886.
- Propert KJ, Mayer R, Nickel JC et al: Followup of patients with interstitial cystitis responsive to treatment with intravesical bacillus Calmette-Guerin or placebo. J Urol 2008; 179: 552.
- Izes JK, Bihrle WI and Thomas CB: Corticosteroid-associated fatal mycobacterial sepsis occurring 3 years after instillation of intravesical bacillus CalmetteGuerin. J Urol 1993; 150: 1948.
- Chen TY, Corcos J, Camel M et al: Prospective, randomized, double-blind study of safety and tolerability of intravesical resiniferatoxin (RTX) in interstitial cystitis (IC). Int Urogynecol J Pelvic Floor Dysfunct 2005; 16: 293.
- McCahy PJ and Styles RA: Prolonged bladder distension: experience in the treatment of detrusor overactivity and interstitial cystitis. Eur Urol 1995; 28: 325.
- Glemain P, Riviere C, Lenormand L et al: Prolonged hydrodistention of the bladder for symptomatic treatment of interstitial cystitis: efficacy at 6 months and 1 year. Eur Urol 2002; 41:79.
- Hosseini A, Ehren I and Wiklund NP: Nitric oxide as an objective marker for evaluation of treatment response in patients with classic interstitial cystitis. J Urol 2004; 172: 2261.
- Soucy F and Gregoire M: Efficacy of prednisone for severe refractory ulcerative interstitial cystitis. J Urol 2005; 173: 841.