Step 2 – Bladder Instillations
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.
Heparin is believed to act as a bladder coating. Several concentrations and treatment modalities have been studied. One study used 10,000 IU heparin in 10cm3 sterile water three times a week for three months with a dwell time of one hour. At three months, 56% of patients reported significant improvement.(1) A portion of those patients continued treatment for up to one year with 40% of patients reporting continued relief. Another study used 25,000 IU in 5ml distilled water twice a week. At three months, 72.5% of patients reported significant relief.(2)
Heparin is frequently combined lidocaine to create an instillation popularly known as a “rescue instillation.” The Hep-Lido-A (aka Parson’s IC Solution) of 20,000IU heparin, 3ml 8,4% bicarbonate with 8ml 1% or 2% lidocaine demonstrated significant short term improvement. (3) Butrick combined 20,000 UI heparin, 20ml 2% lidocaine, 40mg triamicinolone with similar results.(4) Several other studies are available.Adverse events were infrequent and apparently minor. Grade C Ask Questions in Our Rescue Instillation Message Board
Hep-Lido-A (Imprimis Pharma)
Alkalanized Lidocaine and Heparin (Hep-Lido-A) is a patented, proprietary compounded formulation that is instilled directly into the bladder as an immediate treatment option for patients with interstitial cystitis. The compounded preparation includes heparin and alkalinized lidocaine that is carefully buffered to a specific pH level determined and tested for optimal stability and potency.
The American Urological Association’s guidelines indicate bladder instillations as a second-line treatment option when treatments such as diet modifications, stress management, and over the counter products are not enough.
The bladder instillation can be performed in a physician’s office, or can be prescribed and ordered for an identified patient to use the pre-mixed solution at home. The compounded formulation is provided in ready to use pre-filled sterile syringes for easy administration. The instillation is performed by inserting a catheter into the urethra and dispensing the Hep-Lido-A into the bladder. Patients may see relief within 30 minutes of administration. The side effects of bladder instillations may cause discomfort depending on frequency of catheterization.
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When instilled in the bladder, lidocaine numbs the nerves that trigger discomfort. Several formulas have been used, often including sodium bicarbonate, heparin and/or triamcinolone. The sodium bicarbonate alkalinizes the solution thus increasing penetration across the bladder wall thus it must be used carefully to avoid toxicity. The Parson’s Therapeutic solution is an example of a classic rescue instillation formula which has demonstrated significant short term improvement.(3) Another study tested a similar solution without the bicarbonate (20,000 UI heparin, 20 ml 2% lidocaine and 40mg triamcinolone) and reported improved symptoms for 75% of participating IC/BPS patients.(4) Adverse events were typically not serious, earning this treatment option a Grade B.
DMSO (aka RIMSO-50)
Approved in the early 1970’s, the use of Dimethyl sulfoxide (DMSO, RIMSO-50) has gradually diminished due to the growing popularity of heparin and/or elmiron instillations. DMSO is a dilute, sterile, and purified version of an industrial solvent that was found to have anti-inflammatory, analgesic, muscle relaxant, mast cell stimulation and collagen dissolution properties. Patients may receive six to 8 weekly instillations, holding it for roughly 15 to 20 minutes. If improvement is found, a second course of treatment may be suggested. DMSO is rarely used as a long term therapy, nor should it be used if patients show no response to treatment. Many research studies have been conducted which have shown anywhere from 25 to 90% success rates. Adverse events, however, are common.
Research presented at the 2002 and 2003 AUA Annual Meeting by D. Melchior and C. Subah Packer found that DMSO may cause damage to the muscle of the bladder. Her research demonstrated that DMSO triggered intense muscle spasms that at 30% solution which became long lasting and could be irreversible. Given the fact that the FDA approved dosage is a stronger 50% concentration, clinicians and researchers at the meeting agreed that DMSO should be only administered in a cocktail form to maintain a concentration below 30%.(5) Ray Rackley MD (Cleveland Clinic, OH) stated that the Cleveland Clinic no longer uses DMSO and that he believed that DMSO caused much of the damage in bladders that he later had to remove.
Side effects can include intense burning and discomfort, a garlic-like taste and an odor, bladder spasms and irritability. DMSO causes fetal abnormalities in animals and should not be used during pregnancy, within four weeks of a bladder biopsy or if infection is present. Studies showed various levels of success ranging from 25% to 90%. The AUA panel states “If DMSO is used, then the panel suggests limiting instillation dwell time to 15-20 minutes” because longer dwell times are associated with more significant pain. Grade C. Ask Questions in our DMSO Message Board
Consumer Alert – Dr. Robert Moldwin warned clinicians at the AUA 2013 Annual Meeting reporting that atleast one compounding pharmacy in the USA had been shipping industrial grade DMSO to urology clinics. An industrial solvent, this form of DMSO causes immediate destruction of the bladder. (Editor’s Note: We are aware of one case where a young patient lost her bladder due to this error). Before treatment, please verify that your physician is using RIMSO-50, the only form of DMSO approved for human use.
- Parsons CL, Housley T, Schmidt JD et al: Treatment of interstitial cystitis with intravesical heparin. Br J Urol 1994; 73: 504.
- Kuo HC: Urodynamic results of intravesical heparin therapy for women with frequency urgency syndrome and interstitial cystitis. J Formos Med Assoc 2001; 100: 309.
- Parsons CL: Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis. Urology 2005; 65: 45.
- Butrick C, Sanford D, Hou Q et al: Chronic pelvic pain syndromes: clinical, urodynamic, and urothelial observations. International Urogynecology Journal 2009; 20: 1047.
- Melchior D, et al. DMSO – Does it change the functional properties in the bladder wall.” AUA 2002 Annual Meeting Poster