Staged treatment policy- The biggest drawback of IC management is that we do not know which treatment will suit which patient. Multiple treatment options are available. We try one treatment after the other and hope that one of the treatments will give relief to the patient. We can not guarantee that patient will be free of symptoms. In our experience around 80% patients improve(60 %become symptom free and totally alright and 20 are better and have less symptoms) with this protocol. We strictly follow this protocol as it is best option for the patients.

1st stage- cystoscopy hydrodistension with oral therapy
2nd stage- intravesical therapy
3rd stage- surgery

STAGE ONE-All the patients are subjected to diagnostic cystoscopy and therapeutic hydrodistension after their urine culture, and sonography are normal. Cystoscopy is done under spinal anaesthesia and the bladder is distended under gravity till capacity. No attempt is done to overdistend the bladder.We prefer spinal anaesthesia as post surgical recovery is comfortable after spinal anesthesia whereas after general anaesthesia patients are very uncomfortable after surgery. Patients with normal bladder capacity are put on triple drug therapy including amitriptyline, hydroxyzine and gabapin or Pentosan for 3 months. It is important to note that the routine analgesics and antibiotics do not act on such patients and should not be prescribed alone.
If hunners lesions are found on hydrodistension then coagulation of the lesions is done at the same time.

STAGE TWO-If the patient does not respond or there is flare-up during oral therapy, the patient is treated with intravesical rescue solution. The rescue solution is prepared by mixing an anaesthetic agent with steroid and heparin. The solution is usually kept in the bladder for 30 minutes and 6 treatments are given at intervals of 2 weeks. My favourite rescue solution consists of 40 ml sensorcaine 0.5%, 2cc dexamethasone and 25000 unit of heparin. If the patient does not improve with one rescue solution then other intravesical therapies can be tried.
We are working on intravesical tacrolimus in the patiens with intractable IC/BPS who do not improve with other therapies. This formulation has been developed at our center and has been found effective in 50% patients. This is offered to all the patients before surgery.

STAGE THREE-Surgery is offered as a last resort and various procedures are available with varying success rates. Surgery is offered to those patients who have a miserable life and have failed all other therapies.On cystoscopy under spinal anasthesia if patient has less than 150 ml capacity he is advised surgery to increase bladder capacity or to replace bladder. We have done augmentation ileocystoplasty in 6 patients with excellent results.

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