Other Treatments for Interstitial Cystitis and Chronic Bladder Conditions

When first-line treatments for interstitial cystitis (IC) or painful bladder syndrome (PBS) fall short, there are additional options worth knowing about. This article covers procedures and therapies that go beyond oral medications and bladder instillations, including bladder distension, nerve stimulation, bladder training, surgical options, and complementary approaches.

I should say upfront that none of these treatments work for everyone. IC/PBS management often involves trying several approaches before finding what helps. These treatments are typically reserved for patients who have not responded adequately to simpler options, or they may be used alongside other therapies as part of a comprehensive treatment plan.

Bladder Distension (Hydrodistension)

Bladder distension, sometimes called hydrodistension or bladder stretch, involves filling the bladder with sterile fluid under general or regional anaesthesia and keeping it stretched for five to ten minutes. The procedure serves both diagnostic and therapeutic purposes.

How it works

During distension, a cystoscope (a thin viewing instrument) is inserted through the urethra into the bladder. The bladder is then slowly filled with fluid beyond its normal capacity. This stretching allows the urologist to examine the bladder wall for characteristic signs of IC, including pinpoint haemorrhages called glomerulations and, in some cases, Hunner lesions (ulcerated patches found in approximately 5-10% of IC patients) 1.

The diagnostic aspect is important. Glomerulations—tiny bleeding points that appear when the bladder is stretched—are considered a hallmark finding in IC/PBS, though they can occur in other conditions as well.

What the evidence says

Some patients experience symptom relief following hydrodistension, though the improvement mechanism is not fully understood. One theory suggests that stretching disrupts pain-transmitting nerve fibres in the bladder wall. Another proposes that the procedure increases bladder capacity or triggers changes in how the bladder responds to filling.

A systematic review examining hydrodistension outcomes found that approximately 30-50% of patients report at least temporary benefit 2. The relief typically appears within days to weeks after the procedure and may last from several weeks to several months before symptoms gradually return.

What to expect

Directly after the procedure, temporary bleeding and burning during urination are common. Some patients experience a symptom flare before improvement begins. Others feel better almost immediately. The variation in response is characteristic of IC treatment generally—individual responses differ considerably.

If hydrodistension provides relief, the procedure can be repeated when symptoms return. Some patients undergo periodic distensions as part of their long-term management strategy.

My take

Hydrodistension is worth considering if other treatments have not provided adequate relief. The response rate is modest—about a third to half of patients benefit—but for those it helps, the improvement can be meaningful. It is also a useful diagnostic tool, particularly for identifying Hunner lesions that might be treated directly.

Cystoscopy and Treatment of Hunner Lesions

Beyond its diagnostic role, cystoscopy can be therapeutic for the subset of IC patients who have Hunner lesions.

What are Hunner lesions?

Hunner lesions are distinct reddish, inflamed patches on the bladder wall that may crack and bleed when the bladder is stretched. They differ from glomerulations (which are tiny bleeding spots throughout the bladder lining) in that they are larger, more localised, and more obviously abnormal.

Only about 5-10% of IC patients have Hunner lesions, but when present, they are often responsible for a significant portion of symptoms.

Fulguration and ablation

Lesions can be treated during cystoscopy using fulguration (cauterisation with electric current) or laser ablation. The goal is to destroy the abnormal tissue, allowing healthier tissue to grow in its place.

Studies show this approach can provide substantial relief for patients with Hunner lesions. A study published in the Journal of Urology found that fulguration produced symptom improvement in over 90% of patients with lesions, with benefits lasting an average of two to three years before retreatment was needed 3.

Reality check

This treatment is only relevant if you actually have Hunner lesions. Most IC patients do not. If your urologist has performed a cystoscopy and not found lesions, fulguration is not an option for you—there is nothing to treat.

Neuromodulation Therapies

Neuromodulation uses electrical impulses to modify nerve activity, with the goal of improving bladder function and reducing pain. Two main approaches are used for bladder conditions: percutaneous tibial nerve stimulation (PTNS) and sacral nerve stimulation (SNS).

Percutaneous Tibial Nerve Stimulation (PTNS)

PTNS, marketed under names like Urgent PC, delivers mild electrical stimulation through a thin needle placed near the tibial nerve at the ankle. The tibial nerve shares connections with the sacral nerve plexus that controls bladder function.

Treatment involves weekly 30-minute sessions over 12 weeks, followed by monthly maintenance sessions if it works. The procedure is performed in a clinic and requires no anaesthesia or surgery.

Studies on PTNS for overactive bladder show improvement in urgency, frequency, and urge incontinence in approximately 55-80% of patients 4. Evidence for IC/PBS specifically is more limited, but the treatment is sometimes offered when standard options have not helped sufficiently, particularly for patients with predominant urgency and frequency symptoms.

PTNS is relatively low-risk. The main disadvantage is the commitment required—weekly clinic visits for three months, followed by ongoing maintenance treatments.

Sacral Nerve Stimulation (SNS)

SNS, sold under the brand name InterStim, involves implanting a small device (similar to a pacemaker) under the skin of the upper buttock. The device delivers continuous mild electrical pulses to the sacral nerves that control bladder, bowel, and pelvic floor function.

Before permanent implantation, patients undergo a trial period with a temporary external device. If symptoms improve during the trial (typically defined as at least 50% reduction), a permanent implant is offered.

Studies show that roughly 60-70% of patients who proceed to permanent implantation experience meaningful, sustained improvement 5. The device can be adjusted over time to optimise symptom control.

Worth noting

SNS is generally reserved for patients who have not responded to more conservative treatments. It is more invasive than PTNS and requires surgery, but it offers the advantage of continuous stimulation without repeated clinic visits. The device battery lasts several years before replacement is needed.

Both forms of neuromodulation work better for urgency and frequency symptoms than for pain, so they may be more appropriate for some IC presentations than others.

TENS (Transcutaneous Electrical Nerve Stimulation)

TENS is a non-invasive form of electrical nerve stimulation that many people encounter first in other contexts—it is commonly used during childbirth and for general chronic pain management.

How TENS works for bladder conditions

A portable TENS unit delivers mild electrical impulses through electrode pads placed on the skin, typically on the lower back or just above the pubic bone. The electrical stimulation is thought to interfere with pain signals reaching the brain and may also stimulate the release of endorphins, the body’s natural pain-relieving chemicals.

What the evidence says

The evidence for TENS in IC/PBS is modest but suggests benefit for some patients. A small randomised trial found that suprapubic TENS reduced pain intensity and improved quality of life scores compared to sham treatment 6.

In practice

TENS units are relatively inexpensive, have no significant side effects, and can be used at home without medical supervision once you have been shown proper electrode placement. The limitation is that benefit, when present, is typically partial rather than complete—TENS may take the edge off symptoms rather than eliminate them.

I view TENS as a reasonable addition to other treatments rather than a standalone solution. The risk-benefit balance is favourable given the minimal cost and absence of side effects.

Bladder Training

Bladder training (also called bladder retraining or bladder drill) is a behavioural approach that teaches you to gradually increase the intervals between urinations.

Why bladder training matters

When you have IC/PBS or overactive bladder, the urge to urinate can become both intense and frequent. Many patients respond by going to the toilet at the first hint of urgency, which can actually reinforce the pattern. Bladder training aims to break this cycle.

How it works

Working with a continence adviser or physiotherapist, you start by recording your baseline voiding pattern. Then you gradually extend the intervals between toilet visits, using relaxation techniques and distraction strategies to manage the urge.

For example, if you currently urinate every hour, you might aim to extend that to 75 minutes for a week, then 90 minutes, and so on. The goal is to restore a more normal pattern of urinating every three to four hours during waking hours.

What the evidence says

Bladder training has good evidence for urgency and frequency symptoms, particularly in overactive bladder and urge incontinence. For IC/PBS, it is generally used as one component of a multimodal treatment plan rather than as standalone therapy.

The NHS recommends bladder training as a first-line treatment for urgency and frequency symptoms 7. A continence adviser can guide you through the process and adjust the programme based on your progress.

Accessing support

Your GP can refer you to a continence service, or you may be able to self-refer depending on your local NHS trust. Private physiotherapists specialising in pelvic health also provide bladder training support.

Surgery

For IC/PBS, surgery is genuinely a last resort—reserved for patients with severe, refractory symptoms who have not responded to other treatments.

Types of surgical intervention

Bladder augmentation (augmentation cystoplasty) involves enlarging the bladder using a segment of bowel tissue. This increases bladder capacity and may reduce the frequency of painful bladder spasms. Results are variable, and the procedure carries significant risks and lifestyle implications, including the possible need for self-catheterisation.

Urinary diversion redirects urine away from the bladder, either through an external stoma (an opening in the abdomen that empties into a bag) or through an internal pouch created from bowel tissue. This essentially bypasses the bladder entirely.

Cystectomy (bladder removal) is the most drastic option. It eliminates the source of symptoms but requires permanent urinary diversion.

The reality of surgery

These procedures are major operations with significant complication rates and profound lifestyle impacts. They are appropriate only when symptoms are severe enough to justify the risks and when other treatments have genuinely failed.

Importantly, some patients continue to experience pelvic pain even after bladder removal if pain pathways have become sensitised. Surgery does not guarantee resolution of symptoms.

For those considering surgery, the COB Foundation maintains a support network of members who have undergone these procedures and are willing to share their experiences. Connecting with others who have lived through these decisions can be valuable when weighing your options.

Complementary and Alternative Therapies

Many patients explore complementary therapies alongside conventional treatment. Some of these approaches have limited formal evidence, but individual patients report benefit.

What some patients find helpful

Acupuncture has been studied for various chronic pain conditions. A systematic review suggested potential benefit for overactive bladder symptoms, though evidence specifically for IC/PBS is sparse 8.

Physiotherapy, particularly pelvic floor physiotherapy, has stronger evidence. Many IC patients have coexisting pelvic floor muscle tension that contributes to pain and voiding dysfunction. Manual therapy, relaxation techniques, and stretching exercises can address this component of symptoms.

Hypnotherapy has been used for functional bowel disorders with some success and may help with pain management and stress reduction in IC, though formal studies are lacking.

Herbal remedies vary widely. Some, like aloe vera preparations, are marketed for IC, but quality evidence is generally absent. Be cautious about supplements that might affect bladder irritation or interact with medications you are taking.

A word of caution

The COB Foundation recommends consulting your GP or urologist before starting any alternative therapy or supplement, particularly if you are taking prescription medications. “Natural” does not mean “safe”, and some remedies can interact with treatments or worsen symptoms.

Putting It Together

IC/PBS treatment is rarely straightforward. Most patients end up using a combination of approaches—perhaps oral medication alongside bladder training, periodic instillations, and pelvic floor physiotherapy. The treatments described in this article often fit into that broader picture as additional tools when simpler options are insufficient.

If you are exploring these options, work with a urologist experienced in IC/PBS management. Keep a symptom diary so you can track whether treatments are actually helping. Be patient with the process—finding the right combination takes time.

And remember that while we have discussed many treatments that do not help everyone, most patients do find some combination that improves their quality of life. The path to that improvement may be frustrating, but it is worth pursuing.

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References

1. Hanno PM, et al. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol. 2015;193(5):1545-1553. PubMed

2. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Interstitial Cystitis. NIDDK

3. Rofeim O, Hariton M, Bhagat S, Bhagyaraj P. Hunner lesion: a rare cause of suprapubic pain. Case Rep Urol. 2012;2012:645324. PubMed

4. Peters KM, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182(3):1055-1061. PubMed

5. Siegel S, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology. 2000;56(6 Suppl 1):87-91. PubMed

6. Fall M, Lindström S. Transcutaneous electrical nerve stimulation in interstitial cystitis. Urology. 1994;44(1):61-63. PubMed

7. NHS. Treatment for urinary incontinence. NHS

8. Xu H, et al. Acupuncture for overactive bladder in adults: a systematic review and meta-analysis of randomized controlled trials. Acupunct Med. 2013;31(3):285-297. PubMed