Some people benefit from bladder instillations or bladder cocktails, which are mixtures of medicines put directly into the bladder. Types of instillations include:
Dimethyl sulfoxide (DMSO, brand name RIMSO-50) was the first and remains the only FDA-approved bladder instillation specifically for interstitial cystitis (IC). Approved in 1978, its exact mechanism of action is still not fully known, though it is thought to have several effects positive effects:
- Reducing bladder irritation and pain (anti-inflammatory)
- Helping to relax the bladder and pelvic muscles (antispasmodic)
- Relieving pain by depleting the level of substance P levels from bladder nerves
- Increasing bladder capacity by breaking down scar tissue by preventing the formation of collagen, a protein the body uses to create scar tissue
Because of its ability to penetrate the bladder lining, some healthcare providers add DMSO to “bladder cocktails” to aid the absorption of other bladder-instilled medicines, such as heparin, steroids, bicarbonate, and analgesics (pain medicines).
Dosage & Treatment Plan
Typically, your healthcare provider instills a 50% liquid solution of DMSO intravesically, meaning via a catheter directly into your bladder.You then hold the solution in your bladder for up to 15 minutes before urinating it out. Though usually done in your healthcare provider’s office, you can learn you do DMSO instillations at home. You may find your urologist’s nurse practitioner to be very helpful in teaching you this technique.
You will receive a series of instillations, generally every one or two weeks for four to eight weeks, depending on your response to the medicine. You may not see improvement in your symptoms until the third or fourth treatment. If you experience a recurrence in your symptoms, additional treatments may be necessary. Some people with IC find that, once they have had the initial series of instillations, they need only one DMSO instillation when an IC flare occurs. It is best to schedule a treatment as soon as your symptoms begin to recur, rather than waiting until symptoms have intensified.
Wait three to four weeks after a cystoscopy with hydrodistention to start DMSO instillation. This ensures that the bladder has a chance to begin to heal, including any biopsy sites (small areas of tissue samples your doctor may cut from your bladder during cystoscopy with hydrodistention, to help aid in diagnosis). Also, prior to starting DMSO therapy, your healthcare provider orders a urine culture test and, before each instillation, a urinalysis to ensure that you do not have a urinary tract infection.
Potential Side Effects
A strong garlic-like taste or smell may be present on your breath and skin for 24 hours after DMSO instillation. You may not notice this odor, though anyone in close proximity to you may detect it. You may also experience a temporary worsening of bladder symptoms lasting 24 to 72 hours after treatment. Anecdotally, some patients report short-lived flu-like symptoms after DMSO treatment.
You may find that you experience pain during or after the DMSO instillation procedure, which may subside with repeated instillations. If you experience pain:
- Ask your physician to prescribe pain medicines such as anticholinergics, bladder analgesics, or B&O suppositories, that you can use prior to and after instillation.
- Request a pediatric catheter for the instillation.
- Apply a numbing gel such as lidocaine to the urethra prior to catheter insertion.
- Ask your doctor about inserting a numbing agent such as lidocaine or bupivacaine hydrochloride (Marcaine) into the bladder before DMSO instillation.
Other Precautions
In use since the 1970s, DMSO is a safe and effective IC treatment option through patient-reporting and several small-scale studies. However, because of the strong garlic odor that DMSO produces, large-scale placebo-controlled studies in humans are limited. In much higher doses than used to treat IC, DMSO can be teratogenic, meaning that it has the potential to cause birth defects. Therefore, the manufacturer of the product does not recommend its use during pregnancy or when breastfeeding.Because of the potential for cataract formation in animal studies, the manufacturer’s literature recommends that you have full eye examinations prior to and during treatment with DMSO. No studies evaluated the safety and effectiveness of DMSO instillations in children. [Please see manufacturer’s literature for complete details].
To get more information on RIMSO-50, including complete prescribing information, call 888-258-4199 or visit http://www.bionichepharmausa.com/.
To treat IC, sodium hyaluronate solution (Cystistat) is instilled directly into the bladder. Cystistat is not yet approved for use in the United States. However, it is approved for IC treatment in the European Union and Canada as a temporary replacement for a defective mucosal lining of the bladder, which many researchers believe is responsible for causing IC symptoms.
Clinical trials tested the effectiveness of sodium hyaluronate solution, also called hyaluronic acid, in treating IC. As a result, Cystistat is prescribed in more than 20 countries, including the United Kingdom, Canada, Austria, France, Germany, Greece, Ireland, Italy, Netherlands, Portugal, Scandinavia, Spain, Switzerland, China, and others.
Dosage & Treatment Plan
Cystistat is usually instilled once a week for 4 to 6 weeks and then monthly thereafter. One treatment is given every one or two weeks for four to eight treatments, depending on the patient’s response to the medicine. Many patients begin to experience relief after the fifth or sixth instillation. Some patients who respond positively may be able to increase the interval between treatments once the symptoms have stabilized.
Potential Side Effects
Side effects are reported to be minimal, limited primarily to minor discomfort due to catheterization, resulting in initial exacerbation of urinary frequency and urgency.
Pregnancy & Children
Because adequate and well controlled studies have not been performed in pregnant women, the manufacturer does not recommend its use during pregnancy. The safety and effectiveness of Cystistat use in children has not been established.
You or your healthcare provider can obtain more information about Cystistat from Bioniche Pharma by emailing info@cystistat.com.
Heparin is a compound that has both anti-inflammatory and surface protective actions. Heparin can mimic the activity of the bladder’s mucous lining, temporarily “repairing” the GAG layer, which may be defective in IC.
Clinical studies on the effectiveness of heparin are limited. In one uncontrolled investigation, intravesical heparin resulted in some improvement of symptoms in about 50 percent of patients. Another study of patients undergoing DMSO treatments indicated that heparin might help reduce their relapse rate. Patients treated with DMSO alone had a relapse rate of 52 percent, while those maintained with monthly instillations of heparin and followed for 12 months had a relapse rate of 20 percent.
Dosage & Treatment Plan
While this drug can be given either by injection or by bladder instillation, the method of choice for the treatment of IC is bladder instillation. It can be used as a primary treatment method, as a component of an instilled “bladder cocktail” or as a “maintenance medicine” to supplement other types of treatment. Heparin is also combined with alkalinized lidocaine to form a “rescue remedy” for use during IC flares.
A heparin solution of 10,000 units diluted with saline solution is instilled intravesically daily, and held in the bladder for 20 to 30 minutes. Patients can be taught to self-catheterize and administer the treatments at home. After 3 to 4 months the frequency of instillations is reduced to 3 to 4 times per week.
It takes 3 to 6 months to begin to see improvement, but therapy should continue for at least 12 months. If there is no improvement in symptoms after 3 months, the dosage is increased to 20,000 units. Therapy can be continued indefinitely.
Potential Side Effects
The side effects of bladder instillation of heparin are limited primarily to pain, irritation, or discomfort resulting from frequent catheterization.
Below are some ICA Medical Advisory Board members’ bladder cocktail recipes. Many patients may be able to do instillations of these cocktails at home, after in-office education. If a solution causes your patient dysuria, it can be drained by catheter. In that case, in-office administration is more practical.