Interstitial cystitis is complex and therefore requires a multidisciplinary approach to treatment. Strong evidence for complementary and alternative medical therapies is limited, but they have been found to be beneficial for treating patients with IC/BPS and other chronic pelvic pain syndromes (CPPS).

Dietary modification is considered standard IC/BPS therapy and is included in the American Urological Association guidelines. This elimination diet includes an avoidance of certain food types considered to be bladder irritants, including citrus, coffee, artificial sweeteners, alcoholic beverages, arylalkylamine- containing foods and tomato-based products which often exacerbate IC symptoms [4, 7, 9, 10]. It is recommended for each patient to have a dedicated hour of teaching and assessment for food/beverage consumption and adequate nutrition, and to emphasize steady water intake to dilute urine and reduce constipation [8, 11]. Evaluation of food, symptom and voiding diaries are important to identify triggers and compose an individualized and effective elimination diet [11].

IC/BPS is often accompanied by hypertonic, hyperspastic myofascial tissue. Physical therapy can help reduce irritative voiding symptoms by realigning the bony pelvis as well as stretching and strengthening the muscles of the pelvis. Manual therapy, myofascial massage, Thiele massage, and muscle-energy techniques help stretch and strengthening the pelvic floor [6, 8]. Myofascial Massage was shown to be more effective than global massage in treating pelvic pain [2, 3]. Thiele massage was also beneficial in treating chronic pelvic pain, and the technique is often performed by certified pelvic floor physical therapists [12, 13]. Dilator therapy and myofascial trigger point wands have also been used successfully in treating chronic pelvic pain [14].

Bladder retraining and biofeedback are methods for patient initiated control of voiding symptoms, IC/BPS, and pelvic pain [1]. Patients learn to control pelvic floor muscles through visual feedback to achieve conscious control over contraction and relaxation of these muscles with a goal to break the cycle of the spasm [6]. Biofeedback has minimal risks, is safe and has shown to be effective in treating CPPS [15].

Patients with IC/BPS have considerable cognitive and psychosocial changes, and have difficulty coping and have altered pain sensory mechanisms [16]. Changes, including improved coping strategies, can predict positive treatment outcomes by reducing helplessness, increasing perceived control, and decreasing pain catastrophization [17]. Contextual cognitive behavioral therapy (CCBT) may be particularly effective for those with change-resistant behavior as found in multi-problem cases [18]. CCBT incorporates principles of exposure, acceptance, cognitive de-fusion, mindfulness and value-based methods. Primary goals of treatment are to increase patients’ psychological flexibility for dealing with unwanted experiences and improve their engagement in activities that are important, ultimately decreasing the disability associated with chronic pain [18, 19].

Osteopathic manipulative therapy (OMT) includes techniques of muscle energy, balanced ligamentous tension, myofascial release, and counterstrain to help treat symptoms of IC/BPS and stabilization of pelvic support and posture. The philosophy of whole body and individualized therapy is maintained through OMT [20]. Women with IC/BPS responded better to treatment with myofascial physical therapy than to global therapeutic massage [3]. Osteopathy has also been show to help those with chronic pelvic pain syndromes in addition to IC/BPS [21].

Acupuncture has been well-accepted therapy for modulation of bladder storage and emptying functions. There has been evidence of subjective and objective improvement following acupuncture therapy, especially in patients with refractory IC/BPS [22, 23]. Posterior tibial nerve stimulation (PTNS) has been found to show improvement in nighttime voiding, bladder volume, IC problem and symptom indices, and health status scales scores in a small group [24]. Success rates have been found to be 60–80% improvement in leakage episodes, nocturia, daytime frequency, voided volume and number of pads used [25, 26]. Further studies utilizing PTNS for IC/BPS are pending.

Multimodal therapy requires strong patient driven coping mechanisms as well as patience and determination. By actively participating in care, patients maintain a sense of control and can improve coping mechanisms [7]. In a study comparing IC patients and age-matched healthy controls there was greater mean daily stress, with a significant relationship between stress and urgency [27]. Guided imagery has also been found to improve urgency and pain scores in patients [28]. Exercise, stress relief, sleep hygiene, and yoga are alternative methods to reduce stress in the hopes of decreasing the severity of symptoms.

Several over the counter medications have been found useful in reducing IC/BPS symptoms. CystoProtek^® is an oral supplement. The active ingredients include glucosamine sulfate, 280 mg; chondroitin sulfate, 300 mg; Sodium Hyaluronate, 20 mg; quercetin, 260 mg; rutin, 40 mg. Glucosamine sulfate, chondroitin sulfate and Sodium Hyaluronate are glycosaminoglycans (GAG) that may help to protect the bladder lining. Quercetin, an antioxidant, and rutin, with ant-inflmmatory properties, reduce bladder inflammation. CystoProtek^® 4 capsules per day decreased pain scores significantly [29].

Prelief^® is another oral supplement comprised of calcium glycerophosphate. Prelief takes the acidity out of common IC/BPS dietary triggers including coffee, tomato sauce, fruits and wine. This treatment is directed to those patients whose bladder is sensitive to these triggers [6]. In patients who took two tablets before each meal for a total of 4 weeks, pain and discomfort and urgency were significantly decreased and quality of life was either the same or improved [30].

Another over the counter supplement is, Quercetin. Quercetin is a flavonoid found in many plants. With antioxidant qualities it is felt that the supplement help reduce irritative symptoms of IC/BPS. Patients who took 500 mg of quercetin twice a day for 4 weeks discovered symptom improvement [31].

The pharmacologic treatment of IC/BPS can be complex. Uribel^® is an oral treatment that contains methenamine used to treat bladder discomfort, pain and frequent urge to urinate. Methenamine is an active ingredient in Uribel^® and several other medications indicated for the treatment of recurrent UTIs. This anti-infective mechanism has been shown to prevent recurrent UTIs in women and is used in several formulations such as Urogesic-Blue™ for the treatment of IC/BPS although no studies have proved its efficacy in decreasing symptoms in this population [32, 33]. Similar medications such as phenazopyridine also reduce the urinary symptoms of IC/BPS by acting as a local analgesic to the bladder [34].