What’s new in the 2025 CUA IC/BPS guideline?
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a condition many people live with in silence and confusion. If you’ve felt dismissed, misdiagnosed, or overwhelmed navigating treatments, you’re not alone. In Canada, access to urologists who specialize in IC/BPS, is limited and many urologists still lack up-to-date knowledge about the condition, leaving patients without the support they deserve.
The good news? The Canadian Urological Association (CUA) has just released a 2025 guideline (the last update was in 2016) and it’s a big step forward toward personalized, safer and more informed IC/BPS care. Plus the Canadian Urological Association has a great resource for urologists and PCP’s to educate themselves about conditions, including IC/BPS called Uropedia .
Let’s break the new IC/BPS guidelines down together, shall we?
| Topic | 2016 CUA Guideline | 2025 CUA Guideline |
|---|---|---|
| Definition | Adopted the 2009 SUFU definition of IC/BPS. | Still uses the 2009 SUFU definition, with additional focus on clinical variability and phenotype differentiation. |
| Diagnostic Tools | Encouraged basic workup with cystoscopy in select patients. | Recommends routine cystoscopy in all suspected cases to identify Hunner lesions, rule out malignancy, and assess bladder capacity—regardless of age or presentation. |
| Urinalysis/Culture | Standard lab testing. | Maintains urinalysis but suggests further testing in cases of sterile pyuria or persistent symptoms (e.g., Mycoplasma, TB, Candida). |
| Symptom Questionnaires | ICSI/ICPI were mentioned for symptom monitoring. | Emphasizes their use for baseline assessment and monitoring, but not as standalone diagnostic tools. |
| Physical Exam | General pelvic and abdominal exam. | Strongly stresses pelvic floor assessment, musculoskeletal screening, and trauma-informed care, including PTSD screening. |
2025 CUA IC/BPS Diagnosis: Still tricky, but getting better.
The CUA still uses the 2009 definition of IC/BPS: bladder-related pain or pressure that lasts longer than 6 weeks without infection. But now, there’s more guidance on how to better identify IC/BPS and rule out other conditions.
What’s new:
- Routine cystoscopy is now recommended for all suspected IC/BPS cases to check for signs of bladder damage or rare but serious causes like bladder cancer.
- Doctors are urged to screen for pelvic floor dysfunction, trauma history, and overlapping pain conditions like endometriosis or fibromyalgia.
- Emphasis on clinical phenotyping: grouping patients based on where their symptoms come from (e.g., bladder lining, pelvic muscles, trauma, or nerve issues).
Why this matters: A more detailed diagnosis helps doctors avoid “blanket treatments” and target therapies to your personal symptoms.
Treatments: What to try (and what to avoid):
| Treatment | 2025 Recommendation | Notes |
|---|---|---|
| Elmiron (PPS) | ❌ Not recommended | Vision risk, low benefit |
| Bladder Instillations | ❓ Unclear best option | Can help bladder pain |
| Botox | ✔️ For refractory cases | May improve urgency/frequency |
| Cyclosporin A | ❓ No firm stance | Needs close monitoring |
| Pelvic Floor PT | ✔️ Recommended based on phenotype | First-line for those with pelvic floor tenderness/dysfunction |
| Dietary Modification | ✔️ Common first step | Helps identify and manage triggers (e.g., acidic/spicy foods) |
| Trauma-Informed Therapy | ✔️ Advised when relevant | Important for patients with abuse or PTSD history |
| Pain Psychology/Counseling | ✔️ Valuable for many | Can reduce symptom severity and improve quality of life |
| Multimodal Management | ✔️ Essential | Combination of treatments based on phenotype yields best outcomes |
The biggest change that I am happy to see? The guidelines now emphasize shared decision-making, meaning your preferences, lifestyle, and concerns should be central to your care plan and treatments.
Oral Elmiron (PPS) – Not Recommended Anymore
Once considered a mainstay, Pentosan Polysulfate (Elmiron) is now conditionally recommended against due to:
- Minimal benefit in studies
- Risk of serious eye damage (pigmentary maculopathy)
If you’re currently taking Elmiron, talk to your provider about weaning off safely and having your vision checked. Show your doctors this.
Bladder Instillations (aka “Cocktails”)
These involve placing medications directly into the bladder.
What we know now:
- There’s no “best” instillation recipe.
- Common ingredients like DMSO, heparin, lidocaine, and hyaluronic acid may help, especially for bladder-centric pain.
- Safety profiles are generally good.
Botox (OnabotulinumtoxinA)
Botox injections into the bladder are an option for patients who haven’t responded to other treatments.
What to expect:
- May help reduce urgency, frequency and pain.
- Side effects can include temporary urinary retention and UTIs.
Not a cure. Effects are temporary and may need repeating.
Cyclosporin A (Cy-A)
An immune-suppressing drug sometimes used in hard-to-treat IC/BPS cases.
What’s new:
- The guideline does not recommend for or against it.
- May help some people, especially those with Hunner lesions.
- Requires careful monitoring due to risks like high blood pressure and kidney problems.
Instead of a rigid treatment ladder, the 2025 guideline promotes personalized care based on symptom severity, patient goals + response to prior therapies. All with emphasis on foundational treatments like dietary modification and pelvic physiotherapy as part of the overall medical approach.
Phenotyping: Treat the person, not just the bladder!
One of the most patient-centered changes in the 2025 guideline is the focus on clinical phenotyping. This means identifying the type of IC/BPS you have, such as:
- Hunner lesion subtype
- Pelvic floor dysfunction subtype
- Widespread pain subtype (linked to conditions like fibromyalgia)
- Trauma-associated subtype
Why it matters: Understanding your unique symptom pattern can guide more effective treatment. It can be pelvic floor therapy, bladder treatments, or trauma-informed care… OR a combination of all!!
Recognizing Endometriosis and other overlapping conditions
One particularly validating update is the inclusion of endometriosis in the diagnostic process. Once. lol Though the guidelines don’t go into depth, they now recognize that IC/BPS can coexist with endometriosis, and that both may need to be treated for full symptom relief.
Final thoughts on 2025 CUA IC/BPS guideline: Hope for better care
One notable gap in the 2025 guideline is the lack of emphasis on nervous system dysregulation which is a a key piece of the IC/BPS puzzle for many patients due to the chronic pain and anxiety around their pain.
Chronic pain conditions like IC/BPS often involves the nervous system becoming hypersensitive and continues to send pain signals even when there’s no ongoing tissue damage. This is where nervous system regulation strategies like breathwork, somatic practices, trauma-informed therapy and vagus nerve stimulation, all can play a role for some.
But these tools are largely absent from the current CUA guideline. Many patients find significant relief not just through medications or procedures, but through regulating their nervous system and reducing stress-related flares.
Despite this, I’m encouraged by the 2025 CUA guideline. If you’ve been dismissed, misdiagnosed, or pushed through ineffective treatment plans, I hope this shift offers new tools for your healthcare team and to advocate for yourself or a loved one.
If you’ve struggled to be heard, ask your provider:
- Have I been checked for Hunner lesions?
- Can we explore pelvic floor involvement?
- What are the risks of my current treatment?
- Could I benefit from a different approach based on my phenotype?
You deserve care that sees your full story, not just your bladder.
Sources & Links:
Doiron RC, Tadayon B, Violette PD, Locke J, Andrews M, Nadeau G, Gray G, Cox A. 2025 Canadian Urological Association Guideline: Selected treatment recommendations for interstitial cystitis/bladder pain syndrome. Can Urol Assoc J. 2025 Apr;19(4):90-103. doi: 10.5489/cuaj.9182. PMID: 40168684; PMCID: PMC11973989.
