Platelet-rich plasma (PRP) is rich in many growth factors and cytokines, modulating inflammation, and wound-healing regeneration, and effective in patients with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS). The clinical mechanism of PRP is still unclear. Although PRP has been shown effective in improvement of bladder pain symptoms, IC symptom index, and increase bladder capacity, about 40-50 % of patients treated with repeated PRP injections still cannot achieve a satisfactory treatment outcome. Submucosal injection of triamcinolone acetonide can improve the clinical symptoms and quality of life in both men and women with type II/III IC/BPS. This study aims to investigate whether adding triamcinolone on PRP injection can improve treatment outcomes in patients with IC/BPS who failed previous bladder therapy.

This is a pilot study. A total of 20 female patients who had failed previous intravesical PRP injections and medical treatment for IC/BPS were treated with intravesical injections of triamcinolone 40mg (in 10ml) plus 10ml PRP (3-5 times the peripheral blood concentration). Among the patients, 8 were Hunner’s type and 12 were non-Hunner’s type IC/BPS (HIC and NHIC). Before this treatment, patients with HIC received repeated electrocauterization and PRP injections for Hunner’s lesion, while NHIC received repeated PRP injections. However, the IC symptoms and bladder conditions remained unsatisfactory. (Table 1) All patients were proceeded to intravesical PRP plus triamcinolone injection every month till the IC symptoms improved. Assessment tools included Oleary-Sant symptom score (OSS), interstitial IC symptom index (ICSI), and problem index (ICPI), bladder pain visual analog scale (VAS), and variables of uroflowmetry such as maximum flow rate (Qmax), voided volume, and post-void residual volume (PVR). Successful treatment outcome was evaluated by a self-reported global response assessment (GRA) of ≧2.

Among the 20 patients treated with intravesical PRP and triamcinolone injections, 13(65%) had a successful result and 7(35%) did not. Seven (87.5%) of the 8 patients with HIC and 6 (50%) of the 12 NHIC patients reported a successful result. The ICSI, ICPI, OSS, and bladder pain VAS all improved after combined PRP and triamcinolone injections. (Table 1) The IC symptom improvement were noted in HIC and NHIC patients. However, the improvements were not significantly different between NHIC patients with large or small maximal bladder capacity, high or low grade of glomerulations, of baseline VAS severity. (Table 2)

The common pathophysiology of IC/BPS revealed chronic inflammation, increase of urothelial apoptosis, and impaired urothelial cell proliferation, and activating sensory receptors. The exacerbated bladder inflammation further results in the progression to oxidative stress. Current treatment for IC/BPS including cystoscopic hydrodistention, oral medications, intravesical instillations of HA or DMSO could provide short-term relief in a small portion of patients across different phenotype. BoNT-A can inhibit sensory neurotransmitter release and inhibiting inflammatory mediator secretion, is effective in bladder-pain predominant IC/BPS. The rationale for using PRP therapy in IC/BPS lies in its regenerative properties with diverse growth factors and cytokines, which promotes tissue repair, angiogenesis, reduces inflammation and oxidative stress, and enhances urothelial cell regeneration. However, patients with higher grade of inflammation might not be effectively treated simply by repeated PRP injections, the underlying inflammatory pathophysiology should be eradicated. In this study, we have successfully demonstrated that combined PRPO and triamcinolone can significantly improve IC symptoms and reduce bladder pain severity, especially in patients with HIC. Future study using multiple injection in a longer duration might further improve bladder condition of IC/BPS.

Intravesical injections of PRP and triamcinolone can effectively improve IC symptoms and reduce bladder pain in patients with IC/BPS, especially for HIC. Patients who are not satisfactorily treated by conventional therapy or PRP monotherapy might have a chance to improve their bladder conditions and IC symptoms.

Yu WR, Jiang YH, Jhang JF, Kuo HC. Repeated intravesical injections of platelet-rich plasma are safe and effective in the treatment of interstitial cystitis/bladder pain syndrome. Tzu Chi Med J 2024; 37: 72-79.
Kuo HC. Intravesical injections of autologous platelet-rich plasma for the treatment of refractory interstitial cystitis. Low Urin Tract Symptoms 2023; 15:210-5.
Jiang T, Zhou X, Chen Z, Xiong T, Fu J, Liu Z, Yan D, Zhou Z, Shen W. Clinical efficacy of submucosal injection of triamcinolone acetonide in the treatment of type II/III interstitial cystitis/bladder pain syndrome. BMC Urol. 2020 Mar 30;20(1):36.