Is there literature on urology use of intravesical triamcinolone?

Is there literature on urology use of intravesical kenalog?

Comment by InpharmD Researcher

Available urologic literature on intravesical Kenalog (triamcinolone) is limited and primarily focuses on its role in interstitial cystitis/bladder pain syndrome (IC/BPS) as part of combination bladder instillation cocktail regimens rather than as a standalone therapy. One randomized trial (see Table 1) evaluated the addition of triamcinolone 40 mg to a heparin/lidocaine/sodium bicarbonate bladder instillation and found that triamcinolone did not provide additional symptom improvement compared with the cocktail alone. However, other studies have evaluated triamcinolone-containing instillation regimens (e.g., DMSO plus triamcinolone or bupivacaine/heparin/triamcinolone), with reported symptom improvements. Ultimately, data supporting intravesical triamcinolone are limited and mixed, with insufficient evidence to establish its optimal use in urology; further robust data are needed to clarify its role in this setting.

Background

The 2025 Canadian Urological Association guideline on treatment recommendations for interstitial cystitis/bladder pain syndrome (IC/BPS) reviewed the available evidence for intravesical triamcinolone in IC/BPS. One randomized trial (see Table 1) evaluated 90 women with IC/BPS who received six bladder instillations of a heparin (10,000 units), 2% lidocaine, and 8.4% sodium bicarbonate cocktail with or without triamcinolone 40 mg. Both groups demonstrated symptom improvement based on changes in the O’Leary-Sant Questionnaire score (triamcinolone -6.7 points vs. control -5.8 points); however, there was no statistically significant difference between groups (p= 0.31), suggesting no additional benefit with the addition of triamcinolone. The guideline notes that, although intravesical triamcinolone is unlikely to be harmful, current evidence is insufficient to support its routine use for IC/BPS. [1]

Given the unclear etiology of IC/BPS, a 2020 review evaluated available evidence on intravesical treatment, also defined as bladder instillations, for symptomatic relief. Commonly used agents include intravesical lidocaine, hyaluronic acid, DMSO, heparin, or chondroitin sulfate as individual or combined therapies. Despite their common use in practice, the most optimal agents and dosing regimens remain controversial. Evidence surrounding the use of intravesical gentamicin or triamcinolone infiltration is limited to sporadic reports, requiring further investigation. Concerning “cocktail” regimens specifically, referenced studies evaluating DMSO as part of a “cocktail” with heparin, hydrocortisone, triamcinolone, and/or local anesthetic have reported response rates ranging from 61 to 70%, while the question has been raised regarding the additional benefits of these concoctions compared to DMSO alone. Of note, the data in this review regarding triamcinolone primarily describe its use as a component of intravesical bladder instillation cocktails rather than as a standalone intravesical therapy. [2]

A 2020 review also discussed several intravesical “cocktail” regimens containing various combinations of agents for symptomatic management of IC/BPS. One formulation consisting of bupivacaine 0.5%, lidocaine 2% jelly, heparin 10,000 units, triamcinolone 40 mg, and gentamicin 80 mg has been described as the Moldwin “cocktail,” based on a 2008 International Painful Bladder Foundation (IPBF) report. Although this regimen includes intravesical triamcinolone, the review does not provide evidence establishing the role of triamcinolone in this combination. The regimen appears to be named after Robert Moldwin, MD, and administration guidance from the IPBF is based on expert information rather than robust evidence. The IPBF also notes that it is not a medical authority and advises patients to consult their healthcare provider before initiating any treatment. [3], [4]

Literature Review

A search of the published medical literature revealed 3 studies investigating the researchable question:

Is there literature on urology use of intravesical kenalog?

Level of evidence

C - Multiple studies with limitations or conflicting results Read more→

Please see Tables 1-3 for your response.

Bladder Instillations With Triamcinolone Acetonide for Interstitial Cystitis-Bladder Pain Syndrome: A Randomized Controlled Trial
Design	Single-center, randomized, double-blind trial N= 90
Objective	To evaluate the utility of adding triamcinolone acetonide (TA) to a standard bladder instillation (BI) solution for the treatment of interstitial cystitis-bladder pain syndrome (IC-BPS)
Study Groups	BI without TA (n= 45) BI with TA (n= 45)
Inclusion Criteria	Aged ≥18 years; clinical diagnosis of interstitial cystitis–bladder pain syndrome (based on history and symptoms); scored ≥6 points on either the problem or symptom index of the O’Leary-Sant "(OLS) Questionnaire; selected BI as part of treatments
Exclusion Criteria	Contraindications to the bladder instillation ingredients; diagnosis of idiopathic thrombocytopenic purpura (contraindication to heparin); unwillingness to undergo six weekly bladder instillations; inability to speak or read English; bladder instillation within 4 weeks before study recruitment
Methods	Eligible patients were randomized to receive six BIs with TA (1 vial, 40 mg/mL) or without it in addition to a mixture of heparin 10,000 units, 2% viscous lidocaine (10 mL), 8.4% sodium bicarbonate (15 mL of 1 mEq/mL), and 0.5% bupivacaine (10 mL of 5 mg/mL). Patients were allowed to continue other prescribed treatments, including pelvic floor physical therapy, oral medications, and pudendal nerve blocks. A blinded physician or nurse practitioner performed bladder instillations using a standardized technique. All participants were required to lay supine for 2-5 minutes and were instructed not to urinate the instillation until after 30 minutes.
Duration	Enrollment: From January 2019 to October 2020
Outcome Measures	Primary: Change in interstitial cystitis-bladder pain syndrome symptoms from the first to sixth bladder instillation based on the total OLS score (0-36; higher score indicating worse symptoms; estimated minimal clinically important difference of 4 points) Secondary: Group and individual changes in the scores on the OLS subscales, Pelvic Pain and Urgency/Frequency (PUF), Overactive Bladder Questionnaire (OABq), Pelvic Floor Distress Inventory (PFDI-20), sexual function measured by Pelvic Organ Prolapse Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), visual analog scale for bladder pain
Baseline Characteristics		BI without TA (n= 45)	BI with TA (n= 45)
	Age, years	46.6	37.3
	Body mass index, kg/m²	28.3	30.1
	At least 1 concurrent pain disorder	93%	98%
	Current treatment for IC-BPS	64%	71%
	Length of IC-BPS diagnosis A few months 1-2 y 3-5 y 5 y or more	11% 11% 11% 63%	23% 14% 14% 35%
	Scores (total) OLS OAB-q PFDI-20 PUF PISQ-IR (sexually active) VAS	23.4 ± 6.3 59.3 ± 19.6 29.2 ± 14.4 18.8 ± 6.0 32/44 (73) 5.5 ± 2.6	24.2 ± 5.7 68.3 ± 22.3 27.5 ± 10.8 20.6 ± 5.8 37/45 (82) 5.4 ± 2.4
	Participants who discontinued treatment Between 1st and 3rd BI Between 3rd and 6th BI	13% 8%	7% 17%
Results	Endpoint	BI without TA (n= 45)	BI with TA (n= 45)	p-value
	Intention-to-treat analysis* Change in OLS score 3rd BI 6th BI 4.03-point reduction from 1st BI total OLS score 3rd BI 6th BI	-3.7 ± 6.2; p< 0.01 -5.8 ± 8.0; p< 0.01 14 (31%) 24 (53%)	-3.5 ± 6.3; p< 0.01 -6.7 ± 7.1; p< 0.01 21 (47%) 28 (62%)	0.4 0.3 0.2 0.5
	Per-protocol analysis of change in OLS scores at 3rd and 6th BIs demonstrated similar results. Similarly, there were no differences between the groups in the secondary outcomes, despite a significant improvement within each group from the first to third bladder instillation and from the first to sixth bladder instillation in most secondary outcomes. *The intention-to-treat analysis uses a last observation carried forward assumption.
Adverse Events	Common Adverse Events: 11% vs 2%
	Serious Adverse Events: None
	Percentage that Discontinued due to Adverse Events: Two participants in the BI without TA discontinued treatment due to urinary tract infection and bladder spasm. One participant in the BI with TA discontinued the regimen due to burning in her urethra.
Study Author Conclusions	The addition of triamcinolone acetonide to a standard bladder instillation solution does not improve symptoms associated with interstitial cystitis-bladder pain syndrome.
InpharmD Researcher Critique	Long-term outcomes beyond six BIs and the sole efficacy of bladder instillation without adjunct treatments remain unknown. As patients are recruited from a single-center subspecialty clinic, results may not be readily applicable to a bigger patient population.

Table 1 References:
[5] Cardenas-Trowers OO, Abraham AG, Dotson TK, Houlette BA, Gaskins JT, Francis SL. Bladder Instillations With Triamcinolone Acetonide for Interstitial Cystitis-Bladder Pain Syndrome: A Randomized Controlled Trial. Obstet Gynecol. 2021;137(5):810-819. doi:10.1097/AOG.0000000000004348

A prospective, randomized trial comparing intravesical dimethyl sulfoxide (DMSO) to bupivacaine, triamcinolone, and heparin (BTH), for newly diagnosed interstitial cystitis/painful bladder syndrome (IC/PBS)
Design	Prospective, randomized study N= 83
Objective	To compare the effect of bladder instillations using dimethyl sulfoxide (DMSO) with triamcinolone versus bupivacaine, triamcinolone, and heparin (BTH) in women with newly diagnosed interstitial cystitis/painful bladder syndrome (IC/PBS)
Study Groups	DMSO with triamcinolone (n= 42) BTH (n= 28)
Inclusion Criteria	Patients 18 years or older with newly diagnosed IC/PBS who chose to undergo treatment with bladder instillations
Exclusion Criteria	History of pelvic radiation, bladder malignancy, or bladder resection
Methods	Patients were randomized 1:1 to receive 6 weekly bladder instillations of either 50 mL dimethyl sulfoxide (DMSO) plus 1 mL triamcinolone 10 mg/mL or 30 mL 0.5% bupivacaine, 2 mL triamcinolone 10 mg/mL, and 2 mL heparin 10,000 units/mL (BTH). At each weekly visit, bladder capacity was assessed by retrograde bladder filling, patients completed the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) questionnaire, and the instilled solution was retained in the bladder for 15 minutes before voiding. Both groups received a single prophylactic antibiotic dose after each treatment.
Duration	October 2011 to April 2019
Outcome Measures	Primary: Percentage of patients with greater than 29.5% reduction in ICSI score Secondary: Change in bladder capacity, urinary frequency, nocturia, and pain
Baseline Characteristics		DMSO (n= 42)	BTH (n= 28)
	Age, years	46.38 ± 17.83	51.36 ± 12.25
	Body mass index	27.97 ± 12.95	28.02 ± 8.29
	Duration of symptoms, months	32.77 ± 65.51	26.32 ± 23.26
	Sexually active	26/34 (76.47%)	16/25 (64%)
	Post‐menopausal	15/40 (37.5%)	15/27 (55.56%)
	Cystometric testing: first sensation, mL	129.24 ± 81.65	117.62 ± 72.23
	Cystometric testing: fullness, mL	226.62 ± 106.91	260 ± 93.87
	Cystometric testing: maximum capacity, mL	338.62 ± 139.44	447.43 ± 180.38
	Detrusor overactivity	12/31 (38.71%)	12/24 (50.0%)
	Retrofill volume, mL	170.37 ± 76.08	209.07 ± 110.90
	Frequency, h	1.86 ± 0.98	2.12 ± 1.25
	Nocturia, number of voids	3.02 ± 1.90	3.00 ± 2.90
	ICSI score	10.65 ± 3.90	9.48 ± 4.68
Results		DMSO (n= 42)	BTH (n= 28)	p-value
	Reduction in ICSI score	63%	43%	0.15
	Change in ICSI score at visit 5	−4.47 ± 3.56	−2.18 ± 3.11	0.02
	Change in ICSI score at visit 6	−4.73 ± 4.15	−2.24 ± 2.72	0.02
	Of 83 randomized patients, 70 completed all 6 weekly bladder instillations (42 DMSO plus triamcinolone; 28 BTH). A greater than 29.5% reduction in total ICSI score at week 6 occurred in 63% of the DMSO plus triamcinolone group and 43% of the BTH group (p= 0.15). Total ICSI scores decreased in both groups, with greater improvement in the DMSO plus triamcinolone group at visits 5 and 6 (both p= 0.02). Urgency and frequency improved significantly in both groups, while nocturia and pain improved significantly only in the DMSO plus triamcinolone group. Bladder capacity increased from baseline in both groups, with a greater increase after the first instillation in the DMSO plus triamcinolone group, but no statistically significant between-group differences were observed after 6 weeks.
Adverse Events	Three participants withdrew due to discomfort during instillations, two from the DMSO group and one from BTH. One participant developed urinary tract infections despite antibiotic prophylaxis.
Study Author Conclusions	In conclusion, in patients with newly diagnosed IC/PBS, bladder instillations using DMSO with triamcinolone provide greater symptom improvement compared to BTH. The full effect of these therapies emerged only after four sessions of once‐weekly therapy. Further research is needed to examine the longer‐term success of intravesical therapy, and to determine if there is a specific type of patient who is more likely to benefit from a given therapy.
Critique	This prospective, randomized study provides evidence for intravesical triamcinolone-containing bladder instillation regimens; however, triamcinolone was administered in combination with other agents in both treatment groups, preventing assessment of its independent effect. Additional limitations include the lack of a placebo control, inability to blind participants due to the characteristic odor of DMSO, and a smaller-than-planned sample size, which may have reduced statistical power. Dietary adherence, a potential confounder of bladder symptoms, was also not assessed.

Table 2 References:
[6] Moss NP, Chill HH, Sand PK, Chang C, Goldberg RP, Gafni-Kane A. A prospective, randomized trial comparing intravesical dimethyl sulfoxide (DMSO) to bupivacaine, triamcinolone, and heparin (BTH), for newly diagnosed interstitial cystitis/painful bladder syndrome (IC/PBS). Neurourol Urodyn. 2023;42(3):615-622. doi:10.1002/nau.25142

Measuring the success of combined intravesical dimethyl sulfoxide and triamcinolone for treatment of bladder pain syndrome/interstitial cystitis
Design	Retrospective study N= 79
Objective	To investigate change in bladder capacity as a measure of response to combined intravesical dimethyl sulfoxide (DMSO) and triamcinolone instillations for the treatment of newly diagnosed bladder pain syndrome/interstitial cystitis (BPS/IC)
Study Groups	Without detrusor overactivity (DO; n= 45) With DO (n= 34)
Inclusion Criteria	Women with newly diagnosed BPS/IC who were first treated with intravesical DMSO/triamcinolone and completed more than one treatment visit
Exclusion Criteria	Patients previously treated for BPS/IC, history of bladder cancer, pelvic irradiation, intravesical chemotherapy, or bladder resection
Methods	Retrospective analysis of treatment-naïve women with newly diagnosed bladder pain syndrome/interstitial cystitis who received weekly intravesical bladder instillations of 50 mL DMSO plus 1 mL triamcinolone (10 mg/mL) for 4 to 6 weeks. Before each instillation, the bladder was retrograde filled with sterile water to the maximum tolerated capacity, drained after 5 minutes, and the instilled solution was retained for 15 minutes before voiding. Bladder capacity, daytime urinary frequency, nocturia episodes, and Likert scale symptom scores were evaluated.
Duration	May 2008 to November 2010
Outcome Measures	Primary: Change in bladder capacity Secondary: Changes in inter-void interval, nocturia episodes per night, Likert scale symptom scores, time to retreatment
Baseline Characteristics		All patients (N= 79)
	Age, years	46.2 ± 13.9
	Body mass index, kg/m2 (IQR)	23.5 (20.9 to 27.2)
	Parity	2 (0 to 2)
	Duration of symptoms, months (IQR)	12 (3 to 36)
	Maximum cystometric capacity, mL (IQR)	350 (299 to 439.5)
	Number of patients with detrusor overactivity	35 (43.0%)
	Abbreviations: IQR, interquartile range.
Results	Change in outcomes following an initial series of treatments for BPS/IC (N= 79)	First treatment visit	Last treatment visit	Absolute change	Percent change	p-value
	Bladder capacity on retrofill, mL (IQR)	200 (125 to 325)	300 (200 to 450)	75 (25 to 130)	40 (11.1 to 100)	<0.0001
	Inter-void interval, hrs (IQR)	2 (1 to 3)	3 (2 to 3)	0 (0 to 1)	0 (0 to 100)	<0.0001
	Nocturia episodes per night (IQR)	2.5 (2 to 4)	2 (1 to 3)	-1 (-2 to 0)	-20 (-50 to 0)	<0.0001
	Aggregate Likert scale symptom score (IQR)	7 (4 to 12)	4 (1 to 9)	-2 (-5 to 0)	-45 (-71.4 to 0)	<0.0001
Adverse Events	Not reported
Study Author Conclusions	Percent change in bladder capacity is a useful objective measure of response to intravesical DMSO/triamcinolone for newly diagnosed BPS/IC. Clinical outcomes do not differ based upon presence of DO.
Critique	This retrospective study provides supportive evidence for intravesical DMSO plus triamcinolone in treatment-naïve patients with bladder pain syndrome/interstitial cystitis; however, the findings cannot be attributed to triamcinolone alone, as it was administered only in combination with DMSO. Additional limitations include the retrospective design, potential selection and information biases, and use of a nonvalidated symptom questionnaire, which may limit the generalizability of the findings.

Table 3 References:
[7] Gafni-Kane A, Botros SM, Du H, Sand RI, Sand PK. Measuring the success of combined intravesical dimethyl sulfoxide and triamcinolone for treatment of bladder pain syndrome/interstitial cystitis. Int Urogynecol J. 2013;24(2):303-311. doi:10.1007/s00192-012-1832-x