Hunner-lesion BPS/IC refractory to standard therapy — management station

A 42-year-old woman with a five-year history of suprapubic pain that worsens with bladder filling and is relieved by voiding, 16 voids/day and nocturia three times, has had behavioural therapy, amitriptyline 75 mg nocte, hydroxyzine 50 mg nocte, pentosan polysulfate 100 mg three times daily for two years, intravesical DMSO every two weeks, and a single cystoscopy with hydrodistension that showed glomerulations only. Repeat cystoscopy now reveals a reddened mucosal patch with a central scar and waterfall hyperaemia on the posterior wall. Biopsy shows a dense lymphoplasmacytic infiltrate with eosinophilic mast cells. You are the urogynaecology fellow in clinic with the consultant.