Diagnostic Workup for Chronic Cystitis
The diagnostic workup for chronic cystitis requires a thorough evaluation including history, physical examination, laboratory tests, and cystoscopy, with particular attention to ruling out other conditions that mimic chronic cystitis such as interstitial cystitis/bladder pain syndrome (IC/BPS).
Initial Evaluation
History
- Document symptoms present for at least 6 weeks with:
- Number of voids per day
- Constant urge to void
- Location, character, and severity of pain/pressure/discomfort
- Dyspareunia, dysuria
- Ejaculatory pain in men
- Relationship of pain to menstruation in women 1
Physical Examination
- Brief neurological exam to rule out occult neurologic problems
- Evaluation for incomplete bladder emptying to rule out occult retention
- Pelvic examination in women
- Rectal examination in men 1
Laboratory Tests
- Urinalysis and urine culture (essential):
- Document negative urine cultures
- Rule out infection, hematuria, pyuria
- Consider urine culture even with negative urinalysis to detect lower levels of bacteria 1
- Blood tests:
- Complete blood count
- Basic metabolic panel
- C-reactive protein/erythrocyte sedimentation rate 1
Advanced Diagnostic Testing
Cystoscopy
- Indicated when:
- Hunner lesions are suspected
- Need to rule out bladder cancer, stones, or foreign bodies
- Symptoms persist despite initial treatment 1
- May be performed with or without hydrodistention
- Can identify glomerulations or Hunner's ulcers which are diagnostic for IC/BPS 2
- Most patients may tolerate office flexible cystoscopy, but some may prefer general anesthesia 1
Urodynamic Studies
- Not recommended for routine use to establish diagnosis
- Consider when:
- Outlet obstruction is suspected
- Poor detrusor contractility is possible
- Other conditions might explain treatment resistance 1
Imaging
- Consider ultrasound or CT to:
- Assess kidney structure (shape, size, symmetry)
- Rule out obstruction
- Evaluate for cystic disease or reflux disease 1
- CT urography (CTU) may be appropriate for:
- Patients with hematuria
- Suspected upper urinary tract pathology 1
Diagnostic Criteria
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)
- Chronic disorder with symptoms present for at least 6 weeks
- Characterized by bladder/pelvic pain and pressure/discomfort
- Associated with urinary frequency and strong urge to urinate
- Absence of infection or other identifiable causes 1, 3
Exclusion of Other Conditions
- Bacterial cystitis
- Urethritis
- Bladder cancer
- Bladder stones
- Vaginitis
- Vulvar vestibulitis 2
- Renal parenchymal disease 1
Special Considerations
- Symptom questionnaires can help capture and record the presence of all symptoms 3
- IC/BPS is a heterogeneous clinical syndrome with different subgroups or phenotypes 1
- Consider concurrent nephrology evaluation if renal parenchymal disease is suspected 1
- Patients with recurrent symptoms should be evaluated for underlying metabolic disorders 4
Pitfalls to Avoid
- Assuming chronicity based on a single abnormal finding - multiple measurements over time are needed 1
- Overlooking the possibility of recent acute kidney injury or disease 1
- Failing to obtain cultures before starting antibiotics, which can obscure diagnosis 4
- Relying solely on pyuria for diagnosis, especially in catheterized patients 4
- Neglecting to consider IC/BPS in women with chronic pelvic pain and microhematuria 1
By following this systematic approach to the diagnostic workup of chronic cystitis, clinicians can accurately identify the underlying cause and develop an appropriate treatment plan to improve patient outcomes and quality of life.