What is the treatment approach for a patient with symptoms of cystitis and a negative Urinalysis (UA)?

Treatment Approach for Cystitis with Negative Urinalysis

For patients with symptoms of cystitis but negative urinalysis, consider interstitial cystitis/bladder pain syndrome (IC/BPS) as the primary diagnosis and initiate conservative treatment measures before advancing to more invasive therapies.

Diagnostic Considerations

When evaluating a patient with cystitis symptoms (urinary frequency, urgency, dysuria) but negative urinalysis, it's essential to:

• Rule out low-level bacterial infection with urine culture, as bacteria may be clinically significant but not detectable on dipstick or microscopic exam 1
• Consider IC/BPS as a primary diagnosis when cultures remain negative 1, 2
• Exclude other conditions in the differential diagnosis:
  • Urethritis
  • Vaginitis
  • Vulvar vestibulitis
  • Neoplasia
  • Kidney stones

Treatment Algorithm for Cystitis with Negative UA

First-Line Approach

1. Conservative measures:

   • Dietary modifications (avoid bladder irritants like caffeine, alcohol, spicy foods)
   • Stress management techniques
   • Pelvic floor relaxation exercises
   • Adequate hydration

2. Oral medications:

   • Pentosan polysulfate sodium (the only FDA-approved oral therapy for IC/BPS) 3
   • Tricyclic antidepressants (e.g., amitriptyline) for pain modulation
   • Antihistamines (e.g., hydroxyzine) to reduce mast cell activation

Second-Line Approach

If symptoms persist despite first-line treatments:

• Consider intravesical therapies such as dimethyl sulfoxide (DMSO) - the only FDA-approved intravesical therapy for IC/BPS 3
• Intravesical heparin or combination therapies

Third-Line Approach

For refractory cases:

• Consider cystoscopy with hydrodistention to confirm diagnosis and potentially provide therapeutic benefit 1
• Evaluate for Hunner's lesions, which if present, may benefit from fulguration 1

Special Considerations

• Recurrent symptoms: If symptoms recur or persist beyond 4-6 weeks, further evaluation with cystoscopy and/or urodynamics should be considered 1

• Red flags requiring urological referral:

  • Persistent hematuria
  • Abnormal findings on imaging
  • Severe, refractory symptoms affecting quality of life

• Pitfalls to avoid:

  • Treating empirically with antibiotics when cultures are negative
  • Delaying diagnosis of IC/BPS, which can lead to chronic pain and decreased quality of life
  • Failing to consider other pelvic pain syndromes that may overlap with IC/BPS

Monitoring and Follow-up

• Assess symptom improvement using validated questionnaires
• Follow up within 4-6 weeks to evaluate treatment response
• Adjust therapy based on symptom control and quality of life impact
• Consider referral to urology if symptoms persist despite conservative management

Remember that IC/BPS is a diagnosis of exclusion that requires ruling out other conditions with similar presentations. Treatment should follow a stepwise approach from conservative to more invasive options based on symptom severity and impact on quality of life 1.