What are the next steps in managing a patient with chronic pelvic pain after a normal cystoscopy (cystoscopy) has ruled out cystitis?

Management of Chronic Pelvic Pain After Normal Cystoscopy

For patients with chronic pelvic pain after a normal cystoscopy has ruled out cystitis, the next steps should include pelvic imaging with transvaginal and transabdominal ultrasound with Doppler studies, followed by targeted treatments based on identified pathology or empiric treatment for bladder pain syndrome if no specific cause is found. 1

Diagnostic Evaluation

Imaging Studies

• Transvaginal ultrasound with transabdominal ultrasound and Doppler studies should be performed as the initial imaging modality for patients with chronic pelvic pain after normal cystoscopy 1
• These complementary ultrasound techniques provide both anatomic overview and detailed evaluation of pelvic structures that may be causing pain 1
• MRI pelvis should be considered as a problem-solving examination if ultrasound findings are nondiagnostic or inconclusive 1

Potential Etiologies to Consider

• Pelvic venous disorders (pelvic congestion syndrome) - characterized by engorged periuterine and periovarian veins visible on imaging 1
• Intraperitoneal adhesions - difficult to diagnose nonoperatively but may be inferred from peritoneal inclusion cysts 1
• Hydrosalpinx or chronic inflammatory disease 1
• Pelvic floor muscular hypertonicity 1
• Interstitial cystitis/bladder pain syndrome (IC/BPS) - despite normal cystoscopy findings 1

Treatment Approach

For IC/BPS Without Hunner Lesions

• Establish baseline voiding symptoms and pain levels using validated tools (GUPI, ICSI, or VAS) to measure treatment effects 1
• Implement multimodal pain management approaches including pharmacological treatments, stress management, and manual therapy 1
• Consider the following treatment options:

Behavioral/Non-pharmacologic Treatments

• Patient education about the chronic nature of the condition and need for ongoing management 1
• Stress management techniques to address psychological factors that may heighten pain sensitivity 1

Oral Medications (Second-line treatments)

• Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered 1
• Monitor for potential adverse events, particularly with pentosan polysulfate 1

Bladder Instillations (Second-line treatments)

• Dimethyl sulfoxide, heparin, or lidocaine may be administered intravesically 1
• These treatments may provide relief when oral medications are insufficient 1

For Other Pelvic Pain Causes

• Treatment should be directed at the specific etiology identified through imaging 1
• For pelvic venous disorders, referral to interventional radiology may be considered 1
• For pelvic floor dysfunction, referral to physical therapy with expertise in pelvic floor rehabilitation 1

Follow-up and Monitoring

• Periodically reassess treatment efficacy and discontinue ineffective treatments 1
• Consider referral to multidisciplinary pain management if pain control remains inadequate 1, 2
• For persistent, unexplained pain despite initial treatments, consider advanced treatments such as:
  • Neurostimulation trial if other treatments have not provided adequate symptom control 1
  • Cyclosporine A or intradetrusor botulinum toxin A as later-line options for refractory cases 1

Important Considerations

• Chronic pelvic pain affects approximately 15% of adult women in the US, with IC/BPS being a common cause 3
• A normal cystoscopy does not rule out IC/BPS entirely, as many patients with bladder pain syndrome have normal cystoscopic findings 1
• Treatment response may take several months to achieve optimal results 2
• Patient education and involvement in treatment decisions are crucial for successful management 2, 4
• The distinction between Hunner-type IC and bladder pain syndrome is important, as they require different treatment approaches 4