What are the diagnostic steps and treatment options for interstitial cystitis?

Diagnosing Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is diagnosed clinically through a careful history, physical examination, and basic laboratory testing to document characteristic symptoms and exclude other conditions—cystoscopy is NOT required for uncomplicated presentations but should be performed when Hunner lesions are suspected. 1

Essential Diagnostic Criteria

Symptoms must be present for at least 6 weeks with documented negative urine cultures. 1 The diagnosis requires:

• Bladder/pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder 1
• Associated lower urinary tract symptoms including urinary frequency, nocturia, and urgent desire to void 1
• Absence of infection or other identifiable causes 2

Step-by-Step Diagnostic Approach

1. Clinical History Documentation

Document the following specific elements 1:

• Number of voids per day and sensation of constant urge to void 1
• Location, character, and severity of pain, pressure, or discomfort 1
• Dyspareunia (painful intercourse) 1
• Dysuria (painful urination) 1
• Ejaculatory pain in men 1
• Relationship of pain to menstruation in women 1

2. Physical Examination

Perform these specific assessments 1:

• Brief neurological exam to rule out occult neurologic problems 1
• Evaluation for incomplete bladder emptying to rule out occult retention 1
• Pelvic examination to assess for bladder tenderness and exclude other pelvic pathology 3

3. Mandatory Laboratory Testing

Basic laboratory testing includes 1:

• Urinalysis 1
• Urine culture (even if urinalysis is negative, to detect lower bacterial levels not identifiable by dipstick) 1
• Urine cytology if the patient has smoking history or unevaluated microhematuria (due to bladder cancer risk) 1

Do NOT perform the potassium sensitivity test—it lacks specificity and sensitivity to change clinical decision-making. 1

4. Baseline Symptom Documentation

Obtain baseline measurements using validated tools 1:

• Genitourinary Pain Index (GUPI) 1
• Interstitial Cystitis Symptom Index (ICSI) 1
• Visual Analog Scale (VAS) 1
• At minimum, a one-day voiding log to establish low-volume frequency voiding pattern characteristic of IC/BPS 1

Very low voiding frequencies or high voided volumes should prompt a search for an alternate diagnosis. 1

5. When to Perform Cystoscopy

Cystoscopy is NOT necessary for uncomplicated presentations but should be performed in these specific situations 1:

• When Hunner lesions are suspected (this is the ONLY consistent cystoscopic finding diagnostic for IC/BPS) 1
• When diagnosis is in doubt 1
• To exclude bladder cancer, bladder stones, or intravesical foreign bodies 1
• For proper hematuria workup in patients with unevaluated hematuria or tobacco exposure 1

Important caveat: Glomerulations (pinpoint petechial hemorrhages) seen on cystoscopy are NOT diagnostic—they occur in other conditions and even in asymptomatic patients. 1

6. When to Perform Urodynamics

Urodynamics are NOT recommended for routine diagnosis. 1 Consider urodynamic evaluation only when 1:

• Suspicion of outlet obstruction in either sex
• Possibility of poor detrusor contractility
• Other conditions could explain why patients are refractory to behavioral or medical therapies

Key Diagnostic Pitfalls to Avoid

• Do not delay diagnosis waiting for cystoscopy in uncomplicated presentations—this is a clinical diagnosis 1
• Do not rely on glomerulations as diagnostic criteria—they lack specificity 1
• Do not use the potassium sensitivity test—it is not recommended 1
• Do not miss Hunner lesions—these patients respond well to specific treatment (fulguration/triamcinolone injection) and should be identified early 1
• Do not forget to obtain urine culture even with negative urinalysis—lower bacterial levels may be clinically significant 1

Differential Diagnosis Considerations

Must exclude these conditions 1:

• Urinary tract infections
• Bladder cancer
• Bladder stones
• Intravesical foreign bodies
• Endometriosis
• Chronic pelvic pain from other causes
• Overactive bladder without pain