What is the diagnostic approach for Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)?

Diagnosing Bladder Pain Syndrome/Interstitial Cystitis

Diagnose bladder pain syndrome clinically when a patient has bladder/pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder, accompanied by at least one lower urinary tract symptom (frequency, nocturia, or urgency) for at least 6 weeks, after excluding infection and other identifiable causes through basic laboratory testing. 1

Essential Clinical Criteria

The diagnosis requires three components to be present simultaneously:

• Pain component: Bladder or pelvic pain, pressure, or discomfort that the patient perceives as bladder-related 1, 2
• Urinary symptoms: At least one lower urinary tract symptom including urinary frequency, nocturia, or urgent desire to void 1
• Duration and exclusion: Symptoms present for ≥6 weeks with documented negative urine cultures and absence of other identifiable causes 1

Step-by-Step Diagnostic Approach

Initial Clinical Assessment

Perform a focused history documenting:

• Specific pain location, quality, and relationship to bladder filling/emptying 3
• Urinary frequency (use a one-day voiding log to quantify) 1
• Nocturia episodes per night 1
• Factors that worsen or improve symptoms (foods, stress, menstrual cycle) 3
• Impact on sexual function (dyspareunia is common) 4

Conduct a physical examination that includes:

• Pelvic examination to identify pelvic floor muscle tenderness, trigger points, and exclude other pelvic pathology 3
• Brief neurological exam to rule out occult neurologic problems 1
• Assessment for incomplete bladder emptying to exclude occult retention 1

Mandatory Laboratory Testing

Order these tests for every patient:

• Urinalysis and urine culture (mandatory even if urinalysis is negative, as lower bacterial counts may be clinically significant but not detected on dipstick) 3, 1
• Urine cytology if the patient has a smoking history or unevaluated microhematuria, given bladder cancer risk 3, 1

Do NOT perform the potassium sensitivity test - it lacks both specificity and sensitivity to change clinical decision-making 3, 1

Baseline Symptom Documentation

Use validated tools to establish baseline severity:

• Genitourinary Pain Index (GUPI) 1
• Interstitial Cystitis Symptom Index (ICSI) 1
• Visual Analog Scale (VAS) for pain 1
• One-day voiding log to document frequency 1

When to Perform Cystoscopy

Cystoscopy is NOT necessary for diagnosis in uncomplicated presentations 3, 5. However, perform cystoscopy when:

• Hunner lesions are suspected (these inflammatory ulcerations significantly impact treatment approach and should be fulgurated) 3, 5
• Diagnosis is uncertain or symptoms are atypical 3, 1
• Need to exclude: bladder cancer, bladder stones, or intravesical foreign bodies 1
• Patient has risk factors for malignancy (smoking, hematuria) 3

Important caveat: Glomerulations (pinpoint petechial hemorrhages) seen on cystoscopy are NOT diagnostic of IC/BPS - they occur in other conditions like endometriosis and chronic pelvic pain, and can be present in asymptomatic patients 3, 6

When to Consider Urodynamics

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

• Suspicion of bladder outlet obstruction exists 1
• Poor detrusor contractility is suspected 1
• Patient is refractory to behavioral and medical therapies and you need to identify other contributing conditions 1

Critical Differential Diagnoses to Exclude

Rule out these conditions before confirming IC/BPS:

• Urinary tract infections (including low-level bacteriuria) 3, 1
• Bladder cancer 1
• Bladder stones 1
• Endometriosis 3, 1
• Chronic pelvic pain from other causes 1
• Overactive bladder without pain 1
• Neurologic disorders (multiple sclerosis, spinal cord lesions) 1

Common Diagnostic Pitfalls

Pitfall #1: Assuming glomerulations on cystoscopy confirm the diagnosis - they are non-specific and can occur in asymptomatic patients 3, 6

Pitfall #2: Performing cystoscopy on every patient - this is unnecessary in straightforward cases with typical symptoms and negative basic workup 3, 5

Pitfall #3: Ordering the potassium sensitivity test - this outdated test should never be used 3, 1

Pitfall #4: Missing occult urinary retention or neurologic disease by skipping the neurological exam and post-void residual assessment 1

Pitfall #5: Failing to document baseline symptoms with validated tools, making it impossible to assess treatment response later 1