Is Cystoscopy Required to Diagnose Interstitial Cystitis?
No, cystoscopy is not required to diagnose interstitial cystitis/bladder pain syndrome (IC/BPS) in uncomplicated presentations—the diagnosis is primarily clinical, based on history, physical examination, and laboratory tests to exclude other conditions. 1, 2
When Cystoscopy Is NOT Needed
The diagnosis of IC/BPS can be established clinically without cystoscopy when the presentation is straightforward. 1 The essential diagnostic criteria include:
- Symptom duration: Bladder/pelvic pain, pressure, or discomfort associated with urinary frequency and urgency must be present for at least 6 weeks 1, 2
- Negative urine cultures: Documented absence of infection is required 1, 2
- Basic workup suffices: History, physical examination, urinalysis, and urine culture are the foundation of diagnosis 1, 2
A brief neurological exam to exclude occult neurologic problems and evaluation for incomplete bladder emptying should be performed on all patients. 1, 2 If the patient has a smoking history or unevaluated microhematuria, urine cytology should be obtained given bladder cancer risk. 1, 2
When Cystoscopy IS Indicated
Cystoscopy should be performed specifically when Hunner lesions are suspected, as this is the only reliable way to diagnose these inflammatory lesions and they require different treatment (fulguration and/or triamcinolone injection). 1, 2 Early cystoscopic diagnosis is recommended for suspected Hunner lesions without requiring patients to fail other treatments first. 1
Additional indications for cystoscopy include:
- Diagnostic uncertainty: When the diagnosis is in doubt 1
- Excluding mimics: Suspicion of bladder cancer, bladder stones, or intravesical foreign bodies 1, 2
- Hematuria workup: Patients requiring proper hematuria evaluation 1
- Unclear prior findings: When patients report abnormal previous cystoscopy findings that are unclear to the current clinician 1
Important Caveats
The Panel explicitly states that performing cystoscopy for every IC/BPS patient is not advisable since the benefits/risks ratio is unfavorable, particularly for younger patients who have much lower prevalence of Hunner lesions. 1
There are no agreed-upon cystoscopic findings diagnostic for IC/BPS except for Hunner lesions. 1 Glomerulations (pinpoint petechial hemorrhages) may be seen but are not specific—they occur in other conditions like chronic pelvic pain or endometriosis, and can even be present in asymptomatic patients undergoing cystoscopy for other reasons. 1
Urodynamics Are Also Not Routinely Required
Urodynamics are not recommended for routine clinical use to establish an IC/BPS diagnosis. 1 They may be useful only when suspecting outlet obstruction, poor detrusor contractility, or other conditions explaining refractoriness to behavioral or medical therapies. 1, 2
Baseline Documentation Requirements
Before initiating treatment, establish baseline measurements using validated tools such as the Genitourinary Pain Index (GUPI), Interstitial Cystitis Symptom Index (ICSI), or Visual Analog Scale (VAS), along with at least a one-day voiding log. 1, 2 Very low voiding frequencies or high voided volumes should prompt a search for an alternate diagnosis. 1