Management of Interstitial Cystitis with Hematuria
Hematuria in interstitial cystitis (IC/BPS) patients requires a complete urologic evaluation to exclude malignancy and other serious pathology, even though the hematuria itself is often benign and related to the IC/BPS disease process. 1, 2
Initial Diagnostic Approach
Confirm true hematuria by obtaining microscopic urinalysis showing ≥3 RBCs per high-power field on properly collected specimens, as dipstick alone has limited specificity. 2, 3
Perform a proper hematuria workup as mandated by the AUA guidelines, which includes: 1
- Urine culture to exclude infection (even if urinalysis is negative, as lower bacterial counts may be clinically significant)
- Urine cytology in patients with risk factors for transitional cell carcinoma
- Documentation of smoking history (quantified as pack-years), age, and occupational exposures to chemicals/dyes 2, 3
Risk stratify the patient using the 2025 AUA/SUFU criteria based on: 3, 4
- Degree of hematuria (3-10 RBC/HPF = low risk; 11-25 RBC/HPF = intermediate; >25 RBC/HPF = high risk)
- Age (men ≥40 years and women ≥60 years have elevated risk)
- Smoking history (>30 pack-years = high risk)
- History of gross hematuria (automatically high risk)
Mandatory Urologic Evaluation
Cystoscopy is essential for two critical reasons in IC/BPS patients with hematuria: 1, 2
- To identify Hunner lesions, which are the only consistent cystoscopic finding diagnostic for IC/BPS and require specific treatment
- To exclude bladder cancer, stones, and other intravesical pathology that can mimic IC/BPS
Upper tract imaging with CT urography (or MR urography if CT contraindicated) must be performed to evaluate for renal and ureteral pathology, as hematuria evaluation cannot be considered complete without imaging. 2, 3
Clinical Context: Hematuria Prevalence in IC/BPS
Research demonstrates that hematuria occurs in up to 41% of IC/BPS patients during follow-up, which is higher than previously recognized. 5 However, the evaluation rarely reveals life-threatening conditions—in one study of 56 IC/BPS patients with hematuria, only 14% had positive findings (simple renal cysts, stones, reflux nephropathy), and no malignancies were detected. 5
Critical caveat: Despite the generally benign nature of hematuria in IC/BPS, this does not justify skipping the complete evaluation, particularly in patients with risk factors for malignancy. 1, 2
Treatment Considerations After Negative Workup
If Hunner lesions are identified during cystoscopy, these should be treated directly (fulguration or resection), as most patients with Hunner lesions respond to treatment without requiring them to fail other therapies first. 1
For IC/BPS without Hunner lesions, initial treatment should be nonsurgical and may include: 1
- Behavioral modifications
- Oral medications
- Intravesical instillations (such as RIMSO-50/dimethyl sulfoxide administered every 2 weeks until maximum symptomatic relief, then at increased intervals) 6
Concurrent, multimodal therapies may be offered as IC/BPS is a heterogeneous syndrome requiring individualized approaches. 1
Follow-Up Protocol
If hematuria persists after negative initial evaluation, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 2, 4
Consider nephrology referral if hematuria persists with development of: 2, 4
- Hypertension
- Proteinuria
- Evidence of glomerular bleeding (>80% dysmorphic RBCs, red cell casts)
Key Pitfalls to Avoid
Never assume anticoagulation or antiplatelet therapy explains the hematuria—these medications may unmask underlying pathology but do not cause hematuria themselves, and evaluation should proceed regardless. 2, 4
Do not skip cystoscopy even in younger patients or those with known IC/BPS, as bladder cancer can coexist and the only way to definitively identify Hunner lesions is through direct visualization. 1, 2
Tobacco exposure mandates complete evaluation given the high risk of bladder cancer in smokers, regardless of IC/BPS diagnosis. 1, 3