What is the initial workup for a patient presenting with bladder pain?

Initial Workup for Bladder Pain

The initial workup for bladder pain requires a careful history, physical examination, urinalysis, and urine culture as the foundation, with cystoscopy reserved only for specific indications rather than routine use. 1, 2

Essential History and Physical Examination

Document the following specific elements:

• Pain characteristics: Location, quality, relationship to bladder filling/emptying, duration (must be ≥6 weeks for IC/BPS diagnosis), and severity using validated tools (GUPI, ICSI, or VAS) 1, 2, 3
• Urinary symptoms: Frequency, urgency, nocturia, and dysuria—obtain at minimum a one-day voiding log to establish voiding patterns 1, 2
• Associated symptoms: Dyspareunia, ejaculatory pain in men, relationship to menstruation in women 1
• Risk factors: Smoking history (critical for bladder cancer risk assessment) and sexual exposure history 1, 2
• Brief neurological examination: Rule out occult neurologic problems 1, 2
• Evaluate for incomplete bladder emptying: Rule out occult retention 1, 2
• Bimanual pelvic examination: Assess for pelvic floor tenderness and masses 1

Mandatory Laboratory Testing

All patients require:

• Urinalysis and urine culture: Even with negative urinalysis, culture may detect clinically significant bacteria not identifiable on dipstick 1, 2
• Urine cytology: Mandatory if smoking history present OR unevaluated microhematuria, given bladder cancer risk 1, 2

Do NOT perform:

• Potassium sensitivity test: Lacks specificity and sensitivity to change clinical decision-making 1, 2

Cystoscopy: When to Perform

Cystoscopy is NOT necessary for uncomplicated presentations. 1

Perform cystoscopy only when:

• Hunner lesions are suspected: This is the only consistent cystoscopic finding diagnostic for IC/BPS and requires early identification for directed treatment 1, 2
• Diagnosis is in doubt: To exclude other pathology 1
• Hematuria workup required: Especially in smokers or those with unexplained positive cytology 1
• High-risk features present: Solid/sessile tumor appearance, high-grade disease suspected, or upper tract obstruction 1

Important caveat: Glomerulations seen on cystoscopy are NOT diagnostic of IC/BPS—they occur in other conditions and even asymptomatic patients 1

Upper Tract Imaging

Obtain upper tract imaging with:

• CT urography (preferred if patient can receive IV contrast) 1
• Alternatives: Renal ultrasound with retrograde pyelogram, MR urography, or ureteroscopy 1

Timing: Can be deferred until after initial evaluation for purely papillary-appearing lesions, but obtain before TURBT if solid/sessile tumor or muscle invasion suspected 1

Urodynamics: Generally NOT Recommended

Urodynamics are NOT recommended for routine diagnosis. 1, 2

Consider urodynamics only when:

• Suspicion of outlet obstruction (either sex) 1, 2
• Possibility of poor detrusor contractility 1, 2
• Patient refractory to behavioral/medical therapies and alternative diagnosis suspected 1, 2

Critical Exclusionary Diagnoses to Rule Out

The diagnosis of IC/BPS requires excluding:

• Active urinary tract infection (via culture) 2, 3
• Bladder cancer (via cytology, cystoscopy if indicated) 1, 2
• Bladder stones 2
• Endometriosis 1, 2
• Chronic pelvic pain from other causes 2
• Overactive bladder without pain 2

Common Pitfalls to Avoid

• Do NOT delay urine culture before starting empirical antibiotics if infection suspected 4
• Do NOT assume benign cause without excluding malignancy in patients >40 years with new urinary symptoms, especially smokers 1, 4
• Do NOT perform cystoscopy on every patient—the risk/benefit ratio is unfavorable for younger patients with low Hunner lesion prevalence 1
• Do NOT rely on cystoscopic glomerulations as diagnostic for IC/BPS 1

Algorithmic Summary

1. History + Physical (including neurologic exam, voiding log, validated pain scales) 1, 2
2. Urinalysis + Culture (mandatory for all) 1, 2
3. Cytology (if smoking history or hematuria) 1, 2
4. Upper tract imaging (CT urography preferred) 1
5. Cystoscopy (only if Hunner lesions suspected, diagnosis uncertain, or cancer risk) 1, 2
6. Urodynamics (only if refractory to treatment or alternative diagnosis suspected) 1, 2