What is the best course of treatment for a patient with persistent dysuria and discomfort when urinating, despite normal urine results, and a history of cystitis and bilateral micronephrolithiasis?

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

This patient most likely has interstitial cystitis/bladder pain syndrome (IC/BPS), not overactive bladder, and should be started on multimodal therapy including behavioral modifications, oral pentosan polysulfate or amitriptyline, and consideration for bladder instillations, while discontinuing the tamsulosin which is ineffective for this condition. 1

Why This Is IC/BPS, Not Overactive Bladder

The clinical presentation is classic for IC/BPS rather than overactive bladder:

• Persistent dysuria and discomfort despite normalized urine studies - this is the hallmark of IC/BPS, where bladder/pelvic pain and pressure/discomfort persist even after infection is cleared 1
• Failed antimuscarinic therapy (solifenacin) - if this were true overactive bladder, the patient should have responded to solifenacin 1
• Failed alpha-blocker therapy (tamsulosin) - tamsulosin is indicated for bladder outlet obstruction in males, not for female dysuria syndromes 2, 3
• Symptoms present for weeks to months - IC/BPS requires symptoms present for at least 6 weeks 1

Immediate Management Steps

Stop Ineffective Medications

• Discontinue tamsulosin immediately - this medication has no role in female lower urinary tract symptoms and provides no benefit for IC/BPS 2, 3
• Discontinue solifenacin - the failure to respond confirms this is not simple overactive bladder 1

Confirm the Diagnosis

• Obtain a detailed pain history - document the exact location, character, and severity of pain/pressure/discomfort, relationship to bladder filling and voiding, and any dyspareunia 1
• Establish baseline symptom severity - use a validated questionnaire to quantify symptoms and their impact on quality of life 1
• Obtain a frequency-volume chart for at least 1 day - document the number of voids per day and sensation of constant urge to void 1
• Consider cystoscopy to evaluate for Hunner lesions - if Hunner lesions are suspected based on severity of symptoms or refractory nature, cystoscopy should be performed as these patients respond well to specific treatment 1

First-Line Treatment Approach

The 2022 AUA guideline emphasizes that IC/BPS treatment must be individualized, but initial therapy should be nonsurgical and may include concurrent multimodal approaches 1:

Behavioral and Non-Pharmacologic Interventions

• Implement bladder training and timed voiding - establish a regular voiding schedule to reduce urgency 1, 3
• Provide dietary counseling - identify and eliminate bladder irritants including caffeine, alcohol, acidic foods, and artificial sweeteners 1
• Recommend pelvic floor physical therapy - particularly if pelvic floor muscle tenderness is present on examination 1, 3

Oral Pharmacologic Therapy

• Start pentosan polysulfate 100 mg three times daily - this is a first-line oral medication for IC/BPS, though patients should be counseled about the recent FDA warning regarding potential retinal toxicity with long-term use 1
• Alternative: amitriptyline 25-75 mg at bedtime - this tricyclic antidepressant reduces pain and urgency in IC/BPS through central and peripheral mechanisms 1
• Consider hydroxyzine 25-50 mg at bedtime - particularly if the patient has allergic or atopic features 1

Bladder Instillations

• Consider intravesical therapy if oral medications are insufficient - options include dimethyl sulfoxide (DMSO), heparin, or lidocaine instillations 1, 4

Common Pitfalls to Avoid

• Do not continue treating as recurrent UTI - the normalized urine studies with persistent symptoms confirm this is not infectious cystitis 1
• Do not assume this is overactive bladder based solely on urgency and frequency - the presence of pain/discomfort distinguishes IC/BPS from overactive bladder 1, 5
• Do not use fluoroquinolones or other antibiotics - there is no infection present and antibiotics will not help IC/BPS 1
• Do not delay multimodal therapy - concurrent treatments are more effective than sequential monotherapy 1

When to Consider Advanced Interventions

If symptoms remain refractory after 6-8 weeks of conservative management:

• Cystoscopy with hydrodistention - both diagnostic and potentially therapeutic 1
• Fulguration or injection of Hunner lesions - if present, these respond well to direct treatment 1
• Intravesical botulinum toxin - for severe refractory cases 1, 5
• Neuromodulation (sacral or tibial nerve stimulation) - for patients who fail all other therapies 1, 5

Follow-Up Timeline

• Reassess at 6-8 weeks - evaluate symptom improvement using the same baseline questionnaire 1
• Monitor for adverse effects - particularly dry mouth from amitriptyline or visual changes from pentosan polysulfate 1
• Consider referral to a urologist with IC/BPS expertise - if symptoms do not improve with initial multimodal therapy 1