What is the official way to diagnose interstitial cystitis?

Official Diagnosis of Interstitial Cystitis/Bladder Pain Syndrome

The official diagnosis of interstitial cystitis (IC/BPS) is primarily clinical, requiring bladder/pelvic pain or discomfort associated with urinary frequency and urgency for at least 6 weeks, with negative urine cultures and exclusion of other identifiable causes—cystoscopy is NOT routinely required except when Hunner lesions are suspected. 1, 2

Required Clinical Criteria

The American Urological Association establishes that diagnosis requires three essential components:

• Symptom duration of at least 6 weeks with documented negative urine cultures 1, 2
• Bladder/pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder 2
• Associated lower urinary tract symptoms including urinary frequency, nocturia, and urgent desire to void 2

Mandatory Diagnostic Workup

History and Physical Examination

Document the following specific elements:

• Number of voids per day and sensation of constant urge to void 1
• Location, character, and severity of pain, pressure, or discomfort 1
• Dyspareunia, dysuria, ejaculatory pain in men, and relationship of pain to menstruation in women 1
• Brief neurological exam to rule out occult neurologic problems 1, 2
• Evaluation for incomplete bladder emptying to rule out occult retention 1, 2

Required Laboratory Tests

• Urinalysis and urine culture are mandatory—even with negative urinalysis, culture may be needed to detect lower bacterial levels not identifiable on dipstick 1, 2
• Urine cytology if the patient has smoking history or unevaluated microhematuria 2
• Proper hematuria workup in patients with un-evaluated hematuria or tobacco exposure given high bladder cancer risk 1

Baseline Symptom Documentation

• Use validated tools such as the Genitourinary Pain Index (GUPI), Interstitial Cystitis Symptom Index (ICSI), Visual Analog Scale (VAS), and a one-day voiding log 2

When Cystoscopy IS Indicated

Cystoscopy is NOT necessary for routine diagnosis but should be performed in specific situations: 1, 2

• When Hunner lesions are suspected—this is the only consistent cystoscopic finding diagnostic for IC/BPS and significantly changes treatment approach 1, 2
• When diagnosis is in doubt or to exclude bladder cancer, bladder stones, or intravesical foreign bodies 1, 2
• In patients with smoking history or other risk factors for bladder malignancy 1

The 2022 AUA guideline explicitly states there are no agreed-upon cystoscopic findings diagnostic for IC/BPS except Hunner lesions 1. Most patients can tolerate office flexible cystoscopy without hydrodistention, though some prefer general anesthesia 1.

When Urodynamics Are NOT Recommended

• Urodynamics are NOT recommended for routine diagnosis as there are no agreed-upon urodynamic criteria diagnostic for IC/BPS 1, 2
• Consider urodynamics only when suspecting outlet obstruction in either sex, poor detrusor contractility, or other conditions explaining refractoriness to behavioral or medical therapies 1, 2

Tests That Should NOT Be Performed

• The potassium sensitivity test should NOT be performed as it lacks specificity and sensitivity to change clinical decision-making 2

Essential Exclusions

The diagnosis requires ruling out:

• Urinary tract infections (documented negative cultures) 1, 2
• Bladder cancer, bladder stones, intravesical foreign bodies 1, 2
• Endometriosis and chronic pelvic pain from other causes 2
• Overactive bladder without pain 2

Common Pitfalls to Avoid

The evolution from older diagnostic paradigms is critical to understand. Earlier criteria required cystoscopy and hydrodistention for all patients, but current evidence-based guidelines recognize this is unnecessary for uncomplicated presentations 1, 2. The key pitfall is over-relying on invasive testing when the clinical diagnosis can be established through history, examination, and basic laboratory work alone. Only perform cystoscopy when Hunner lesions are suspected or other pathology needs exclusion 1, 2.