What is the next step in evaluating a female patient of reproductive age with pelvic pain, difficulty urinating (dysuria), and pain when holding urine, who has a negative Urinalysis (UA) for Urinary Tract Infection (UTI)?

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) Evaluation

This patient most likely has Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), and the next step is to establish baseline symptom severity using a voiding diary and pain assessment, followed by consideration of cystoscopy if Hunner lesions are suspected. 1

Clinical Diagnosis

The presentation of pelvic pain, difficulty urinating (dysuria), and pain with bladder filling in the setting of a negative urinalysis for UTI is classic for IC/BPS. 1, 2 This diagnosis requires:

• Symptoms present for at least 6 weeks 1, 2
• Documented negative urine cultures (not just negative urinalysis) 1
• Pain, pressure, or discomfort perceived to be related to the bladder 1, 2
• Associated lower urinary tract symptoms (frequency, urgency) 1, 2

Critical Distinction from UTI

While this patient has dysuria, several features distinguish IC/BPS from UTI:

• Pain that worsens with bladder filling and improves with urination is characteristic of IC/BPS 2
• Many IC/BPS patients describe "pressure" rather than classic dysuria 2
• The negative UA makes bacterial cystitis unlikely, though you must obtain a formal urine culture to exclude low-level bacteriuria not detected on dipstick 1

Immediate Next Steps

1. Confirm Negative Urine Culture

Order a formal urine culture even with negative urinalysis to detect lower bacterial levels (clinically significant but not identifiable on dipstick). 1 This is mandatory before diagnosing IC/BPS.

2. Establish Baseline Measurements

Document the following to measure future treatment response: 1

• At minimum, a 1-day voiding diary documenting frequency and voided volumes 1
• Pain severity and location using a standardized scale 1
• Number of voids per day 1
• Sensation of constant urge to void 1
• Relationship of pain to menstruation 1

3. Focused Physical Examination

Perform: 1

• Brief neurological exam to rule out occult neurologic problems 1
• Evaluation for incomplete bladder emptying (post-void residual) to rule out occult retention 1
• Pelvic examination to assess for tenderness, masses, or pelvic organ prolapse 1

4. Consider Cystoscopy Selectively

Cystoscopy should be performed if Hunner lesions are suspected. 1 Hunner lesions are the only consistent cystoscopic finding diagnostic for IC/BPS, and patients with these lesions respond well to specific treatments (fulguration or injection). 1 Early cystoscopy is recommended in suspected cases without requiring failure of other treatments first. 1

However, cystoscopy is NOT routinely required for IC/BPS diagnosis in most patients. 1 There are no other agreed-upon cystoscopic findings diagnostic for IC/BPS. 1

Differential Diagnosis to Exclude

Before finalizing an IC/BPS diagnosis, rule out: 1, 3

Urologic Mimics

• Overactive bladder (urgency to avoid incontinence, not pain) 2, 3
• Urethral diverticulum 3
• Periurethral masses (Skene gland cyst/abscess) 3
• Bladder stones or foreign bodies (if suspected, cystoscopy indicated) 1

Gynecologic Causes

• Endometriosis (cyclic pain pattern) 1
• Pelvic inflammatory disease (fever, cervical motion tenderness) 1
• Ovarian pathology 1

Other Considerations

• Sexually transmitted infections (especially if vaginal discharge present) 4
• Mycoplasma genitalium (if persistent urethritis with negative initial testing) 4

What NOT to Do

Do not treat with antibiotics when no infection is documented. 2 This leads to antibiotic resistance and disruption of protective vaginal flora. 2

Do not perform urodynamics routinely. 1 There are no agreed-upon urodynamic criteria for IC/BPS diagnosis, and urodynamics should only be considered if suspecting outlet obstruction, poor detrusor contractility, or when patients are refractory to treatment. 1

Do not delay diagnosis by requiring 6 months of symptoms. 1 The 6-week threshold allows earlier treatment initiation. 1, 2

Treatment Initiation

Once IC/BPS is confirmed, initial treatment should be non-surgical and individualized based on patient phenotype. 1 The 2022 AUA guideline no longer uses tiered treatment lines but categorizes options as behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures, and surgery. 1 Concurrent multi-modal therapies may be offered. 1