What is the approach to evaluating a patient with bladder pain, considering their past medical history, including previous urological conditions, surgeries, or infections?

Workup of Bladder Pain

Begin evaluation by confirming the presence of bladder-related pain, pressure, or discomfort lasting more than 6 weeks, accompanied by lower urinary tract symptoms, and systematically exclude infection and other identifiable causes through targeted history, physical examination, urinalysis with culture, and selective use of cystoscopy. 1, 2

Initial Clinical Assessment

History Taking

• Document the specific character of pain (pain, pressure, or discomfort) and its perceived relationship to the bladder 1, 2
• Confirm symptom duration of at least 6 weeks before considering interstitial cystitis/bladder pain syndrome (IC/BPS) 1, 2
• Assess for pain patterns: worsening with bladder filling, improvement with urination, exacerbation with specific foods or drinks 1
• Document location of pain: suprapubic, urethral, vulvar, vaginal, rectal, lower abdominal, or back pain 1
• Note that many patients describe "pressure" rather than "pain" and may actually deny pain when directly asked 1
• Record associated urinary symptoms: frequency (present in 92% of IC/BPS patients), urgency, and nocturia 1
• Obtain past medical history focusing on previous urological conditions, surgeries, infections, and current medications 1, 3
• In women, evaluate for coexisting conditions such as endometriosis, as these frequently overlap with IC/BPS 1
• In men, assess for symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), which may present similarly 1

Quantitative Symptom Assessment

• Use validated questionnaires to document baseline symptoms: Interstitial Cystitis Symptom Index (ICSI), Genitourinary Pain Index (GUPI), or Visual Analog Scale (VAS) 2, 4
• Complete a one-day voiding log to document frequency and voided volumes 2

Physical Examination

• Perform digital rectal examination (DRE) to assess prostate size, consistency, and tenderness in men 1, 3
• Palpate the suprapubic area to rule out bladder distention 1, 3
• Conduct a brief neurological examination focused on the perineum and lower limbs to rule out occult neurologic problems 2
• Assess pelvic floor muscle tone and tenderness, as pelvic floor dysfunction commonly coexists 2

Mandatory Laboratory Testing

Urinalysis and Culture

• Perform urinalysis using dipstick to check for hematuria, proteinuria, pyuria, glucosuria, ketonuria, and positive nitrite 1, 3, 2
• Obtain urine culture to document sterile urine, which is required for IC/BPS diagnosis 1, 2
• If dipstick is abnormal, examine urinary sediment and perform culture 1

Urine Cytology

• Order urine cytology if the patient has a smoking history or unevaluated microhematuria to exclude bladder cancer 2

Post-Void Residual (PVR)

• Measure PVR volume via bladder scanning or catheterization to evaluate for incomplete bladder emptying and rule out occult retention 3, 2

Selective Diagnostic Procedures

Cystoscopy Indications

Cystoscopy is NOT necessary for routine diagnosis but should be performed in specific circumstances 2:

• When Hunner lesions are suspected (these require specific treatment with fulguration or triamcinolone injection) 2, 4
• When diagnosis is in doubt or symptoms are atypical 2
• To exclude bladder cancer, bladder stones, or intravesical foreign bodies 2
• In patients with risk factors for malignancy (smoking history, age >40, microhematuria) 1, 2

Tests to AVOID

• Do NOT perform the potassium sensitivity test, as it lacks specificity and sensitivity to change clinical decision-making 2

Urodynamics

• NOT recommended for routine diagnosis 2
• Consider only when there is suspicion of outlet obstruction, poor detrusor contractility, or other conditions that could explain refractoriness to behavioral or medical therapies 2

Differential Diagnosis to Exclude

Mandatory Exclusions

Before diagnosing IC/BPS, systematically rule out 1, 2:

• Urinary tract infections (via culture)
• Bladder cancer (via cytology and/or cystoscopy in high-risk patients)
• Bladder stones (via imaging or cystoscopy)
• Intravesical foreign bodies
• Endometriosis (in women with pelvic pain)
• Chronic pelvic pain from other causes
• Overactive bladder without pain (distinguished by absence of pain component)

In Men Specifically

• Evaluate for chronic prostatitis/CPPS, which may be indistinguishable from IC/BPS 1
• Consider benign prostatic hyperplasia if obstructive symptoms predominate 1

Imaging Considerations

When to Image

• Upper tract imaging (CT urogram, renal ultrasound with retrograde pyelogram, or MRI urogram) if hematuria is present or upper tract pathology is suspected 1
• CT or MRI of abdomen and pelvis if cystoscopic appearance suggests muscle invasion or high-grade disease 1

Common Pitfalls to Avoid

• Do not delay diagnosis by requiring symptom duration longer than 6 weeks; definitions used in research trials should be avoided in clinical practice 1
• Do not rely on urinary frequency alone for diagnosis, as it does not distinguish IC/BPS from other lower urinary tract disorders 1
• Do not dismiss patients who deny "pain" but describe "pressure" or "discomfort" 1
• Do not perform invasive testing (urodynamics, cystoscopy) when not indicated by clinical presentation 2
• Do not use a single PVR measurement as definitive, since values can fluctuate 3

Diagnostic Confirmation

IC/BPS is diagnosed when all three criteria are met 1, 2:

1. Bladder/pelvic pain, pressure, or discomfort perceived to be bladder-related
2. At least one lower urinary tract symptom (frequency, urgency, nocturia) present for >6 weeks
3. Absence of infection or other identifiable causes on workup