What is Interstitial Cystitis (IC)/Painful Bladder Syndrome (PBS) in women's health?

What is Interstitial Cystitis/Painful Bladder Syndrome in Women's Health

IC/PBS is a chronic bladder condition defined as an unpleasant sensation (pain, pressure, or discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms lasting more than six weeks, in the absence of infection or other identifiable causes. 1, 2

Core Definition and Diagnostic Criteria

• The American Urological Association uses a symptom-based definition requiring at least six weeks of symptoms, which allows earlier treatment initiation compared to older definitions requiring longer durations 2
• This is fundamentally a diagnosis of exclusion—you must rule out urinary tract infections, bladder carcinoma, and other identifiable pathology before making this diagnosis 3, 4
• The condition predominantly affects women of middle age, with prevalence estimated at 45 per 100,000 women compared to only 8 per 100,000 men 5

Cardinal Symptoms to Identify

Pain characteristics:

• Pain is the hallmark symptom, typically perceived in the suprapubic region but may extend throughout the pelvis 2
• Critical pitfall: Many patients describe "pressure" rather than "pain"—you must use broad descriptors when evaluating patients, as dismissing those who don't use the word "pain" leads to missed diagnoses 2
• Pain characteristically worsens with bladder filling and improves with urination 2, 6
• Pain may be exacerbated by specific foods or drinks 2

Urinary symptoms:

• Urinary frequency occurs in 92% of patients but is not specific to IC/PBS 2
• Urinary urgency is present in 84% of patients, but differs qualitatively from overactive bladder 2
• Key distinction: IC/PBS patients void to avoid or relieve pain, whereas overactive bladder patients void to avoid incontinence 2, 6
• IC/PBS patients experience a more constant urge to void rather than the sudden compelling urge of overactive bladder 2, 6
• Nocturia is common 7

Diagnostic Workup Algorithm

Mandatory initial testing:

• Obtain urinalysis and urine culture to rule out infection—this is non-negotiable 2
• Perform careful history documenting pain characteristics, voiding patterns, and symptom duration 2
• Physical examination should assess for pelvic tenderness and exclude other pelvic pathology 4

When to perform cystoscopy:

• Perform cystoscopy only in patients for whom Hunner lesions are suspected, as this is the only reliable way to diagnose their presence 2
• Cystoscopy is not required for diagnosis in all patients 2

What NOT to do:

• Do not perform urodynamics for routine clinical use—there are no agreed-upon urodynamic criteria diagnostic for IC/PBS 2
• Never treat with antibiotics when no infection is documented, as this leads to antibiotic resistance and disruption of protective flora 2

Pathophysiology Relevant to Clinical Understanding

• The etiology is likely multifactorial, involving defective urothelium, neurogenic upregulation, and mast cell activation 4
• The urothelium functions as an active sensor releasing signaling molecules when stretched, with increased prostaglandin release during distension that sensitizes sensory nerves and amplifies pain 6
• In IC/PBS, this represents an exaggerated version of normal filling sensation that becomes pathologic 6

Common Diagnostic Pitfalls

• Misdiagnosis due to symptom overlap: IC/PBS symptoms overlap significantly with endometriosis, recurrent UTI, chronic pelvic pain, overactive bladder, and vulvodynia 4
• Delayed diagnosis: The condition is often misdiagnosed or diagnosis is delayed due to the wide spectrum of symptoms and physical exam findings 2
• Using research definitions in clinical practice: Research or clinical trial definitions can lead to misdiagnosis or delays in treatment—use the clinical definition requiring only six weeks of symptoms 2
• Dismissing patients who describe "pressure": This descriptor is common and legitimate in IC/PBS 2

Treatment Framework

Treatment hierarchy (most to least conservative):

• First-line: Supportive therapies including behavioral modifications, physical therapy, and patient education 3, 4
• Second-line oral medications: amitriptyline, cimetidine, hydroxyzine, pentosan polysulfate (PPS) 1
• Second-line intravesical treatments: DMSO, heparin, lidocaine 1
• Pain management should be considered throughout therapy with the goal of maximizing function and minimizing pain 1
• Manual physical therapy techniques are appropriate 1
• Surgical treatment is appropriate only after other treatment options have been found ineffective 1

Evidence for intravesical treatments:

• BCG and oxybutynin show the most promise and are reasonably well-tolerated 8
• Resiniferatoxin showed no evidence of effect and caused pain that reduced treatment compliance 8
• Evidence for DMSO is very limited with no apparent differences from placebo in available data 8

Special Considerations in Women's Health

• IC/PBS frequently coexists with endometriosis in women with chronic pelvic pain, sometimes referred to as the "Evil Twins" syndrome 1
• Cystoscopic findings consistent with IC may be present in asymptomatic women undergoing tubal ligation 1
• The condition significantly decreases quality of life and requires frequent follow-up 3, 4