What is the diagnostic approach and treatment for a middle-aged woman with a suspected Hunner lesion, presenting with pelvic pain, urinary frequency, and urgency?

Hunner Lesion Diagnosis and Treatment

Cystoscopy is the only reliable method to diagnose Hunner lesions, and when identified, these lesions should be treated immediately with fulguration (electrocautery) and/or triamcinolone injection, as this represents one of the few IC/BPS therapies that provides months of symptom improvement from a single procedure. 1, 2

Diagnostic Approach

When to Suspect Hunner Lesions

• Consider Hunner lesions in middle-aged women presenting with the triad of pelvic pain, urinary frequency, and urgency that has persisted for at least 6 weeks with negative urine cultures 3
• Hunner lesions are more common in older IC/BPS patients; younger patients have much lower prevalence, making routine cystoscopy in all IC/BPS patients inadvisable 2
• Patients with Hunner lesions typically have more severe disease, characterized by lower bladder capacity (mean 531 cc vs 845 cc without lesions) and earlier first sensation to void (mean 35 cc vs 87 cc) 4

Cystoscopic Technique

• Flexible cystoscopy with local anesthesia in the office can identify most Hunner lesions without requiring hydrodistention or general anesthesia 2, 5
• For comprehensive evaluation, perform cystoscopy with hydrodistention and redistention, as mild distention makes Hunner lesions easier to identify when cracking and mucosal bleeding become evident 1
• Hunner lesions appear as areas of erythema, often with a central coagulum, inflamed or non-inflamed appearance, groupings of lesions, or a "red waterfall" bleeding pattern 5
• The lesion typically reproduces the patient's pain when touched by the cystoscope 6

Critical Diagnostic Pitfall

• Do not confuse glomerulations with Hunner lesions—glomerulations are non-specific findings that can occur in asymptomatic patients and other conditions 2
• However, 100% of patients with Hunner lesions will have glomerulations after hydrodistension, with moderate to severe glomerulations strongly associated with Hunner lesion presence (47% moderate, 35% severe) 4
• Failure to perform adequate bladder distention may result in missed Hunner lesions 2

Additional Diagnostic Considerations

• Perform random bladder biopsies during cystoscopy to exclude bladder carcinoma, which can mimic IC/BPS clinically (3 out of 55 clinically suspected IC/BPS cases were actually bladder cancer in one series) 7
• Pathology of Hunner lesions typically shows inflammatory cystitis, often with epithelial denudation 6

Treatment Algorithm

First-Line Treatment: Immediate Endoscopic Intervention

When Hunner lesions are identified, proceed directly to treatment without requiring patients to fail other therapies first 2

Treatment Options (all equally effective):

1. Fulguration with electrocautery alone 1
2. Triamcinolone injection alone 1
3. Combination: triamcinolone injection after electrocautery 1

• A prospective randomized trial showed no difference in recurrence-free time between transurethral resection (TUR) and transurethral coagulation (TUC), with median recurrence-free periods of 12.2 months vs 11.5 months respectively 8
• TUC has lower complication rates (3.4% bladder injury) compared to TUR (7.9% bladder injury), so surgeons should choose the method with which they are most comfortable 8

Expected Outcomes

• Mean symptom improvement of 76%, with 100% improvement reported in some patients 6
• Significant improvements in daytime frequency (50% reduction), nocturia (49% reduction), pain (68% reduction), and symptom scores (48% reduction) at 3 months post-treatment 7
• Hydrodistension alone (without lesion treatment) shows declining efficacy: 54% effective at 3 months, 25% at 6 months, and only 13.5% at 12 months 7

Managing Recurrence

• Counsel patients that symptoms can recur and periodic retreatment is likely necessary as response decreases over time 1
• Recurrence of symptoms should prompt repeat cystoscopy to identify recurrent lesions 6
• All patients who had symptomatic recurrence in one series improved after repeat ablation 6
• Multiple electrocauterizations do not significantly diminish bladder capacity 1

Common Clinical Pitfalls

Avoid These Errors:

• Delaying cystoscopy by requiring patients to fail multiple treatments first—this delays definitive diagnosis and effective treatment 2
• Performing cystoscopy on every young IC/BPS patient when Hunner lesions are not suspected (unfavorable benefit/risk ratio) 2
• Mistaking glomerulations for Hunner lesions or vice versa 2
• Failing to perform random biopsies to exclude malignancy 7
• Not counseling patients about the likelihood of needing repeat treatments 1