Symptoms of Hunner Lesions
Hunner lesions present with severe bladder-centric symptoms including marked urinary frequency, urgency, nocturia, and bladder/pelvic pain that is distinctly worse than non-Hunner lesion interstitial cystitis/bladder pain syndrome. 1
Primary Clinical Manifestations
Urinary Symptoms:
- Severe urinary frequency - patients with Hunner lesions have significantly greater frequency compared to non-Hunner IC/BPS patients 2
- Marked nocturia - substantially more pronounced nighttime voiding compared to other IC/BPS phenotypes 2
- Intense urgency - strong, often painful urge to void that is bladder-focused rather than generalized 1
- Reduced bladder capacity - anatomic bladder capacity is diminished due to fibrosis and chronic inflammation 1
Pain Characteristics:
- Bladder/pelvic pain or pressure perceived to be related to the urinary bladder 1, 3
- Bladder-centric pain - the discomfort is distinctly focused on the bladder rather than diffuse pelvic pain 4, 2
- Pain reproduced on cystoscopic contact - touching the lesion with the cystoscope reproduces the patient's characteristic pain 5
- Dyspareunia may be present in women 1
Patient Demographics and Presentation
- Older age of onset - Hunner lesions are significantly more common in patients 50 years or older (14.9% prevalence) compared to those under 50 (7.8% prevalence) 2
- Chronic symptoms - symptoms must be present for at least 6 weeks with documented negative urine cultures 1, 3
- Higher symptom severity scores - patients with Hunner lesions have significantly higher Interstitial Cystitis Symptom Index (ICSI) scores compared to non-Hunner IC/BPS 2
Distinguishing Features from Non-Hunner IC/BPS
Critical caveat: Clinical phenotyping alone cannot reliably differentiate Hunner lesion IC/BPS from non-Hunner bladder pain syndrome. 2 While patients with Hunner lesions have worse bladder-centric symptoms, there is no distinct clinical phenotype that eliminates the need for cystoscopy. 2 The prevalence of associated conditions like irritable bowel syndrome and the number of UPOINT phenotype domains do not differ between Hunner and non-Hunner subtypes. 2
Cystoscopic Findings (Diagnostic Gold Standard)
Visual appearance during cystoscopy:
- Classic lesions with or without a central coagulum 6
- Inflamed or non-inflamed lesions with variable appearance 6
- Circumscribed inflammatory ulcerations in the bladder wall 7
- Areas of erythema that may appear as single or grouped lesions 6, 5
- Red waterfall bleeding appearance in some cases 6
- Cracking and mucosal bleeding that becomes evident with mild bladder distention 1
Most Hunner lesions can be identified during office flexible cystoscopy with local anesthesia without requiring hydrodistention or general anesthesia. 8, 6
Histopathologic Correlation
- Subepithelial chronic inflammatory changes with epithelial denudation on biopsy 4, 5
- Inflammatory cystitis is consistently found in patients who respond to treatment 5
Clinical Importance
The presence of Hunner lesions fundamentally changes treatment approach and prognosis. 8, 4 Treatment with fulguration and/or triamcinolone injection results in 76% mean improvement with some patients achieving 100% improvement, representing one of the few IC/BPS therapies with durable benefit (measured in months) from a single procedure. 8, 5 However, symptoms can recur and periodic retreatment is typically necessary. 1