In a 66‑year‑old woman with suprapubic/bladder tenderness, urinary frequency, urgency, cloudy urine, two negative urinalyses, and a markedly distended bladder on ultrasound with a normal post‑void residual volume (~26 mL), what is the appropriate next diagnostic step and management?

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Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS): Diagnosis and Management

Direct Answer

This 66-year-old woman with suprapubic pain, urgency, frequency, cloudy urine, two negative urinalyses, and a distended bladder with normal post-void residual most likely has interstitial cystitis/bladder pain syndrome (IC/BPS), and the next diagnostic step is cystoscopy to evaluate for Hunner lesions. 1


Clinical Reasoning

Why This Is IC/BPS and Not UTI

  • Negative urinalyses twice effectively rule out bacterial UTI, as negative leukocyte esterase and nitrite have 90.5% negative predictive value for excluding infection 2
  • IC/BPS requires symptoms present for at least 6 weeks with documented negative urine cultures 1
  • The symptom cluster of bladder/pelvic pain + urgency + frequency distinguishes IC/BPS from isolated overactive bladder (which lacks pain) 3, 4
  • Cloudy urine alone without positive culture does not indicate infection and should not trigger antibiotic therapy 1

Why the Bladder Distension Matters

  • A markedly distended bladder on ultrasound with normal post-void residual (26.5 cc) indicates the bladder is filling excessively between voids rather than failing to empty 5
  • This pattern is consistent with IC/BPS patients who may have reduced functional bladder capacity due to pain/urgency but retain normal emptying mechanics 1
  • The normal PVR (<50 cc) rules out urinary retention or detrusor underactivity as the cause of her symptoms 1, 6

Next Diagnostic Step: Cystoscopy

Strong Recommendation for Cystoscopy

Cystoscopy should be performed in this patient to evaluate for Hunner lesions, which are the only consistent cystoscopic finding diagnostic for IC/BPS. 1

  • Hunner lesions are found in a subset of IC/BPS patients and respond specifically to directed treatment (fulguration or injection), making early diagnosis by cystoscopy valuable 1
  • Most IC/BPS patients tolerate office flexible cystoscopy without hydrodistention, though some prefer general anesthesia 1
  • Patients with Hunner lesions should not be required to fail behavioral or medical treatments before cystoscopy, as early diagnosis allows targeted therapy 1

What Cystoscopy Will Show

  • Hunner lesions (if present) are diagnostic and guide treatment 1
  • Glomerulations (petechial hemorrhages) after hydrodistention may support the diagnosis but are not specific 3, 7
  • Normal cystoscopy does not exclude IC/BPS, as most patients have non-Hunner IC/BPS 1

Additional Diagnostic Considerations

Rule Out Mimics Before Finalizing IC/BPS Diagnosis

  • Bladder cancer, bladder stones, and intravesical foreign bodies must be excluded, which cystoscopy will accomplish 1
  • Hematuria workup should be performed given her age and any tobacco exposure history, as bladder cancer risk is elevated in smokers 1
  • Urine culture (not just urinalysis) may be indicated to detect lower bacterial levels not identified by dipstick 1
  • Brief neurological exam should rule out occult neurologic problems 1

Document Baseline Symptoms

  • Obtain baseline voiding symptoms and pain levels using a voiding diary (at minimum one day) to measure treatment response 1
  • Document number of voids per day, sensation of constant urge, and location/character/severity of pain 1
  • Assess dyspareunia and relationship of pain to any triggers 1

Management Algorithm for IC/BPS

Initial Treatment: Behavioral and Non-Pharmacologic

The 2022 AUA Guideline no longer uses tiered treatment lines; instead, treatment is individualized based on patient phenotype, starting with conservative measures. 1

  • Behavioral therapies include:
    • Fluid management (avoid excessive intake; target ~1 liter urine output per 24 hours) 8
    • Dietary modifications (avoid caffeine, alcohol, acidic foods, artificial sweeteners) 6, 8
    • Bladder training with scheduled voiding 6
    • Pelvic floor physical therapy 6

Oral Pharmacologic Options

  • Pentosan polysulfate (though new guidance addresses potential adverse events) 1, 3
  • Tricyclic antidepressants (e.g., amitriptyline) for pain modulation 3
  • Antihistamines (e.g., hydroxyzine) 3

Bladder Instillations

  • Dimethyl sulfoxide (DMSO) 3
  • Heparin or combination intravesical therapies 3
  • Hydrodistention (therapeutic, not just diagnostic) 3

Procedures and Surgery

  • Fulguration or injection of Hunner lesions if identified on cystoscopy 1
  • Major surgery (augmentation cystoplasty or urinary diversion) is reserved for refractory cases after all other options exhausted 1, 6

Critical Pitfalls to Avoid

Do Not Treat as UTI

  • Antibiotic therapy offers no relief in IC/BPS and promotes resistance 3, 9
  • Pyuria alone (if present) is not an indication for antibiotics in the absence of positive culture 2
  • Asymptomatic bacteriuria (if incidentally found) should never be treated in elderly patients 2

Do Not Misdiagnose as Overactive Bladder

  • Pain/pressure/discomfort distinguishes IC/BPS from OAB, which presents with urgency/frequency without pain 1, 4
  • Antimuscarinics used for OAB may worsen IC/BPS symptoms in some patients 6

Do Not Delay Cystoscopy in Suspected Hunner Lesion Cases

  • Early cystoscopy allows targeted treatment of Hunner lesions without requiring patients to fail multiple therapies first 1
  • Failure to diagnose Hunner lesions delays effective treatment (fulguration/injection) 1

Concurrent Multimodal Therapy

IC/BPS is heterogeneous, and concurrent multimodal therapies may be offered rather than sequential monotherapy. 1

  • Combine behavioral modifications + oral medications + bladder instillations as appropriate for the individual patient 1
  • Shared decision-making regarding treatment selection based on side effect profiles and patient preferences is essential 1, 6

Special Considerations for This 66-Year-Old Woman

Genitourinary Syndrome of Menopause

  • Genitourinary syndrome of menopause can worsen IC/BPS symptoms and should be optimized concurrently 6
  • Consider vaginal estrogen therapy if atrophic changes are present 6

Pelvic Organ Prolapse

  • Bladder outlet obstruction from pelvic organ prolapse can contribute to OAB-like symptoms and should be assessed on physical exam 6

Comorbidities to Address

  • Constipation, obesity, and diabetes can exacerbate urinary symptoms and should be managed 6, 8

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Management of Suspected UTI with Negative Cultures

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Research

Interstitial cystitis: urgency and frequency syndrome.

American family physician, 2001

Research

Managing patients with a distended bladder.

Clinical journal of oncology nursing, 2000

Guideline

Overactive Bladder in a 55-Year-Old Female

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Guideline

Management of Urinary Symptoms in Elderly Males

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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