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:
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