How should I diagnose and treat interstitial cystitis (painful bladder syndrome)?

Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Diagnostic Approach

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a clinical diagnosis requiring bladder-related pain, pressure, or discomfort lasting more than 6 weeks with documented negative urine cultures, accompanied by lower urinary tract symptoms such as frequency, urgency, and nocturia. 1

Essential Diagnostic Workup

Laboratory Testing:

• Obtain urinalysis and urine culture in all patients to exclude urinary tract infection 1, 2
• Consider urine culture even with negative urinalysis to detect low-level bacterial growth not visible on dipstick 1, 2
• Obtain urine cytology in patients with smoking history or unexplained microscopic hematuria due to bladder cancer risk 1, 2
• Do not perform the potassium sensitivity test - it lacks sufficient specificity and sensitivity to guide clinical decisions 2

Physical Examination:

• Perform brief neurological examination to exclude occult neurologic disorders 1, 2
• Assess for incomplete bladder emptying to rule out occult retention 1, 2
• Document dyspareunia in women and ejaculatory pain in men 1

Baseline Symptom Documentation:

• Record at least a one-day voiding log to identify the characteristic low-volume, high-frequency voiding pattern 1, 2
• Use validated pain instruments: Genitourinary Pain Index (GUPI), Interstitial Cystitis Symptom Index (ICSI), or Visual Analog Scale (VAS) 1, 2
• If voiding frequencies are unusually low or volumes unusually high, investigate alternative diagnoses 2

Role of Cystoscopy

Perform cystoscopy when:

• Hunner lesions are suspected - this is the only reliable method to confirm their presence and should be done early without requiring failure of other therapies 1, 2
• Diagnosis remains uncertain after initial evaluation 2
• Unexplained hematuria or tobacco exposure history exists 1, 2

Do not perform routine cystoscopy on every IC/BPS patient - the risk-benefit ratio is unfavorable, especially in younger individuals with low prevalence of Hunner lesions 1, 2

Urodynamics

Urodynamic studies are not recommended for routine diagnosis 1, 2. Consider urodynamics only when evaluating for outlet obstruction, poor detrusor contractility, or other conditions explaining refractory symptoms 1, 2

Critical Diagnostic Pitfall

Avoid applying research criteria (e.g., NIDDK criteria) in routine practice - they lead to underdiagnosis in approximately 60% of patients 2. Do not rely on cystoscopic glomerulations as diagnostic; only Hunner lesions are considered diagnostic for IC/BPS 1, 2

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Treatment Algorithm

Treatment should proceed from conservative to less conservative therapies, with surgical options reserved only after other alternatives are exhausted or when an end-stage small, fibrotic bladder is confirmed. 1

First-Line Treatments (Offer to All Patients)

Behavioral Modifications:

• Educate patients about normal bladder function, the chronic nature of IC/BPS, and that no single treatment is effective for the majority 1, 3
• Implement fluid management to alter urine concentration and volume 1, 3
• Avoid common bladder irritants such as coffee and citrus products 1
• Apply local heat or cold over the bladder or perineum 1, 3
• Teach pelvic floor muscle relaxation and bladder training with urge suppression 1, 3
• Implement stress management techniques and relaxation strategies 3

Multimodal Pain Management:

• Initiate pharmacological approaches, stress management, and manual therapy if available 1
• Pain management should be continually assessed for effectiveness 1, 4
• Refer to pain specialists if pain control is inadequate with standard approaches 4

Second-Line Treatments

Oral Medications (listed alphabetically, no hierarchy implied):

• Amitriptyline - recommended as one of the most effective oral medications 3
• Cimetidine 1, 3
• Hydroxyzine 1, 3
• Pentosan polysulfate 1

These medications are grouped together because their efficacy for any individual is unpredictable and they are associated with minor adverse events 1

Intravesical Treatments:

• Dimethyl sulfoxide 1
• Heparin 1, 3
• Lidocaine 1, 3

Third-Line Treatment for Hunner Lesions

If Hunner lesions are identified on cystoscopy, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone as the primary treatment. 4 This is the most effective intervention for this specific subtype of IC/BPS 4. Hunner lesions become easier to identify after distention when cracking and mucosal bleeding become evident 4

Fourth-Line and Beyond

Advanced Interventions (for patients failing conservative treatments):

• Sacral neuromodulation 4, 5
• Pudendal neuromodulation 5
• Cyclosporine A 4, 5
• Intradetrusor botulinum toxin A injections 4

Surgical Options (Last Resort)

Reserve for patients with severe, unremitting symptoms that have failed all other treatment options:

• Substitution cystoplasty 4, 3
• Urinary diversion with or without cystectomy 4, 3
• For patients with end-stage structurally small bladders, diversion may be indicated at any time the clinician and patient believe appropriate 3

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Treatment Principles

Reassessment:

• Periodically reassess treatment efficacy and stop ineffective treatments 1
• If no improvement occurs within a clinically meaningful timeframe, reconsider the diagnosis 1

Treatments That Should NOT Be Offered:

• Long-term oral antibiotic administration 4
• Intravesical BCG 4

Important Considerations:

• IC/BPS is a chronic condition with periods of flares and remissions requiring ongoing management 4, 3
• Multiple simultaneous treatments may be considered if in the patient's best interests 1
• Sexual dysfunction is common and significantly impacts quality of life; successful treatment of IC/BPS symptoms can improve sexual function 4