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Diagnosis and Management of Interstitial Cystitis/Painful Bladder Syndrome

(Published May 2008)

Diagnosis

Challenges of diagnosis

  • Currently available diagnostic criteria, which were developed for research, have been shown to miss many patients with the condition.1
  • Techniques that are painful and invasive have been used for diagnosis, but some experts believe these to be inaccurate and unnecessary.2
  • There are currently no biological markers for use in diagnosis.
  • The diagnosis of IC/PBS remains one of exclusion.3,4

Differential diagnosis of IC/PBS:
Bladder carcinoma
Drug effects: cyclophosphamide, aspirin, NSAIDs, allopurinol
Endometriosis
Overactive bladder
Radiation cystitis
Urinary tract infection

Approach to diagnosis

  • The general approach to diagnosis of IC/PBS tends to be empirical.
  • Once other conditions are excluded, patients with characteristic signs and symptoms generally are treated for presumed IC/PBS.
  • In certain circumstances, some clinicians may choose to evaluate further, with cystoscopy with hydrodistention under general anesthesia, urodynamic studies, or lidocaine instillation.
  • Clinicians should especially consider IC/PBS in patients who may have been misdiagnosed with another condition.
  • It is also important to identify any comorbid conditions, such as pelvic floor dysfunction, that may serve as “secondary pain generators,” exacerbating symptoms in patients who have IC/PBS.
  • Bladder carcinoma and drug effects are rare but should be considered in patients with relevant findings, such as microhematuria on cystoscopy.
  • Note that cyclophosphamide, aspirin, NSAIDs, and allopurinol are associated with a nonbacterial cystitis that resolves when the drugs are discontinued.4
  • Two or more of these conditions can occur concurrently.

Avoid underdiagnosis by considering IC/PBS in:5,6

  • A patient treated for overactive bladder who continues to experience persistent urge with associated suprapubic/pelvic discomfort or pain
  • A patient who does not respond to empirical antibiotics for “recurrent urinary tract infection,” especially if bacterial cystitis is not present and the patient has mounting discomfort with bladder filling
  • A female patient who continues to have pelvic pain after therapy for endometriosis (medical and/or surgical), especially if she has urinary frequency or change in pain or discomfort with bladder filling or emptying
  • A male patient who has been treated for “prostatitis” with therapies such as antibiotics, alpha blockers, or NSAIDs but continues to have pelvic pain perceived to be associated with the bladder, and possibly irritative voiding symptoms

Caveats for diagnosis

  • Be wary of making a diagnosis of IC/PBS in patients who have OAB unless adequate treatment of involuntary detrusor contractions fails to resolve symptoms.
  • Similarly, avoid making a diagnosis of IC/PBS in patients who have a history of recurrent UTI unless adequate antibiotic treatment fails to resolve symptoms.
  • Be aware that although urgency is a common symptom of IC/PBS, it is also characteristic of OAB.

Components of basic assessment

  • History
  • Physical examination
  • Urinalysis
  • Urine culture
  • Cystoscopy with hydrodistention under general anesthesia
  • Cytology (when indicated)

History

  • Elicit a detailed history of voiding symptoms, pelvic pain or discomfort, urinary frequency and urgency, and nocturia.
  • Ask the patient to keep a voiding log for assessing urinary frequency.
  • Use a variety of terms to query about bladder pain. Some patients who have IC/PBS do not complain of pelvic pain but, if asked, will admit to discomfort or pressure that is relieved by voiding.
  • Ask about the timing and course of symptoms. A distinguishing characteristic of IC/PBS is progressive bladder pain or discomfort with increased bladder filling.

Physical exam

  • Perform a pelvic exam in women and a digital rectal exam in men. Many patients who have IC/PBS have exquisite tenderness at the bladder neck, at the perineum between the anus and scrotum in men, and at the anterior vaginal wall near the urethral meatus in women.7
  • Perform assessment of pelvic floor muscle strength and pelvic floor muscle tenderness.
  • Evaluate for vaginal vault, introital, or vestibular pathology and periurethral or urethral lesions.

Urinalysis

  • Assess for signs of infection.
  • If hematuria is present, further work-up (e.g., cystoscopy with hydrodistention or urine cytology) is needed to rule out other pathology, such as renal stones or cancer.

Urine culture

  • Assess for signs of infection.
  • Recurrent UTI can cause symptoms similar to IC/PBS.

Cystoscopy with hydrodistention under general anesthesia

  • Characteristic finding: diffuse glomerulations.
  • Can have short-term therapeutic benefit in up to 50 percent of patients.4
  • How procedure is performed:
    • With the patient under general anesthesia, the urologist performs a cystoscopic examination, obtains urine for cytology, and distends the bladder with sterile water for 1–2 minutes.
    • The bladder is emptied and then refilled to look for lesions or ulceration.
    • The urologist then distends the bladder again for 8 minutes. The bladder is then emptied again, at which time the urologist may take a biopsy specimen.

Cytology (when indicated)

  • Send for urine cytology in patients who are at higher risk for bladder cancer.

Other intravesical diagnostic tests

  • Lidocaine challenge.
    • Therapeutic technique that may be useful for diagnosis, though it is not yet validated.
    • Can help differentiate bladder from nonbladder sources of pain.
    • How procedure is performed:
      • Intravesical catheter is used to fill bladder with lidocaine, with a variable combination of heparin, gentamicin, triamcinolone, or other agents.
      • Patients are instructed to keep mixture in bladder for 30 minutes if possible before voiding.
      • Pain relief may last for days.
  • Potassium chloride challenge (Parsons’ test).
    • Tests for epithelial leakage or bladder sensitivity; not specific to IC/PBS.2
    • Not widely used by urologists in this country.
    • Some experts feel it may be helpful in the subset of patients who have minimal pain.
    • Test is positive if instillation elicits irritative voiding symptoms and/or pain.
    • How procedure is performed:
      • Intravesical catheter is used to fill bladder with potassium chloride (0.4 M solution, 400 meq/L).
      • After 5 minutes of retaining solution in the bladder, the patient rates his or her level of symptoms and pain.
      • A positive result is pain and re-creation or exacerbation of IC/PBS symptoms.
      • For more information, see http://drlowellparsons.org/uploads/PST_instr.doc.

Imaging studies

  • Pelvic ultrasound.
    • Useful for assessing other causes of pelvic pain (which can coexist with IC/PBS and exacerbate symptoms), including ovarian cysts and uterine fibroids.8
    • Requires full bladder, which can be painful for patients who have IC/PBS. Vaginal probe is an alternative, although this option also may be painful.
  • Intravenous pyelogram.
    • Useful for ruling out urinary system obstructions, such as kidney stones.
    • Requires intravenous injection of contrast material and X-ray.

Urodynamic studies

 

  • Generally show normal function, with the exception of hypersensitivity and reduced bladder capacity.
  • Can help assess bladder compliance: check for reproduction of symptoms with bladder filling and rule out detrusor overactivity.4
    • How procedure is performed:
      • Intravesical catheter is used to fill bladder with sterile water.
      • The urologist then asks the patient about sensations (first urge to void, discomfort) while measuring changes in pressure and volume.
      • The procedure can be painful for patients who have IC/PBS because of the need for catheterization and bladder filling.
  • Pain on bladder filling and low volume at first sensation of fullness are characteristic of IC/PBS.8

References

  1. Hanno PM, Landis JR, Matthews-Cook Y, Kusek J, Nyberg L, The Interstitial Cystitis Database Study Group. The diagnosis of interstitial cystitis revisited: lessons learned from the National Institutes of Health Interstitial Cystitis Database Study. J Urol. 1999;161:553-7.
  2. Hanno PM. Painful bladder syndrome (interstitial cystitis). In: Hanno PM, Wein AJ, Malkowicz SB, editors. Penn Clinical Manual of Urology. Philadelphia: Saunders; 2007.
  3. National Institutes of Diabetes and Digestive and Kidney Diseases. Overcoming bladder disease: A report of the Bladder Research Progress Review Group. Chapter 8. National Institutes of Health. Bethesda, MD; August 2002.
  4. Hanno PM. Painful bladder syndrome/interstitial cystitis and related disorders. In: Wein AJ, editor. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders; 2007, p. 330-70.
  5. Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology. 2007;69(Suppl 4A):60-3.
  6. Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol. 2002;100:337-41.
  7. Rosenberg MT, Newman DK, Page SA. Interstitial cystitis/painful bladder syndrome: symptom recognition is key to early identification, treatment. Cleve Clin J Med. 2007;74(Suppl 1):S54-S62.
  8. Moldwin RM. The Interstitial Cystitis Survival Guide. Oakland, CA: New Harbinger Publications; 2000.