Interstitial cystitis (IC) is a treatable condition, and early recognition with prompt initiation of therapy may increase the chance of treatment success.1 Therefore, it is important to perform a thorough patient evaluation when pelvic pain and urgency/frequency symptoms are present.

Evaluate for IC at the onset of symptoms
    At the onset, evaluate for IC in patients presenting with
  • Urinary urgency/frequency*
  • Pelvic pain, which may include dyspareunia
Diagnostic workup of IC includes
    √
    √
    Patient history4
    √
    Physical examination
  • Evaluate for anterior vaginal wall and bladder base tenderness5
    √
    Laboratory analysis
  • Urinalysis with culture and sensitivity, cytology as indicated
  • Rule out infection and bladder cancer4
    √
    Optional diagnostic procedures
  • Potassium Sensitivity Test (PST)6
  • Intravesical anesthetics7-9
  • Cystoscopy ± hydrodistention4

    In assessing pain, consider that
  • Pelvic pain may be constant or episodic, and may be referred (lower abdomen, urethra, perineum, and medial thighs)10,11
  • Flares may be associated with menstruation and/or allergies10,11
  • Pain may be associated with sexual intercourse10
  • Pain may occur during bladder filling, which may be relieved with voiding12
    • Urinary urgency is associated with a desire to relieve pain versus fear of leakage13

*May include nocturia.
†Although patients with IC are likely to have higher scores, the questionnaire cannot exclude other conditions with similar symptoms and is not sufficient to diagnose IC independent of medical history, physical examination, and appropriate diagnostic measures.
‡ A score of 10 or higher was associated with a 74% to 91% likelihood of a positive PST.
    References:
  1. Zhang HF, Aquilina JW, Chen A, Creanga DL, Wan GJ, Nickel JC. Early initiation versus late initiation of pentosan polysulfate sodium treatment after interstitial cystitis diagnosis: effect on symptom improvement. Poster presented at: Meeting of the American Urogynecologic Society; October 19-21, 2006; Palm Springs, CA.
  2. O'Leary MP, Sant GR, Fowler FJ Jr, Whitmore KE, Spolarich-Kroll J. The interstitial cystitis symptom index and problem index. Urology. 1997;49(suppl 5A):58-63.
  3. Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology. 2002;60:573-578.
  4. Hanno PM. Interstitial cystitis and related disorders. In: Walsh PC, ed-in-chief; Retik AB, Vaughan ED Jr, Wein AJ, eds; Kavoussi LR, Novick AC, Partin AW, Peters CA, associate eds. Campbell’s Urology. Vol 1. 8th ed. Philadelphia, PA: Saunders; 2002:631-670.
  5. Howard FM. Physical examination. In: Howard FM, Perry CP, Carter JE, El-Minawi AM, Li R-Z, eds. Pelvic Pain: Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:26-42.
  6. Parsons CL. Potassium sensitivity test. Tech Urol. 1996;2:171-173.
  7. Moldwin RM, Sant GR. Interstitial cystitis: a pathophysiology and treatment update. Clin Obstet Gynecol. 2002;45:259-272.
  8. Parsons CL. Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis. Urology. 2005;65:45-48.
  9. Moldwin R, Brettschneider N. The use of intravesical anesthetics to aid in the diagnosis of interstitial cystitis. Poster presented at: Research Insights Into Interstitial Cystitis: A Basic and Clinical Science Symposium; October 30-November 1, 2003; Alexandria, VA.
  10. Parsons CL. Interstitial cystitis: epidemiology and clinical presentation. Clin Obstet Gynecol. 2002;45:242-249.
  11. Parsons CL, Stanford EJ, Kahn BS, Sand PK. Tools for diagnosis and treatment. Female Patient. May 2002;(suppl):12-17.
  12. Eisenberg ER, Moldwin RM. Etiology: where does prostatitis stop and interstitial cystitis begin? World J Urol. 2003;21:64-69.
  13. Rosenberg MT, Moldwin RM, Stanford EJ. Early diagnosis and management of interstitial cystitis: what primary care clinicians should know. Womens Health Primary Care. 2004;7:456-463.
The Pelvic Pain and Urgency/Frequency (PUF) Questionnaire
The PUF questionnaire is a screening aid for patients who may have IC. This self-administered symptom questionnaire takes only a few minutes to complete and can save your patient weeks, months, or even years of frustration.

Patients’ responses to questions concerning voiding problems, persistent pelvic pain, and pain during or after sexual intercourse are weighed to determine the intensity of symptoms. IC should be considered if a patient records a PUF score of  ≥10,*2 although lower scores may indicate IC in patients who
  • Are early in the course of the disease
  • Have a mild case of the disease
  • Are not sexually active

Downloadable PUF Questionaire

*Although patients with IC are likely to have higher PUF scores, the questionnaire cannot exclude other conditions with similar symptoms and is not sufficient to diagnose IC independent of medical history, physical examination, and appropriate diagnostic measures.
  1. Zhang HF, Aquilina JW, Chen A, Creanga DL, Wan GJ, Nickel JC. Early initiation versus late initiation of pentosan polysulfate sodium treatment after interstitial cystitis diagnosis: effect on symptom improvement. Poster presented at: Meeting of the American Urogynecologic Society; October 19-21, 2006; Palm Springs, CA.
  2. Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology. 2002;60:573-578.
Additional diagnostic options
Although there is currently no definitive diagnostic test for IC, several diagnostic tools are available. Three common procedures are described below, and the advantages and disadvantages of each are examined.

    Potassium Sensitivity Test (PST)
    Instillation of a potassium solution into the bladder to provoke symptoms of IC2
  • Pros: localization of the bladder as the source of pain; detects abnormal bladder epithelial permeability3; sensitivity in approximately 80% of IC patients4; simple procedure performed in the office
  • Cons: potential to provoke pain and may be uncomfortable for the patient; lacks specificity, particularly in patients with acute urinary tract infection and radiation cystitis5
    Intravesical anesthetics
    Instillation of an anesthetic solution into the bladder to relieve symptoms of IC6
  • Pros: localization of the bladder as the source of pain7; may provide therapeutic benefit6,8; simple procedure performed in the office
  • Cons: patients without pain at the time of testing cannot be assessed; may lack specificity due to local absorption of the anesthetic in a nearby location9; “rebound” pain may occur once the anesthetic solution has worn off6,9
    Cystoscopy ± hydrodistention
    Visual examination of the bladder for characteristic IC findings: Hunner’s ulcer and/or glomerulations (petechial hemorrhages) 10
  • Pros: historically considered the diagnostic gold standard; if positive, serves as visual documentation to support clinical suspicion of IC; may provide therapeutic benefit (when combined with hydrodistention)11; biopsy can be performed to rule out bladder cancer
  • Cons: requires general or spinal anesthesia (when combined with hydrodistention); glomerulations are not specific for IC12; absence of characteristic findings does not exclude IC13
    References:
  1. Zhang HF, Aquilina JW, Chen A, Creanga DL, Wan GJ, Nickel JC. Early initiation versus late initiation of pentosan polysulfate sodium treatment after interstitial cystitis diagnosis: effect on symptom improvement. Poster presented at: Meeting of the American Urogynecologic Society; October 19-21, 2006; Palm Springs, CA.
  2. Parsons CL. Potassium sensitivity test. Tech Urol. 1996;2:171-173.
  3. Parsons CL, Greenberger M, Gabal L, Bidair M, Barme G. The role of urinary potassium in the pathogenesis and diagnosis of interstitial cystitis. J Urol. 1998;159:1862-1867.
  4. Parsons CL. Prostatitis, interstitial cystitis, chronic pelvic pain, and urethral syndrome share a common pathophysiology: lower urinary dysfunctional epithelium and potassium recycling. Urology. 2003;62:976-982.
  5. Teichman JMH. Potassium sensitivity testing in the diagnosis and treatment of interstitial cystitis. Infect Urol. 2003;16:87-94.
  6. Moldwin R, Brettschneider N. The use of intravesical anesthetics to aid in the diagnosis of interstitial cystitis. Poster presented at: Research Insights Into Interstitial Cystitis: A Basic and Clinical Science Symposium; October 30-November 1, 2003; Alexandria, VA.
  7. Moldwin RM, Sant GR. Interstitial cystitis: a pathophysiology and treatment update. Clin Obstet Gynecol. 2002;45:259-272.
  8. Parsons CL. Successful downregulation of bladder sensory nerves with combination of heparin and alkalinized lidocaine in patients with interstitial cystitis. Urology. 2005;65:45-48.
  9. Rosenberg MT, Moldwin RM, Stanford EJ. Early diagnosis and management of interstitial cystitis: what nonspecialists should know. Womens Health Gynecol Edition. 2005;5:108-115.
  10. Hanno PM. Interstitial cystitis and related disorders. In: Walsh PC, ed-in-chief; Retik AB, Vaughan ED Jr, Wein AJ, eds; Kavoussi LR, Novick AC, Partin AW, Peters CA, associate eds. Campbell’s Urology. Vol 1. 8th ed. Philadelphia, PA: Saunders; 2002:631-670.
  11. Ottem DP, Teichman JMH. What is the value of cystoscopy with hydrodistension for interstitial cystitis? Urology. 2005;66:494-499.
  12. Waxman JA, Sulak PJ, Kuehl TJ. Cystoscopic findings consistent with interstitial cystitis in normal women undergoing tubal ligation. J Urol. 1998;160:1663-1667.
  13. Hanno PM, Landis JR, Matthews-Cook Y, Kusek J, Nyberg L Jr, and 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: 553-557.