Applying the Criteria
IC/BPS remains a diagnosis of exclusion.12 The most common disorders seen in the differential diagnosis for IC/BPS (ie, “confusable diseases”6) include bacterial cystitis, vaginitis, pelvic pain, vulvodynia, urinary tract infections, yeast infections, sexually transmitted infections, endometriosis, overactive bladder, and genitourinary malignancies.5,12
Biopsy or cystoscopy with short-duration, low-pressure hydrodistention can be performed on patients who present with persistent pelvic pain and urinary symptoms.2,12 Common cystoscopic findings in patients with IC/BPS include Hunner’s lesions, glomerulations, and inflammatory infiltrates on biopsy.12,21 Hunner’s lesions are described as “patches of red mucosa exhibiting small vessels radiating to a central pale scar.”21 These lesions may also be referred to as Hunner’s ulcers.12 Not always visible on cystoscopy, Hunner’s lesions may be seen only after hydrodistention of the bladder under anesthesia.
Cystoscopic findings can be misleading for providers, as not all stages of IC/BPS manifest in the same manner. No single laboratory finding will identify IC/BPS. The only way to diagnose this disease is to rule out all other diseases with similar presentations.18
When to Refer
Specific findings that may indicate the need for referral include severe pain, hematuria, chronic UTI, and pyuria. Generally, however, the decision to refer the patient with IC/BPS to a urologist or urogynecologist depends on the primary care provider’s comfort level. Some providers choose to refer as soon as identifying symptoms of IC/BPS have been confirmed, whereas others may wish to proceed with further evaluation and/or treatment before referring.2,22
Even if the provider decides to refer immediately after identifying symptoms, it is important to initiate some patient education: for example, explaining that the patient will likely require further tests, including cystoscopy and possibly urodynamic evaluation.2,23 Smokers and other patients at high risk for bladder cancer should be referred for cystoscopy.2
If the primary care provider chooses to proceed with evaluation and treatment before referring the patient, follow-up is typically recommended at one-month intervals for the first three months, then every three months thereafter.18 This allows the clinician to monitor a patient’s progress and address concerns that may develop. Symptoms may be slow to respond to treatment, so it is essential to encourage the patient to adhere to the prescribed regimen. If three to six months of first-line treatment yield no response, further consultation and evaluation are warranted. Overall, a multidisciplinary approach that includes the participation of a urologist, a gynecologist, or other appropriate specialist will help ensure optimal treatment and care.18
A good tool that is often used to gauge the patient’s progress is the O’Leary/Sant Voiding and Pain Indices23-25 (see Figure 224). Reviewing patient responses to this questionnaire, with its precise numerical system, at each follow-up appointment can be especially helpful.
On the next page: Treatment >>