Applied Evidence

When to suspect interstitial cystitis

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The symptom profile and comorbidities associated with this painful condition can make it difficult to diagnose—unless you know what to look for.




Suspect interstitial cystitis (IC) in a patient who has had suprapubic pain, pressure, or discomfort and frequency of urination for >3 months in the absence of a urinary tract infection or other pelvic condition with similar symptoms. A

Mild symptoms of IC can be largely contained with dietary changes, off-label oral agents such as amitriptyline or hydroxyzine, and muscle relaxants to reduce pelvic floor muscle spasm. B

Use pentosan polysulfate with caution; although the drug is approved for the treatment of IC, recent studies indicate it has little benefit. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE Jan D, a 27-year-old woman, comes in requesting treatment for pelvic pain and urinary frequency, symptoms she’s had for about 6 months. She describes a feeling of pressure over the suprapubic area that’s relieved by voiding, sensitivity over the vulvar area, and both daytime frequency and nocturia. The patient has a history of allergies and chronic fatigue syndrome (CFS) of 2 years’ duration. When you inquire about her prior medical history, Jan reports that she had frequent urinary tract infections (UTIs) during adolescence.

You order a urinalysis and culture, both of which are negative. If Jan were your patient, what would your next step be?

Interstitial cystitis (IC) is a painful bladder disorder that predominantly affects young and middle-aged women, with an average age of onset of 40 years.1,2 But men can also develop IC, as can women of any age.2 Estimates of prevalence among US women range from less than 1% to more than 6%.2,3 In recent years, however, the number of cases reported has multiplied, the combined result of greater awareness of IC and population surveys based on symptoms rather than on established criteria alone.4

Because the disorder is recognized as a major source of chronic pelvic pain and disability, the term interstitial cystitis/bladder pain syndrome (IC/BPS) is now used by the American Urological Association and many experts to describe it.1,5

Early diagnosis and management of IC/BPS are keys to substantial symptom reduction and improved quality of life. Yet it is often under- or misdiagnosed, both because of the many comorbidities found in patients with the disorder and because its symptoms overlap with those of other common conditions.5

Family physicians are often the first practitioners whom patients with IC/BPS turn to for help. Yet a recent survey of physician practices found significant knowledge gaps with regard to IC/BPS among primary care physicians.6 This evidence-based review is designed to raise awareness of this chronic condition and better prepare you to diagnose and treat it.

IC/BPS: An overview

IC/BPS is characterized by at least 3 to 6 months of pain, pressure, or discomfort over the suprapubic area or the bladder, accompanied by frequency of urination during the day and night in a patient who does not have a UTI.1 There is no known etiology or cure. While evidence suggests that about 90% of those affected are female, some urologists consider chronic bacterial prostatitis to be the male equivalent of IC/BPS, and therefore maintain that the proportion of men with IC/BPS may be considerably higher. 2,3

Chronic pain—the most common symptom—is regional and diffuse over the lower pelvic area, and can be severe. In one study of more than 600 patients with IC/BPS, the most common locations of the pain were the lower abdomen, cited by 80% of those surveyed; the urethral area, cited by 74%; and the low back, by 65%.7 (Dyspareunia is also common, and contributes to the poor quality of life associated with this condition.8)

For about 40% of female patients, the pain and urinary frequency are highest perimenstrually.8 Physical or psychological stress, spicy foods, and smoking can exacerbate symptoms.9,10

Genetics may play a role. Some evidence suggests a genetic predisposition to IC/BPS. In one study, 5 of 8 monozygotic twins of patients with the condition (but 0 of 8 dizygotic twins) were found to have either probable or confirmed IC/BPS. In addition, IC/BPS was 17 times more common in first-degree relatives of patients with the disorder than in the general population.11

There is no established pathogenesis. No infectious organism (bacterial, fungal, or viral) has been identified as a cause for IC/BPS.12 However, an increased number of activated bladder mast cells has been documented in patients with IC/BPS—a possible reason for the pain and some of the histology associated with the condition.9 Inflammation is present to variable degrees and not in all patients.


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