Editing CUA: Interstitial Cystitis (2016) (section)

== Diagnosis and Evaluation ==

=== UrologySchool.com Summary ===
* '''<span style="color:#ff0000">Mandatory (1):'''
*# '''<span style="color:#ff0000">History and Physical Exam'''
* '''<span style="color:#ff0000">Recommended (4):'''
*# '''<span style="color:#ff0000">Urinalysis/culture'''
*# '''<span style="color:#ff0000">Symptom scores'''
*# '''<span style="color:#ff0000">Frequency volume chart'''
*# '''<span style="color:#ff0000">Cystoscopy'''
* '''<span style="color:#ff0000">Optional (5):'''
*# <span style="color:#ff0000">'''PVR'''
*# <span style="color:#ff0000">'''Urine cytology'''
*# <span style="color:#ff0000">'''Imaging'''
*# <span style="color:#ff0000">'''Intravesical anesthetic challenge'''
*# <span style="color:#ff0000">'''Hydrodistension'''
* '''Not recommended: potassium sensitivity test, bladder biopsy, urodynamics'''

=== Mandatory (1): ===

==== History and Physical Exam ====

===== History =====
* '''<span style="color:#ff0000">Signs and Symptoms'''
**'''<span style="color:#ff0000">Characteristic presentation includes a combination of pain, frequency, nocturia, and urgency'''
*** '''<span style="color:#ff0000">Pelvic pain is the main descriptor of IC/BPS'''
**** '''Pain that occurs only during voiding is not consistent with IC/BPS'''
***** Vulvar disorders, which cause pain when urine makes contact with the vulva, should instead be considered
**** In early or milder IC/BPS, patients may not describe frank pain, but rather describe sensations of “pressure,” “burning,” “sharp,” or “uncomfortable sensation of having to urinate.” Typically, this sensation is felt in the supra-pubic area, but it can be referred to areas located in the pelvis, including the urethra, vagina, labia, inguinal area, perineum, and/or lower abdomen or back
*** '''Frequency is the most common presenting symptom i.e. patients seek medical attention for frequency, not the pain'''
** '''Patients may describe periods of worsening symptoms, which may be triggered''' by stress, intercourse, menses, or consumption of coffee, alcohol, citrus fruits, tomatoes, carbonated beverages, and spicy foods
*** '''Symptoms of IC/BPS are generally worse a few days prior to menses, in contrast to endometriosis, which is worse during menses'''

===== Physical Exam =====
* '''<span style="color:#ff0000">Abdominal and pelvic exam</span>''', with particular focus on looking for masses, bladder distension, hernias, and tenderness.
** '''The female pelvic exam should screen for vulvodynia, vaginitis, atrophic changes, prolapse, cervical pathology, and adnexal masses or tenderness'''.
*** Point tenderness, a mass, and expression of pus on palpation of the urethra are classic signs of a urethral diverticulum.
* '''<span style="color:#ff0000">Digital rectal examination in males is essential</span>'''
* '''<span style="color:#ff0000">A musculoskeletal and focused neurological exam may also be contributory</span>'''.
** Although there is no physical finding specific to patients with IC/BPS, suprapubic tenderness and bladder neck point tenderness, in both males and females, is very often noted.
** In males, tenderness may be elicited by palpating the perineal area between the scrotum and anus
** In females, palpating the anterior vaginal wall along the course of the urethra up to the bladder neck may elicit pain.
* '''<span style="color:#ff0000">Palpation of the levator muscles</span>''' in both sexes, looking for tenderness, spasm/tight bands, and/or trigger points, is important for both diagnosis and treatment recommendations
** '''Pelvic floor or rectal spasms may respond well to pelvic floor physiotherapy'''.
** Hypo or hypersensitivity of the perineum, in combination with a weak or absent anal reflex, may suggest pudendal nerve entrapment.

=== Recommended (4): ===

==== Labs ====
#'''<span style="color:#ff0000">Urinalysis +/- culture'''
#* If signs of UTI are identified on urinalysis (e.g. positive for leukocytes), a culture and sensitivity is required.
#** '''If sterile pyuria persists''', '''consider testing for Chlamydia trachomatis, Mycoplasma, Ureaplasma, Corynebacterium species, Candida species, and Mycoplasma tuberculosis.'''
#* '''Absence of leukocytes does not rule out IC/BPS'''

==== Other ====
#'''Symptom scores'''
#* '''Useful to establish baseline symptom severity and to track response to therapeutic intervention'''
#* Options include:
#*# Interstitial Cystitis Symptom Index (ICSI)
#*# Bladder Pain/IC Symptom Score (BPIC-SS)
#*# Pain, Urgency, Frequency (PUF)
# '''Frequency/volume chart'''
#* To differentiate polyuria from the classic small voided volumes expected with IC/BPS.
# '''Cystoscopy'''
#* Expected to be normal
#* Used to:
#*# Rule out bladder cancer/carcinoma in situ
#*# Identify Hunner’s lesions that reflect severe disease, or even different disease (information that may impact treatment decisions)
#*# Determine effect on pelvic pain during bladder filling and emptying
#*# Objectively evaluate “functional” bladder capacity
#*# Facilitate appropriate pelvic examination
#*# Reassure the patient

=== Optional (5): ===
* '''Post-void residual'''
** '''Recommended with a history of poor emptying and/or palpable bladder'''
* '''Urine cytology'''
** '''Indicated if microscopic hematuria is present or if there are other risk factors for urothelial carcinoma'''
* '''Imaging'''
** '''Abdominal or pelvic ultrasonography, or other imaging modalities, may be useful when alternative clinical conditions are questioned, but are expected to be normal if IC/BPS is the only diagnosis.'''
* '''Intravesical anesthetic challenge'''
** '''An anesthetic challenge test, such as an alkalized lidocaine test, instills 10‒20 mL of an anesthetic mixture into an empty bladder. This fluid is held for 10‒15 minutes and then drained by catheter.'''
** '''This test can be performed after cystoscopy and can provide both relief to the patient, as well as diagnostic information and guide future therapy.'''
* '''Hydrodistension (HD)'''
** '''Performed under general or regional anesthetic'''
** '''Bladder is filled with NS by gravity drainage at a pressure of 80 cm H2O to its maximum anesthetic capacity (determined whereby the inflow backs up in the drip chamber or leakage occurs per urethra despite compression against the cystoscope) and distension is maintained for 2 to no more than 10 minutes; the bladder is drained at the end and capacity is measured'''
** '''HD under general anesthetic allows for stratification of patients into those with ulcers and glomerulations from those with no obvious mucosal abnormalities'''
** '''As the literature is conflicting regarding its utility, HD for diagnostic purposes may be appropriate in certain situations such as:'''
*** '''Patient is unable to tolerate cystoscopy under local anesthetic and is having a general anesthetic'''
*** '''When a patient has failed other treatment options and HD to assess disease severity may contribute information to the diagnosis'''
*** '''Assessing a patient for clinical trial eligibility'''

=== Not recommended (3): ===
# Potassium chloride sensitivity test
#* Based on the assumption that a “dysfunctional epithelium” (glycosaminoglycan [GAG] layer) allows potassium ions to cross the abnormally permeable urothelium, depolarize nerves and muscles, and results in pain.
#* Sensitivity/specificity of the test are poor, adding no information over history and cystoscopy.
# Bladder biopsy
#* There are no specific features found on bladder biopsy to confirm a diagnosis of IC/BPS.
# Urodynamics