Interstitial Cystitis/Painful Bladder Syndrome

Alis Kolter Panzera, MSN, CRNP

Disclosures

Urol Nurs. 2007;27(1):13-19. 

In This Article

Evaluation

History and Physical Examination

PBS/IC can be a difficult diagnosis to make and clinicians must consider all of the patient's symptoms. Differential diagnosis for PBS/IC can include bladder cancer, kidney problems, overactive bladder, vaginal infections, sexually transmitted infections, endometriosis, radiation cystitis, and urethral diverticulitis (Myers & Arya 2000; Parsons, 2004).

A thorough history is essential. Clinicians should inquire about the patient's chief complaint(s) as well as the onset, duration, and location of symptoms, characteristics of the symptoms, and relieving and aggravating factors. The Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale is a noninvasive diagnostic tool for screening patients with chronic pelvic pain (Parsons, 2004). The PUF patient symptom scale consists of eight self-report items, takes approximately 5 minutes to complete, and helps in evaluating the presence and severity of PBS/IC symptoms. The PUF is often used in conjunction with the potassium sensitivity test (PST; described later); the higher the PUF score the greater the correlation with a positive PST (Parsons et al., 2002).

A common physical examination finding includes suprapubic tenderness on abdominal examination. Most patients with PBS/IC report tenderness over the bladder base when the clinician applies pressure to the anterior vaginal wall during bimanual examination (Parsons, 1996a). High tone pelvic floor muscle dysfunction is another common finding. As many as 81% of patients with PBS/IC have high tone pelvic floor muscle dysfunction; therefore, it is essential that clinicians evaluate patients for this as part of the physical examination (Lukban & Whitmore, 2005). To do so, the clinician places a gloved finger against the proximal and distal lateral vaginal walls, asking the patient to report discomfort ranging from pressure to severe pain. Pelvic floor muscles are evaluated individually and graded separately on a scale of 0 to 4. Zero represents no pressure or pain associated with examination while a score of 4 indicates severe pain during the examination (Whitmore, Kellogg-Spadt, & Fletcher, 1998).

Patients should be asked to keep a voiding diary for 3 days to accurately record fluid intake and urine output. A measuring container, such as a hat, should be used to record precise amounts of urine output. This will help establish the severity of frequency and urgency symptoms as well as providing objective documentation of the number of daily voids and voided volumes. The diary can also be an invaluable tool in determining baseline symptoms and, later on, as a method for evaluating the effects of therapy. Finally, the diary can help determine if diet is a factor in causing symptoms to worsen (certain foods that irritate the bladder, such as alcohol, caffeine, or carbonated drinks) (Myers & Arya, 2000).

Laboratory Studies

Laboratory studies to rule out other conditions include a urinalysis and a urine culture, both of which are generally negative. Urine cytology may be warranted to rule out the possibility of carcinoma, particularly in the presence of microhematuria. Vaginal cultures for chlamydia, herpes, or other sexually transmitted infections should be obtained as clinically indicated.

Testing

Parsons (1996b) developed the PST to aid in the diagnosis of PBS/IC. This office test can be used to identify individuals who have symptoms originating from the bladder or individuals who have abnormal epithelial permeability of the bladder. Before the procedure begins the patient is asked to rate her urgency and pain today on a 0 to 5 point scale (0 = none; 5 = severe). Via an 8 or 10 French catheter, a first solution (40 ml of sterile water) is instilled into the patient's bladder slowly over 2 to 3 minutes. The patient is then asked "How much urgency to urinate do you have now compared to before the solution was placed?" and asked to answer on a 0 to 5 point scale (0=none; 5 = severe). Next the patient is asked "How much pain in the bladder do you have now compared to before the solution was placed?" (again choosing an answer from the same 0 to 5 point scale). The sterile water installation is then drained, a solution of potassium (40 mL 0.4 M KCL) is instilled, and the same questions are asked and scored. If pain occurs, the KCL solution is drained, the bladder is flushed with 60 ml of sterile water, and a rescue solution (40,000 units of heparin, 8 cc 1% lidocaine, and 3 cc sodium bicarbonate) is instilled if needed. The PST is considered positive if the individual has a 2/5 or greater change for either urgency or pain noted between the two solutions (Parsons, 1996b). Eighty percent of patients with PBS/IC will react positively to the PST, whereas fewer than 3% of non-PBS/IC individuals have a positive response (Parsons, 2003).

Urodynamic studies are helpful in evaluating PBS/IC and consist of a series of tests evaluating urinary function during bladder filling, storage, and emptying. The most important urodynamic procedure in evaluating PBS/IC is the cystometrogram (CMG) or filling study. First, the patient is catheterized. If pain is an issue, 2% lidocaine gel can be used as the lubricant. Next, the bladder is manually filled with water or saline to determine bladder capacity and the volume at which urinary urgency occurs. Characteristic CMG findings for PBS/IC include a decreased maximum bladder capacity (usually less than 350 ml), sensory urgency, and pain on bladder filling (Karram, 1999; Nigro & Wein, 1997). The procedure is generally well tolerated. Occasionally patients with PBS/IC will be unable to tolerate urodynamic testing because of the pain associated with the catheterization or from the filling process. If this occurs, testing is stopped. If necessary, a bladder analgesic such as phenazopyridine HCL (Pyridium®); methenamine, phenyl salicylate, methylene blue, benzoic acid, atropine sulfate, hyoscyamine sulfate (Prosed®); or methenamine, methylene blue, salicylate, sodium biphos, hyoscyamine sulfate (Urelle®) can be give for post-procedure pain.

Cystoscopy is primarily used to rule out other bladder pathologies such as carcinoma. Office cystoscopy with local anesthesia is frequently normal in patients with PBS/IC, but can be more painful than for non-PBS/IC patients. Thus, cystoscopy with hydrodistension is done to both diagnose and, in some cases, treat the symptoms of PBS/IC. Done under twilight anesthesia, the bladder is filled with water at 80 cm to 100 cm of water pressure and held for 1 to 10 minutes. The bladder is then drained and examined via the cystoscope (Tchetgen et al., 2005). The clinician looks for glomerulations (pinpoint petechial hemorrhages) or the rarer red Hunner's ulcers (Erickson & Davies, 1998; Tchetgen et al., 2005). To diagnose PBS/IC, glomerulations must be diffuse and located in three of four bladder quadrants (Tchetgen et al., 2005). As with the CMG, cystoscopy in individuals with PBS/IC often reveals a decreased bladder capacity. For example, the "normal" female bladder generally holds well over 1,000 ml under anesthesia whereas individuals with PBS/IC are usually only able to retain 850 ml or less (Parsons, 1990).

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