Interstitial Cystitis: Enhancing Early Identification in Primary Care Settings

Brittany N. Heck, FNP, MSN

Disclosures

Journal for Nurse Practitioners. 2007;3(8):509-519. 

In This Article

Clinical Presentation

In the absence of a definitive diagnostic test, the diagnosis of IC or PBS is made clinically, after performing a comprehensive history and physical examination. The variable clinical presentation of IC often perplexes many primary care providers, given the similarity of this syndrome to other gynecologic and urologic disorders. Reaching an accurate diagnosis relies on the clinician's ability to promptly identify the signs and symptoms characteristic of IC and PBS, while simultaneously ruling out other disorders that present similar in nature.

Presenting Signs and Symptoms

Patients with IC typically complain of urinary urgency, frequency, and pelvic pain that progressively worsen over time. Initially, symptoms are mild, with one primary distinguishing symptom. A study examining the clinical course of IC found that 70% of women had only one symptom at the onset of disease.[18] Although patients may complain of any one or a combination of symptoms, typically patients in the early stages of disease present with either urinary urgency or frequency. As many as 14 to 15 voids per day have been reported by persons with IC or PBS[19]; however, many of these patients do not recognize the symptoms as a significant problem. Depending on the stage of disease, the pain that ensues in patients with IC generally worsens over time, eventually becoming the dominant symptom. Characteristically, the pain of IC or PBS is relieved on urination and returns once the bladder begins to refill. Identifying the bladder as the primary source of pain is often difficult, because many patients with IC or PBS experience generalized pain throughout the pelvis. FitzGerald et al[20] report that 80% of patients with IC or PBS complained of lower abdominal pain, 74% reported urethral pain, 65% reported lower back pain, and 27% reported pain in any other area. Furthermore, the description of pain is not uniform; patients may describe the pain as a dull ache, burning, or pressure sensation.[20]

Early symptoms of the disorder are not constant; rather, they present cyclically, marked by flares and remissions. Patients often report the onset of symptoms in relation to allergy exacerbation, hormonal cycles, and sexual activity.[19] Women often report worsening symptoms the week before menstruation, and dyspareunia has been identified in at least half of patients with IC or PBS.[21] In addition, patients commonly report the exacerbation of symptoms after ingesting the following foods: coffee, alcohol, chocolate, or spicy foods.[22] A history of frequent UTIs may also clue clinicians into the presence of IC and PBS.

When the presentation of symptoms is unclear, specific tools are available to assist in quantifying the symptoms of IC. Currently, there are two validated questionnaires for IC or PBS, the O'Leary-Sant (OLS) symptom and problem index and the pelvic pain and urgency/frequency (PUF) scale, shown in Figure 2, Figure 3.[23,24,25] Both questionnaires distinguish IC or PBS from other diagnoses such as recurrent UTIs, nonbacterial prostatitis, bladder cancer, and benign prostatic hypertrophy.[25]

Figure 2.

Figure 3.

The OLS index includes 2 parts, a symptom index, which measures urgency and pain in patients with IC or PBS, and a problem index, which measures the degree to which patients experience each symptom. A score greater than six points on each symptom index is generally indicative of IC or PBS.[2] In addition to serving as an effective screening tool in patients with IC or PBS, the OLS index is an effective follow-up tool to monitor patient responses to treatment interventions.[26] Similarly, the PUF scale also measures both the presence and the severity of symptoms in patients with IC or PBS. Specifically, the scale focuses on the symptoms of urinary urgency, frequency, and pelvic pain, but it further quantifies the symptoms in relation to sexual intercourse. Results show that, on a scale with a maximum score of 35, patients with a score greater than 5 have a 55% chance of having IC or PBS, and patients with a score greater than 10 have a 74% chance of having IC or PBS.[24]

Physical Findings

The physical examination of a patient suspected of IC or PBS must be comprehensive to identify patients who may have coexisting diseases. Women should receive a thorough pelvic examination, including a bimanual examination and Papanicolaou (Pap) test. These tests can assist clinicians in ruling out other diseases that present similarly to IC and PBS such as vaginitis, vulvar lesions, vulvodynia, and endometriosis.[27] Women with IC or PBS commonly have bladder base and suprapubic tenderness on palpation of the area.[28] The Pap test in women with IC or PBS will be normal, ruling out the possibility of an infections cause. Men presenting with symptoms of IC or PBS should have a digital rectal examination; pain elicited in the perineum or prostate regions in men may suggest the presence of IC or PBS.[28] However, it should be noted that prostatitis presents similarly on examination.

Differentiating IC or PBS from Other Common Disorders

As a diagnosis of exclusion, an accurate diagnosis of IC or PBS can only be made after ruling out other disorders that mimic the symptom presentation. Common diseases such as UTI, endometriosis, overactive bladder (OAB), vulvodynia, and chronic prostatitis (CP) present similarly to that of IC,[21] and should be ruled out early in the diagnostic process. Symptoms such as urinary urgency, frequency, and dysuria, typically characterize the presence of a UTI; however, they closely resemble the symptoms of IC and PBS. A routine urinalysis and culture should always be performed, because patients with IC or PBS generally do not have bacteria or blood within their urine.[27] Cases presenting with microscopic hematuria on urinalysis warrant further testing, and cytology studies should be obtained to rule out more serious conditions such as carcinoma of the bladder.[5]

It is important to distinguish IC and PBS symptoms from those common to endometriosis, a disorder also marked by frequent complaints of pelvic pain. Evidence suggests that IC or PBS and endometriosis frequently coexist. In a retrospective study examining 60 patients with reports of chronic pelvic pain, Chung et al[29] found that 97% of the study sample had IC or PBS and 93% had endometriosis. Distinction between the two conditions can be accomplished by noting differences in the occurrence of pain in relation to the menstrual cycle. Although patients with IC and PBS experience premenstrual pain, patients with endometriosis generally report worsening pain during menses.[30] To avoid the misdiagnosis of either disease, clinicians should include both IC or PBS and endometriosis as a differential in all patients reporting chronic pelvic pain.

In addition, symptoms observed in patients with OAB syndrome also present similarly to those of IC and PBS. It is important to note that the pain accompanying a diagnosis of IC is rarely present in patients with OAB.[31] Abrams et al[31] also report another distinguishing characteristic; urinary urgency and frequency in patients with IC or PBS commonly result from the pain sensed on urine filling the bladder, whereas the urgency of OAB results from fear of losing urine, related to incontinence.

Vulvodynia and CP are two other common diseases that must be ruled out before a diagnosis of IC and PBS can be reached. Kennedy et al[32] compared the rates of IC and PBS in patients with a known diagnosis of vulvar disease and found that patients were twice as likely to have a diagnosis of IC and PBS than were controls. Although patients with vulvodynia complain of vulvar pain and dyspareunia, rarely do they report symptoms associated with IC or PBS such as urinary urgency, frequency, and nocturia.[21] These distinctions can help clinicians differentiate between the two diseases. Similarly, the clinical presentation of CP is almost identical to that of IC. Both diseases are marked by urinary urgency, frequency, and pelvic pain, while simultaneously presenting in the absence of infection. When such similarities exist on history and physical examination, clinicians often confirm the diagnosis of IC or PBS by performing a potassium sensitivity test (PST),[33] which is described in the next section.

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