Management of Interstitial Cystitis with Hematuria

Initial Diagnostic Approach

The American Urological Association (AUA) recommends a complete urologic evaluation to exclude malignancy and other serious pathology in patients with interstitial cystitis (IC) and hematuria, as the hematuria itself is often benign and related to the IC disease process 1, 2
The AUA guidelines mandate a proper hematuria workup, which includes urine culture to exclude infection, urine cytology in patients with risk factors for transitional cell carcinoma, and documentation of smoking history, age, and occupational exposures to chemicals/dyes 1, 2, 3, 4
Patients should be risk stratified using the 2025 AUA/SUFU criteria based on the degree of hematuria, age, smoking history, and history of gross hematuria 3, 4

Cystoscopy is essential to identify Hunner lesions, which are diagnostic for IC, and to exclude bladder cancer, stones, and other intravesical pathology that can mimic IC 1, 2
Upper tract imaging with CT urography (or MR urography if CT is contraindicated) must be performed to evaluate for renal and ureteral pathology 2, 3

If Hunner lesions are identified during cystoscopy, they should be treated directly (fulguration or resection) as most patients respond to treatment without requiring other therapies first 1
For IC without Hunner lesions, initial treatment should be nonsurgical and may include oral medications 1, 3

If hematuria persists after negative initial evaluation, repeat urinalysis should be performed at 6, 12, 24, and 36 months with blood pressure monitoring at each visit 2, 4
Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 2, 4

Never assume anticoagulation or antiplatelet therapy explains the hematuria, as these medications may unmask underlying pathology but do not cause hematuria themselves 2, 4
Do not skip cystoscopy even in younger patients or those with known IC, as bladder cancer can coexist and the only way to definitively identify Hunner lesions is through direct visualization 1, 2
Tobacco exposure mandates complete evaluation given the high risk of bladder cancer in smokers, regardless of IC diagnosis 1, 3