Painful Bladder Syndrome (PBS)/Interstitial Cystitis (IC) Diagnosis and Management

Definition and Clinical Presentation

The American Urological Association defines Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC) as a chronic condition characterized by an unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms lasting more than six weeks, in the absence of infection or other identifiable causes 1, 2
PBS/IC is part of a broader bladder symptom complex that includes patients with bladder, urethral, and/or pelvic pain, lower urinary tract symptoms, and sterile urine cultures 1
The condition is defined by symptoms lasting at least six weeks, which allows for earlier treatment initiation compared to definitions requiring longer symptom durations 2
Pain is the hallmark symptom, typically perceived in the suprapubic region but may extend throughout the pelvis and to extragenital locations 3
Many patients describe their symptoms as "pressure" rather than pain, making it important to use broad descriptors when evaluating patients 3, 4
Pain typically worsens with bladder filling and improves with urination, and may be exacerbated by specific foods or drinks 3

Urinary frequency is almost universal (92% of patients) but is not specific to PBS/IC 3
Urinary urgency is extremely common (84% of patients) but differs qualitatively from overactive bladder urgency 3
PBS/IC patients typically void to avoid or relieve pain, whereas overactive bladder patients void to avoid incontinence 3
PBS/IC patients may experience a more constant urge to void rather than the sudden compelling urge characteristic of overactive bladder 3

Diagnosis requires careful history, physical examination, and laboratory testing to document symptoms and exclude other disorders 4
Basic laboratory testing should include urinalysis and urine culture to rule out infection 4
Cystoscopy should be performed in patients for whom Hunner lesions are suspected, as this is the only reliable way to diagnose their presence 5
There are no agreed-upon urodynamic criteria diagnostic for PBS/IC, and urodynamics are not recommended for routine clinical use 5
The condition is often misdiagnosed or diagnosis is delayed due to the wide spectrum of symptoms and physical exam findings 4

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) shares similar clinical characteristics with PBS/IC 2
CP/CPPS is characterized by pain in the perineum, suprapubic region, testicles, or tip of the penis, often exacerbated by urination or ejaculation 2
The diagnosis of PBS/IC should be strongly considered in men with pain, pressure, or discomfort perceived to be related to the bladder and associated with urinary frequency, nocturia, or an urgent desire to void 2
Some men may meet criteria for both conditions, and treatment approaches can include therapies for both PBS/IC and CP/CPPS 2

Using research or clinical trial definitions in clinical practice, which can lead to misdiagnosis or delays in treatment 1
The American Urological Association recommends against treating with antibiotics when no infection is present, which can lead to antibiotic resistance and disruption of protective flora 6