Introduction
Painful bladder syndrome/interstitial cystitis (PBS/IC) is characterized by a constellation of symptoms including pelvic pain, urinary urgency and frequency, pain with bladder filling, and dyspareunia. Painful bladder syndrome (PBS) and interstitial cystitis (IC) are two names for the same disorder. PBS is the term preferred by the International Continence Society, but since the term IC is so familiar to most physicians, its use remains widespread. Therefore, we will refer to the condition as PBS/IC.
Painful bladder syndrome/interstitial cystitis is generally considered in the context of chronic pelvic pain (CPP). CPP is defined as noncyclic pain lasting longer than 6 months and affects an estimated 15% of women in the United States. About 10% of gynecology referrals are for CPP. A large analysis of multiple studies indicated that 37% of cases of CPP are gastrointestinal in origin, with urologic conditions accounting for an estimated 31% of cases, and gynecologic causes occurring in 20% of cases. Other causes include musculoskeletal and psychologic.
Urologic conditions that account for CPP in women include bladder neoplasm, chronic or recurrent urinary tract infection, radiation cystitis, urethritis, urolithiasis, uninhibited bladder contractions, urethral diverticulum, chronic urethral syndrome, and PBS/IC. A thorough evaluation to rule out these other causes is recommended before giving a woman the diagnosis of PBS/IC. Since there is no way to diagnose PBS/IC definitively, the diagnosis is largely one of exclusion. In women with overactive bladder refractory to medical management, PBS/IC should be considered.
The mean age at onset of PBS/IC is 42 years, although 30% of those diagnosed are younger than 30 years of age. The disorder also affects men but is more common in women, with a female-to-male ratio of 10:1. The estimated prevalence among women in the US is 0.5%.
The most common symptoms of PBS/IC are urinary urgency and frequency, often associated with nocturia; 92% of patients report these symptoms. Suprapubic pelvic pain, often associated with bladder filling and relieved with voiding, is found in 70% of patients. Dyspareunia occurs in 50% of women with the diagnosis. Less common symptoms include vulvar, rectal or low back pain. Dysuria is not common. Symptoms tend to wax and wane, with flare-ups followed by periods of relative quiescence. Frequently women with this condition will be diagnosed with recurrent urinary tract infections. The symptoms will appear to have resolved with antibiotic treatment, but the transient resolution of symptoms is simply part of the natural history of the disorder. There is significant overlap between PBS/IC and other diagnoses, especially overactive bladder, which is characterized by urinary urgency and frequency without pelvic pain, and endometriosis, which can present with suprapubic pelvic pain and pain with bladder filling but usually lacks the urgency and frequency that are hallmarks of PBS/IC. There have been some reports noting an association between PBS/IC and vulvodynia and irritable bowel syndrome.
Several questionnaires exist for quantifying symptoms in PBS/IC. It is important to note that none of these questionnaires has been sufficiently studied for establishing the diagnosis. The most commonly used questionnaires are the O’Leary–Sant Interstitial Cystitis Symptom Index and Problem Index questionnaire and the Pelvic Pain and Urgency/Frequency symptom scale. The Pelvic Pain and Urgency/Frequency symptom scale has also been validated in US Spanish. These questionnaires can be useful in following the course of the disorder and the response to treatment.
The diagnosis of PBS/IC is determined by the presence of symptoms consistent with PBS/IC and the exclusion of other possible etiologies based on physical exam and diagnostic testing. Certain historical factors such as a history of pelvic radiation and chemical cystitis due to cyclophosphamide use probably excludes the diagnosis. Other exclusion criteria for the diagnosis set by the National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health (NIDDK/NIH) for research purposes include bacterial cystitis within the last 3 months, history of bladder calculi, genital herpes in the last 12 weeks, history of uterine, cervical, vaginal or urethral cancer, urethral diverticulum, history of tuberculous cystitis, history of benign or malignant bladder tumors, and active vaginitis.
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