Urine microscopy and culture must be performed to exclude intercurrent urinary tract infection. It also allows assessment of microscopic hematuria or sterile pyuria to direct further investigations, that is, urine cytology/cystoscopy/renal imaging to exclude renal tract malignancy or stone disease and urine culture for tuberculosis. There is more emphasis on the possibility of low-grade intracellular infection with elevated urinary leucocyte count causing lower urinary tract symptoms (LUTS) which in some units are being treated with prolonged low-dose antibiotics with some success and controversy.
56
Screening for voiding dysfunction to exclude it as a cause of urinary frequency/urgency/bladder pressure should be performed. This can be done by catheter or preferably by bedside bladder scan or formal renal tract imaging. If screening is positive, then urodynamic testing should be carried out. Otherwise, the use of urodynamics in the assessment of patients with BPS is not recommended and is usually extremely uncomfortable. If performed, the findings would include voiding dysfunction, a low-capacity bladder, or poor compliance. The Interstitial Cystitis Database Study Group analyzed urodynamic data and compared them to data collected from voiding diaries.
57 It showed that urodynamic data closely correlated with the findings of the voiding diaries, and therefore, it has been suggested that urodynamics are unnecessary in the evaluation of BPS because the voiding diary, which is noninvasive, captures the necessary information.
Cystoscopy without anesthesia can be used to exclude confusable bladder pathology such as malignancy or bladder stone disease and on inspection can reveal HLs on filling but does not allow for sufficient hydrodistension of the bladder and assessment for the presence of glomerulations (pinpoint petechial hemorrhages), cascade bleeding, maximum bladder capacity, or therapeutic interventions. Although there are technical variations in how hydrodistention is performed, Nordling et al.
58 outlined a detailed description. It is performed with the patient under general or regional anesthesia with a full cystoscopic examination of the bladder performed first. Cystoscopic irrigant (water, saline, or glycine) is then
infused at a pressure of 80 to 100 cm H
2O (this distance above the bladder, i.e., gravity fill) into the bladder until filling into the drip chamber stops; this may require urethral occlusion as water may bypass the cystoscope around the urethra. During filling, the anesthetist may note patient tachycardia or increased respiratory rate indicative of pain. The bladder is distended for 2 to 5 minutes before all the irrigant is released from the bladder under direct vision. The volume of instilled fluid is measured and noted as the patient’s anesthetic bladder capacity. Glomerulations may be noted as petechial hemorrhages during bladder emptying and should be quantified as to the number of bladder quadrants in which they are observed (
Fig. 38.3). The bladder is then refilled to 20% to 50% of bladder capacity to allow visualization of HLs (
Fig. 38.4), appearing as fissures or cracks in the epithelium (these findings are often seen on first fill), and biopsies (both superficial and deep including detrusor muscle) taken if required. Although HLs are considered pathognomic of IC, the presence of glomerulations is not, occurring in up to 45% of normal subjects without symptoms of BPS at volumes higher than their usual functional bladder capacity. For example, 9 out of 20 asymptomatic women had glomerulations when having tubal ligation and cystoscopy with bladder fill volume of 950 mL.
59 Conversely, glomerulations are often not found in subjects with symptomatic BPS, and therefore, absence of identifiable epithelial changes at cystoscopy does not exclude BPS.