Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.
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The diagnostic journey for Interstitial Cystitis (IC/BPS) is often long and frustrating for patients, primarily because there is no single definitive test that can instantly confirm the disease. Instead, the diagnosis is one of exclusion. At Liv Hospital, the diagnostic protocol is designed to systematically rule out other conditions that mimic IC—such as urinary tract infections, bladder cancer, overactive bladder, endometriosis, and sexually transmitted infections—before confirming the diagnosis of Bladder Pain Syndrome. The philosophy is to reach a diagnosis efficiently to validate the patient’s symptoms and initiate appropriate therapy, moving away from the historical trend where women suffered for years without a name for their condition.
The evaluation is comprehensive, combining a detailed clinical history with non-invasive and invasive testing. The medical team looks for the characteristic phenotype of the disease while ensuring that no “red flag” conditions (like malignancy) are overlooked.
The cornerstone of diagnosis is a thorough clinical assessment. A detailed history focuses on the duration of symptoms (typically required to be present for more than 6 weeks), the nature of the pain (filling vs. emptying), and the presence of triggers.
Voiding Diary: Patients are asked to keep a Voiding Diary for 24 to 72 hours. This log records the time and volume of each void, fluid intake, and pain levels. In IC patients, this diary typically reveals frequent, small-volume voids (often less than 150ml) and frequent nocturnal awakening, objectively documenting the functional impact of the disease.
The first line of objective testing is a Urinalysis and Urine Culture. This is mandatory to rule out an active bacterial infection. In classic IC, the urine culture is sterile (negative for bacteria). However, the urinalysis may show microscopic hematuria (traces of blood) or pyuria (white blood cells) due to the chronic inflammation of the bladder wall. If the culture is positive for bacteria, the patient is treated for a UTI, and the diagnosis of IC is reconsidered only if symptoms persist after the infection is cleared.
Urine Cytology: In patients with hematuria or risk factors for smoking, urine cytology is performed. This involves examining shed bladder cells under a microscope to screen for high-grade bladder cancer (carcinoma in situ), which can present with symptoms identical to IC (pain and frequency).
While office cystoscopy (looking into the bladder with a camera) can be performed to rule out tumors or stones, the definitive diagnostic procedure for IC is Cystoscopy with Hydrodistention performed under anesthesia.
Therapeutic Value: Interestingly, hydrodistention is also therapeutic. The stretching of the bladder can damage the sensory nerve endings, providing symptom relief for some patients for weeks or months.
During the cystoscopy, if any suspicious lesions or Hunner’s ulcers are identified, a cold-cup biopsy is taken. The primary purpose of the biopsy is not to diagnose IC (as the findings can be non-specific chronic inflammation), but to definitively rule out bladder carcinoma, tuberculosis, or eosinophilic cystitis.
However, histological examination can reveal an increased number of mast cells in the detrusor muscle or mucosa. While not pathognomonic, mastocytosis (high mast cell count) supports the diagnosis of IC and suggests that therapies targeting histamine release may be effective.
Potassium Sensitivity Test (PST): Although less commonly used today due to its painful nature, the PST involves instilling a potassium solution into the bladder. In a healthy bladder, the lining blocks the potassium. In an IC bladder with a permeable epithelium, the potassium penetrates the wall and stimulates nerves, causing immediate severe pain. A positive test confirms the “leaky epithelium” theory.
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A standard office cystoscopy can cause significant pain for an IC patient and limits the amount of fluid that can be instilled. Performing the procedure under anesthesia allows the urologist to distend (stretch) the bladder fully without causing pain. This stretching is necessary to reveal specific signs like glomerulations (pinpoint bleeding) or Hunner’s lesions, which may not be visible when the bladder is not fully expanded.
The Potassium Sensitivity Test (PST) is designed to test the integrity of the bladder’s protective lining (the GAG layer). If the lining is healthy, potassium solution placed in the bladder causes no sensation. If the lining is defective (as in IC), the potassium penetrates the wall and stimulates the nerves, causing pain. This helps confirm the “leaky bladder” theory, although it is used less frequently now due to the discomfort it causes.
A biopsy cannot definitively “diagnose” IC because the microscopic findings of chronic inflammation are non-specific. The primary role of a biopsy is to rule out other serious conditions that look like IC, such as bladder cancer (carcinoma in situ) or tuberculosis. However, finding a high number of mast cells in the biopsy can support the diagnosis of IC.
While both conditions cause frequency and urgency, the driving force is different. OAB is caused by involuntary muscle spasms of the bladder, often associated with a fear of leaking urine (incontinence). IC is driven by pain and sensory hypersensitivity; patients urinate frequently to avoid the pain of a full bladder, not because the muscle is spasming. Urodynamics can scientifically distinguish between the two.
Diagnosis is often delayed because the symptoms of IC overlap with many common conditions like urinary tract infections, yeast infections, endometriosis, and fibroids. Patients are often treated repeatedly for UTIs despite negative cultures before a urologist considers IC. The diagnosis requires ruling out all these other possibilities, which takes time and specialized testing.
Interstitial cystitis (IC), also known as bladder pain syndrome (BPS), is a chronic condition. It causes bladder and pelvic pain, along with urinary urgency and
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