A 33 year old woman complains of having urinary urgency for the past year. She urinates more than 8 times a day. She gives a history of having suprapubic pain if her bladder is full, resulting in the need to urinate frequently as suprapubic pain is relieved by voiding. A urine culture was sent and results have come back negative. On cystoscopy, Hunner’s ulcers were seen on the bladder wall. What is the SINGLE most likely diagnosis?
A. Endometriosis
B. Sexually transmitted infection
C. Overactive bladder
D. Bladder cancer
E. Interstitial cystitis
Interstitial cystitis (Bladder pain syndrome) - A chronic and debilitating disorder characterized by urinary frequency, urgency, nocturia, and suprapubic or pelvic pain - Remains a diagnosis of exclusion after all other causes for the symptoms have been ruled out - The term ‘interstitial cystitis’ is usually reserved for patients with typical cystoscopic features
Presentation - Persistent or recurrent pain perceived in the urinary bladder region - Suprapubic pain worsening with bladder filling - Pain relieved by voiding but returns when bladder fills again - Urinary frequency and urgency - In women the symptoms are often worse during menstruation
It presents in a similar fashion to symptoms of a urinary tract infection (urgency, frequency, dysuria, suprapubic pain). This is why it is important to send a midstream urine for urine cultures to rule out a UTI.
Investigations - Cystoscopy for the sole reason of excluding bladder malignancy: o Around 10% of people with interstitial cystitis have Hunner’s ulcers. They are reddened mucosal areas associated with small vessels radiating towards a central scar
Management - First line o Bladder training
o Pelvic floor relaxation techniques (avoid pelvic floor exercises) o Avoid triggers like coffee, citrus fruits, smoking which can exacerbate symptoms o Analgesics such as NSAIDS - Second-line o Amitriptyline →has anticholinergic effects o Oxybutynin o Gabapentin Other management unlikely to be asked at this stage