Diagnosis A careful history should be obtained, along with a sterile urine specimen for analysis and culture. Many women treated repetitively for chronic cystitis take multiple courses of antibiotics on the basis of symptoms without ever having the presence of an infection confirmed by cultures. Detrusor overactivity may be the cause of frequency, urgency, and urge incontinence, but that is not usually a factor in dysuria or painful urination. Women older than 50 years (particularly those who smoke or are exposed to chemicals at work) are at risk for bladder cancer, and this possibility must be considered, especially if hematuria is present. Urinary cytologic assessment is sometimes helpful in detecting early tumors of the urinary tract, and cystoscopy and intravenous urography are mandatory in the evaluation of patients with hematuria.
Other possible causes for painful voiding must be considered in the differential diagnosis, including urethral diverticula; vulvar disease; endometriosis; chemical irritation from soaps, bubble bath, or feminine hygiene products; urinary stones; urogenital atrophy from estrogen deprivation; and sexually transmitted disease.
The diagnosis of bladder pain syndrome or interstitial cystitis is largely one of exclusion. The ideal diagnostic test for interstitial cystitis is not determined, and there are myriad proposed tests.
Treatment Typically, the evaluation of bladder pain syndrome results in no definitive diagnosis, and management focuses on the treatment of symptoms.
Frequency–urgency syndromes should be managed with a careful voiding regimen (similar to that used in the treatment of urgency urinary incontinence) and local care.
The use of urinary tract analgesics such as Prosed DS may be helpful in reducing urethral irritation. Prosed DS is a polypharmaceutical agent containing a mixture of methenamine, methylene blue, phenyl salicylate, benzoic acid, and hyoscyamine that has a soothing effect on many irritative urinary tract symptoms.
There is no scientific evidence linking diet to painful bladder syndrome, but many doctors and patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inﬂammation. Some patients note that their symptoms worsen after eating or drinking products containing artificial sweeteners. Patients may try eliminating various items from their diet and reintroducing them one at a time to determine which, if any, affect their symptoms. Instruction in the basics of vulvar and perineal hygiene is important (thorough drying; avoidance of most body powders, perfumes, or colored irritating soaps; avoidance of tight-fitting undergarments) to avoid other factors that may contribute to painful voiding.
Hydrodistention of the bladder (usually under anesthesia) is recommended as a treatment option and can result in clinical improvement in some patients. Likewise, bladder installations are commonly used for acute treatment of bladder pain syndrome. The medications used range from local anesthetics to bladder specific medications including resiniferatoxin, dimethyl sulfoxide, BCG, pentosan polysulfate, and oxybutynin. Some patients benefit from the instillation into the bladder of 50 mL of a 50% solution of dimethylsulfoxide (DMSO) for 20 to 30 minutes every other week for four or five sessions. A recent Cochran review found that evidence is limited and randomized controlled trials are needed to adequately assess outcomes. Intravesical installations of BCG and oxybutynin are reasonably well tolerated, and evidence is the most promising for these agents (157).