Symptoms include severe and disabling urinary frequency and urgency, nocturia, and occasional dysuria and hematuria. Suprapubic, pelvic, urethral, vaginal, vulvar, or perineal pain is common and can be relieved to some extent by emptying of the bladder (111).
Pelvic examination usually reveals anterior vaginal wall and suprapubic tenderness. Pelvic ﬂoor muscles are invariably involved, and tender to palpation. Urinalysis may reveal microhematuria without pyuria, although results are usually normal.
The diagnosis is one of exclusion and is no longer based on cystoscopy. Patients who should be excluded include those younger than 18 years, those with symptoms for less than 9 months, absence of nocturia, frequency less than eight times per day, genitourinary infection (including bacterial cystitis, vaginitis, herpes), radiation-or chemotherapy-induced cystitis, bladder calculi, genitourinary cancers, lack of urgency with bladder filling greater than 350 cm3, involuntary bladder contractions, or relief with antibiotics, antispasmodic, or anticholinergics.
National Institutes of Health (NIH) Consensus Criteria for diagnosis of IC states that patients must have at least two of the following: (i) pain on bladder filling relieved by emptying, (ii) pain in suprapubic, pelvic, urethral, vaginal, or perineal region, (iii) glomerulations on endoscopy or decreased compliance on cystometrogram (111a).
Patients can be evaluated with cystoscopy with hydrodistension and biopsy. Petechial bladder mucosal hemorrhages (glomerulations) are characteristic of IC. The use of a pelvic pain and urgency or frequency symptom scale and a bladder potassium intravesical test can promote early diagnosis; it is still debatable whether a positive potassium test is definitive for interstitial cystitis or if a positive test is a manifestation of bladder hyperalgesia (112).
Although there is no definitive cure for IC/BPS, patients can achieve remission with multidisciplinary therapy. First-line treatments are primarily behavioral modification such as bladder training and stress management, cognitive-behavioral therapy, dietary modifications or restriction of acidic, spicy, and fermented foods, and pelvic ﬂoor muscle physical therapy. Urinary alkalinization can be useful (113). TCAs have been efficacious. Amitriptyline 10 mg can be taken at bedtime and titrated as tolerated up to 150 mg or to relief of symptoms. Amitriptyline has antihistaminic, anticholinergic, and sodium channel blocking properties that are potentially therapeutic for opposing the histamine from mast cell degranulation, the urinary frequency, and the neuropathic pain, respectively. Oral pentosan polysulfate sodium (PPS) is the only U.S. Food and Drug Administration (FDA) approved oral therapy for IC and is modestly beneficial (114). Pentosan polysulfate is a heparinlike moiety that resembles the GAG layer, but should not be used with NSAIDs because of the bleeding risk.
Intravesical therapy can be first or second-line. With an intravesical mixture of lidocaine, bicarbonate, and heparin instilled three times a week for 3 weeks, 57% of women reported resolution of pain (115). Dimethylsulfoxide (DMSO) is the only FDA approved intravesical treatment of IC. Intravesical 50% DMSO showed significant symptomatic improvement compared to placebo in two randomized controlled trials. Intravesical solutions containing dissolved PPS showed some promise but are not FDA approved and are under investigation (116).