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Interstitial cystitis (IC) is considered a diagnosis of exclusion. According to the National Institutes of Health (NIH) IC research criteria, IC is characterized by "painful bladder symptoms in the absence of infection or other identifiable conditions." Diagnostic evaluation includes symptom history, urine culture to rule out bacterial infection, and tests to exclude other conditions such as pelvic inflammatory disease, sexually transmitted disease or bladder cancer. Endometriosis and vulvodynia also need to be ruled out. However, they may exist along with IC. In addition, kidney disease, bladder calculi (stone formation), tuberculosis and radiation cystitis must be ruled out.

After other disease processes have been excluded, the "gold standard" examination to confirm the diagnosis of IC is cystoscopy with hydrodistention under general or regional anesthesia. This procedure involves slowly stretching the bladder with fluid, thereby allowing your physician to see changes that are typical of IC. Some of these changes include the presence of glomerulations (pinpoint hemorrhages that occur on the bladder wall, and are seen in the majority of IC patients), or Hunner's ulcers (or patches), which may be present in a small minority. Ten percent of patients who present with symptoms of IC have neither glomerulations nor Hunner's ulcers upon cystoscopy with hydrodistention. However, these patients may have IC, and need to receive treatment for their symptoms.

Cystoscopy with hydrodistention is not performed in your doctor's office. This is because the bladder needs to be filled to a high pressure in order to see the typical abnormalities of IC, a pressure that would cause significant pain to an IC patient (or even a patient who does not have IC), who was not anesthetized. In addition, in-office cystoscopy may not reveal the glomerulations on your bladder which are the hallmark of IC, and the diagnosis may be missed.

 

Cystoscopy with hydrodistention is usually performed as an outpatient surgical procedure. You will be admitted to the hospital, but in most cases, you will be discharged the same day as the procedure. Prior to this procedure, you may be required to have basic blood work done, just as you would before any surgery. During the cystoscopy with hydrodistention, you will be given general anesthesia, or your pelvic region will be numbed by spinal nerve-blocking agents. You will not feel any pain during the procedure.

A cystoscope, which is used to examine the interior of the bladder, will be inserted through your urethra and into your bladder. This "scope," which is fitted with a miniature camera, will enable your physician to see the interior surface of your bladder. Once the cystoscopic examination has been performed, the bladder is filled to a high pressure with fluid (hydrodistended). The hydrodistention causes the bladder wall to stretch out, allowing your physician to inspect for the typical changes of IC. The cystoscope may also be fitted with instruments for obtaining biopsies of your bladder wall. While biopsy is not necessary for the diagnosis of IC, it is useful in ruling out bladder cancer, and can be helpful in determining if there are increased numbers of mast cells in the bladder wall, which may support the diagnosis of IC.

Hydrodistention may reduce pain and discomfort in some IC patients, and therefore may be therapeutic as well as diagnostic. IC patients who are helped by hydrodistention report improvement that lasts 3 to 6 months, at which time the procedure may be repeated for continued therapeutic benefits. Not all IC patients are helped by this procedure. It may take up to several weeks to notice any improvement from the hydrodistention. No additional treatment measures (e.g., DMSO, Clorpactin, silver nitrate) should be performed during the cystoscopy with hydrodistention procedure.

 

Hydrodistention was first advocated for use in the management of IC in 1930. It is believed that the distention of the bladder wall may cause the nerves to go into a "state of shock," thereby stopping the transmission of pain. Also, it may stimulate production of bladder surface mucin, the normal protective coating of the bladder surface. Hydrodistention is performed by filling your bladder to 80 cm water pressure for 8 minutes, at which point the bladder is drained and re-filled. A portion of the drained fluid is often blood-tinged. If you have IC, re-inspection of the bladder will most likely reveal the pinpoint hemorrhages (the hallmark finding in IC patients) that develop throughout the bladder after distention.

After the Procedure: After the cystoscopy with hydrodistention procedure, you will be moved to a recovery room. As the anesthesia begins to wear off, you may experience pelvic pressure and/or pain. You will be required to urinate before being discharged from the hospital. Typically, your first voids after this procedure can be painful, and your urine may contain blood. A catheter is not commonly left in place after this procedure, as IC patients tend to experience pain with prolonged catheterization. Remember to ask for pain-relieving medications upon being discharged from the hospital. Oral pain-reducing medications can be prescribed to help alleviate any discomfort you may experience following the procedure. You may experience some discomfort for several weeks, including pelvic pain and/or urethral burning.

Your physician will schedule a follow-up appointment with you to discuss various IC treatment options. If bladder instillations are being considered as a possible treatment, they should not be initiated until your bladder has had time to recover from the cystoscopy with hydrodistention, usually 3 to 4 after the procedure.

 

• Sant, G and Hanno, P, Interstitial Cystitis: Current Issues and Controversies in Diagnosis, Urology: Interstitial Cystitis Supplement to June, 2001, Philip M. Hanno, MD, Vicki Ratner, MD, Grannum R. Sant, MD and Alan J. Wein, MD, Editors, pp. 82-88.
• Pontari, M, et al, Logical and Systematic Approach to the Evaluation and Management of Patients Suspected of Having interstitial Cystitis, Urology: Interstitial Cystitis Supplement to May 1997, Alan J. Wein, MD & Philip M. Hanno, MD, Editors, pp. 114-120.
• Interstitial Cystitis: Clinical and Endoscopic Features. Denise A. Nigro & Alan J. Wein, in Interstitial Cystitis, Sant, ed., 1997.