The Interstitial cystitis patient
History: A Thirty-four year old female presented with urinary frequency and urgency which occurred in the daytime and nighttime and had been present for 5 months. The patient voided 4 times per evening. She also described pelvic "discomfort" which subsided for a short time after emptying her bladder. The patient also noted moderate pain with sexual intercourse. There were no complaints of urinary leakage nor was there any recent history of urinary tract infection. Her local doctor performed several urine cultures and found them to be negative. Nevertheless, he gave the patient several trials of antibiotics; all failed to improve the patients symptoms. The patient was placed on bladder relaxant and showed little clinical improvement. The patient was sent for urological consultation.

Physical examination: Some mild tenderness of the lower abdomen was noted. The pelvic examination demonstrated discomfort when the front portion of the vaginal wall was pressed.

Laboratory testing:
  • Urinalysis: negative
  • Urine culture (we will often look for very low colony counts of bacteria): negative
  • Urine cytology (a urine test to look for bladder cancers): negative
  • Bladder Scan (a test to measure the amount of urine left behind in the bladder after voiding): no urine left behind
  • 48 Hour Voiding diary: the interval between voids ranged from every 15 minutes to 45 minutes. Voided volumes ranged from 1/2 ounce to 3 1/2 ounces.
Can other tests be performed? 
They can but it depends on the patient and the clinical circumstances. Other tests might include: urodynamic evaluation (bladder function testing), kidney x-rays, CAT scans or pelvic ultrasound exams, cultures for sexually transmitted diseases; the patient might need to be evaluated by a gynecologist with vaginoscopy, culposcopy, or even laparoscopy if a gynecological problem is suspected. For the time being, were going to keep this patient problem pretty "simple."
Interstitial cystitis is strongly suspected. The urologist counseled the patient regarding hydrodistention of the bladder and the ambulatory procedure was scheduled.

Hydrodistention findings: Cystoscopy (this means looking into the bladder with a special instrument called a cystoscope) demonstrated no bladder cancers or any inflammatory lesions, i.e., Hunners ulcers. The bladder was distended and 700 cc of fluid could be instilled (normal anesthetic bladder capacity ranges from 800-1200cc). No bladder tears were noted during the filling process. Few glomerulations (small bleeding points that occur in many IC patients during hydrodistention) were seen.
Now, lets review this patients diagnostic work-up a bit. This patient had many of the typical symptoms of IC. She was voiding very frequently "around the clock" with relatively small volumes. She gave no history of associated problems like a poor urinary stream or constipation, symptoms that would make me suspect abnormalities like PFD. She had some associated pelvic discomfort and physical examination demonstrated some bladder tenderness. No uterine or ovarian problems were detected on the pelvic examination either. Its now looking more and more like this problem is restricted to the bladder. The patients laboratory work showed no evidence of infection or cancer.

Hydrodistention was performed for several reasons:

1. To firm up the diagnosis. Please note that the only problem detected on hydrodistention was a slight decrease in the patients bladder capacity. Can you have a decrease in your bladder capacity and not have IC? Absolutely. Glomerulations were not seen to any significant degree but does this mean that the patient doesnt have IC? - Absolutely not! In this instance, the hydrodistention helped confirm the diagnosis but certainly didnt "make" the diagnosis. On the other hand, I have been surprised at the hydrodistention findings of some patients, where I was not particularly impressed with the patients history or exam but the distention findings showed very severe disease.

2. To actually see how bad the bladder problem is. The bladder can be inspected for tumors or inflammation. The "anesthetic bladder capacity" (the capacity of the bladder at a given water pressure, usually 80 cm H2O, while the patient is under anesthesia) gives the physician an idea of how "significant" the problem is. This patients bladder capacity was slightly below normal. If her capacity was 300 cc, Ill likely have more problems with the patient related to capacity issues. Thats the type of patient that I might want to start with bladder retraining protocols early, once their pain is under control.

3. To potentially improve patient symptoms. Hydrodistention may improve symptoms in 30-60% of IC patients.