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Diagnosis of PBS/IC
Sang-Kuk Yang
Konkuk University
Diagnosis : NIDDK
 NIDDK criteria
 developed at 1987 NIDDK conference  revised in 1988
 developed to standardize criteria for entrance into research protocols
 inclusion criteria
• must have glomerulation or Hunner’s ulcers on hydrodistention
 exclusion criteria
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bladder capacity >350cc
phasic involuntary contractions
duration of symptoms < 9months
Frequency < 8/day
Age < 18 years
Hanno PM et al. J Urol 1999;161:553-7
Diagnosis : NIDDK ICDB
 NIDDK ICDB criteria
 Broaden criteria – include IC-like patients
 Unexplained urgency or frequency or pelvic pain of 6 months
 baseline cystoscopy : not mandatory
 less strict than the NIDDK criteria
 NIDDK criteria : too restrictive for clinical use
 ICDB criteria : led to increasing numbers of patients being
diagnosed
Hanno PM et al. J Urol 1999;161:553-7
Definition of ICS
 Painful bladder syndrome
 the complaint of suprapubic pain related to bladder filling, accompanied
by other symptoms such as increased daytime and night-time frequency, in
the absence of proven urinary infection or other obvious pathology
 Interstitial cystitis : subset of PBS
 a specific diagnosis and requires confirmation by typical cystoscopic
and histologic features “Without specific definition of bladder lesion”
Abrams P et al. Neurourol Urodyn 2003;21:167-78
Disparity in Prevalence data
Prevalence varys Widely depending upon Definition and methodology
Multifactorial etiology of
PBS/IC
PBS becoms BPS ?
Interstitial cystitis
Bladder pain syndrome
Urological
Pelvic pain syndrome
Chronic pelvic pain
Diagnosis : Clinical History
 Symptoms
Pelvic pain : essential
• Typical suprapubic pressure sensation
• Pain should be brodened to “pressure” and “ discomfort”
• Pain in lower abdomen, low back, inguinal area, vagina, urethra,
scrotum or testes, multiple locations
• Pain with/after intercourse in vagina, penile shaft can last for days.
• Dysuria
• Over 50% with constant pain – severity is highly variable
• Pain characterized as spasms, worse in upright position, worse with
emotional stress
Diagnosis : Clinical History
 Symptoms
Frequency / Urgency
 Frequency : May be presenting Symptom
 Urgency : Confused with OAB Sx
 often develops gradually – not noticed immediately
 8~60 voids/day
 nocturia - variable
Diagnosis : Problem
 Symptoms
Problems
 the diagnosis of PBS/IC is clinical and based on symptomatology
 PBS/IC is a diagnosis of exclusion.
 there is no evidence to qualify or quantify the symptoms to include or
exclude patients from the diagnosis of PBS/IC.
Differential Diagnosis
Urological disorders
Overacitive bladder
Bacterial cystitis
Chronic abacterial prostatitis (CPPS)
CIS bladder/Carcinoma
Urethritis
Urethral diverticulum (symptomatic)
Urethral or bladder calculus
Radiation cystitis
Gynocological disorders
Endometriosis
Pelvic inflammatory disease
Vulvadynia
Vulvar vestibultitis
Vaginitis
Urogenital atrophy
Active herpes infection
Pelvic malignancy/Large fibroid
Major pelvic prolapse
Gastrointestinal disorders
Irritable bowel syndrome
Inflammatory bowel disease
GI pelvic malignancy
Colovesical fistula
Diverticular disease
Hernia
Diagnosis : Sx index
 Clinical symptom scales
 evaluate the severity of symptomatology
monitor disease progression or regression
 O’Leary/Sant symptom index = ICSI
 University of Wisconsin
 Pelvic pain (VAS) and Urgency/Frequency Scale
Problems
 None shown to be of value for diagnosis
Diagnosis : PE
 Physical examination
 abdominal, pelvic and neurological exam findings
 suprapubic tenderness to deep palpation on bimanual exam
 bladder base and urethra tender in females
 spasticity of levator muscles
 males with normal genitalia and DRE
 exam must R/O : active vaginitis, urethral diverticulum, CaP, POP
Diagnosis
 Hydrodistention under cystoscopy
 Method
• should be done under anesthesia to allow sufficient distention
• irrigant should be 80~100 cm H2O above bladder to avoid rupture
• distention held at capacity for 1~2 mins, then drained
 Positive findings
• glomerulations
• Hunner’s ulcer
• Fissures and Fibrosis that bleeds
 Important to R/O – CIS, papillary bladder cancer
Diagnosis : Hydrodistention
 Hydrodistention under cystoscopy
Problems
 cystoscopic findings (Hunner’s ulcer, glomerulations) are not well
described and classified
 glomerulations not specific for IC – seen in most inflammations
 glomerulations absent in up to 20% of patients with classic symptoms
 no correlation between degree of glomerulations and symptoms
 research into treatment results and prognosis as related to
cystoscopic findings is needed.
 only Hunner’s ulcers – diagnostic for IC
Glomerulation in ureter stone patient
Diagnosis : Cystoscopy
 Hydrodistention under anesthesia
Glomerulation
Hunner’s ulcer
Diagnosis : PST
 Potassium sensitivity test (PST, Parsons test)
 Saline vs 0.2 M KCl infusion : 500 cc
 positive test may indicate increased permeability and/or increased
neural activity.
 easy to perform – office procedure
Problems
 not recommended as diagnostic tool – inflammatory diseases like
radiation and bacterial cystitis, malignancy have positive test.
 not physiologic of concentration of KCl
 Low sensitivity (69.5%) low specificity (50%, positive, chronic
prostatitis, gynecologic pain)
Parsons CL et al. Neurourol Urodyn 1994;13:515-20, Chambers GK et al. J Urol 1999;162:699-701
Diagnosis : UDS
OAB
PBS/IC
Pain
Overlapping Sx of PBS with OAB
Kirkemo A et al. Urology 1997; 49 suppl 1:76-80
Diagnosis : Bladder biopsy
 Bladder biopsy
 confirm diagnosis and for DDx
 pathologic findings are not well described and classified
 therapeutic benefit from accompanying hydrodistention
 Fibrosis – prognostic value
 research purposes
Problems
 costs and complications
 No pathognomonic findings
Sant GR etl al. Urology 2001;57 suppl 1:82-8
Diagnosis : Clinical markers
 Antiproliferative factor (APF)
 unique protein found only in urine of IC patients
 APF is expressed solely in the bladder epithelium of IC patients with
no expression evident in normal human bladder epithelial cells.
 APF activity and altered levels of HB-EGF and EGF identified in IC
urine are related
 APF up-regulates bladder epithelial cell production of EFG and downregulates production of HB-EGF in vitro
Erickson DR et al. Urology 2001;57 suppl 1:15-21, Erickson DR et al. J Urol 2007;177:556-60
Diagnosis : Clinical markers
 Antiproliferative factor (APF)
Implications
 APF may cause the epithelial thinning or ulceration seen in IC
 urine APF may be useful as a diagnostic biomarker for IC, and as a
disease parameter for treatment studies
 agents that inhibit APF production or activity may potentially be useful
for the treatment of IC
When Suspect IC/PBS ?
Pain, Frequency/Nocturia and Urgency
AND
Physical exam excludes Vaginitis, Urethral
or Vulvar lesion or Infection
AND
UA is negative for Hematuria
AND
Urine culture during symptoms is Negative
AND
No Hx of Neurological problem, Pelvic trauma,
Malignancy of recent Pelvic Surgery
Beset with Problem
 Lack of uniform definition PBS/IC
 Unknown etiology
 Uncertain pathophysiology
 Lack of standardized methodology
 Lack of readily available diagnostic marker
What is Needed ?
 Evidence-based, symptom-specific definition
 Studies on true incidence, prevalence, natural history, risk
factor
 Validate diagnostic marker
 Ability to differentiate PBS/IC from myriad of other
causes of voiding dysfunction and bladder pain