Interstitial cystitis guideline reflects new thinking on diagnosis, treatment

Linthicum, MD-The AUA has finalized its first-ever clinical guideline for one of urology's most vexing conditions to diagnose and treat-interstitial cystitis.

The guideline for interstitial cystitis/bladder pain syndrome (IC/BPS)-as it is referred to in the document-represents a shift from earlier practice that often relied on more invasive tests and treatments. It bases diagnosis of uncomplicated presentations largely on symptoms and ruling out other pathologies, rather than on results of more invasive tests such as cystoscopy and hydrodistention or urodynamics. That will apply to most patients, guideline panel chair Philip M. Hanno, MD, MPH, professor of urology at the University of Pennsylvania, Philadelphia, told Urology Times.

The treatment algorithm also emphasizes noninvasive therapies in the earliest steps, progressing through less conservative approaches, but with pain management at every step and an emphasis on shared decision making with patients.

The document, Dr. Hanno said, "makes suggestions based on the evidence, but, given the nature of the disorder, the majority of it is up to the providers and how they and the patient want to move along the algorithm. It doesn't confine or restrict the relationship between the doctor and the patient and what they feel is the best thing to do."

Broad definition of condition used

The symptom-based diagnosis relies on a very broad definition of IC/BPS: "an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks' duration, in the absence of infection or other identifiable causes."

The guidance in the text, however, adds specifics, noting that pain is the hallmark symptom, although some patients may identify it as pressure or discomfort; that frequency is an almost universal symptom; and that urgency is nearly universal as well but is related more to pain than to fear of wetting. A careful history, physical exam, and lab tests to rule out other conditions are part of the initial assessment.

Although the guideline is very open, "It does make suggestions that are very important," Dr. Hanno said. In terms of diagnosis, one of those important suggestions is that the potassium test is not worthwhile, a point Dr. Hanno highlighted "because that's really been a problem." The test's results aren't specific and don't affect the treatment plan, and the test itself can be painful and risks triggering a severe symptom flare.

In addition, cystoscopy and urodynamics are not considered useful for uncomplicated presentations. Complicated presentations are considered those with incontinence, overactive bladder-type symptoms, gastrointestinal signs and symptoms, microscopic or gross hematuria, pyuria, or gynecologic signs and symptoms.