Clinical Evaluation in IC

Comprehensive History

A thorough clinical examination ( fig 1) of the patient presenting with symptoms of interstitial cystitis (IC) should focus on a comprehensive patient history. Details of the onset, duration, location and characteristics of symptoms should be noted. Prior diagnosis of conditions known to overlap with IC symptoms should be excluded. History should be elicited with regards to relieving and aggravating factors of the symptoms.^1,2

Voiding Dairy

The voiding dairy is an important tool to determine baseline symptoms. All the patients are asked to maintain a voiding dairy, which records daily fluid intake and urine output. Certain foods such as alcohol, caffeine and carbonated drinks can cause irritation of the bladder. Awareness on this helps in exclusion of such food items and prevent worsening of symptoms. This also helps to evaluate the effectiveness of therapy.²

Physical Examination

A detailed examination of the abdomen, pelvis and neurologic system should be performed in all patients presenting with symptoms of IC. The physical examination should include palpation for a full bladder and a bimanual examination looking for adnexal masses. In addition, rectal examination to evaluate masses, tenderness and rectal and pelvic floor muscle tone should be performed. Further evaluation for other diagnosis such as spinal cord or nerve root dysfunction is indicated in the presence of abnormalities in sensory and motor function. In females, a thorough pelvic examination with bimanual examination and Papanicolaou (PAP) smear is mandatory. This helps to rule out diseases such as vaginitis, vulvar lesions and endometriosis.^{1, 2}

A few of the findings elicited during examination of both the sexes are as listed below:

• Discomfort with palpation over the urethra and bladder base in women
• Suprapubic tenderness on abdominal examination
• High tone pelvic floor muscle dysfunction
• Urethral tenderness correlating with the finding of Hunner ulcer on cystoscopy
• Pain in the perineum or prostrate regions on digital rectal examination in men ^{1, 2}

Symptom Scores¹

There are specific tools that aid in quantifying the symptoms of IC. These also help in distinguishing IC from other diagnosis such as urinary tract infections, prostatitis and benign prostatic hypertrophy. The two validated questionnaires for patients presenting with symptoms of IC are as follows:

• The O'Leary-Sant (OLS) symptom and problem index
• The pelvic pain and urgency/frequency (PUF) scale

O'Leary-Sant symptom index

It is an effective screening tool in patients with IC. The symptom index in this score measures urgency and pain in patients with IC. The problem index measures the degree to which patients experience each symptom. IC is diagnosed when a score of greater than 6 is noted in each symptom index. This also serves as an effective follow-up tool to monitor therapeutic benefits.

A detailed score index is available at http://www.medscape.com/viewarticle/564326.^{4, 5}

Pelvic PUF Symptom Scale

The PUF is a noninvasive screening tool to identify IC in patients presenting with chronic pelvic pain. This score focuses on the urgency/frequency issues in IC, and the pain and symptoms associated with sexual intercourse. A score of greater than 5 indicates 55% chance of PBS/IC, while patients with a score greater than 10 has 74% chance of PBS/IC. This is rated on a scale with a maximum score of 35. On an average, a score greater than 10 which includes scores for symptom, bother and total scores in the eight self-report items is highly suggestive of IC. Studies have shown a great correlation between a high PUF score and a positive potassium sensitivity test.

Details of PUF score is available at http://www.medscape.com/viewarticle/564326.^2,5

Diagnostic Criteria

The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) developed consensus criteria for the diagnosis of IC. These criteria developed in 1987 and 1988 aimed to ensure a comparable platform among the different groups of patients studied for symptoms of IC. However, these criteria have clinical limitations in defining IC and also in providing a set of diagnostic criteria. There is an emphasis on cystoscopic findings in this criteria. Though majority of the patients with IC do not fulfil these criteria, there definitely is a consensus among the specialists that the patients who do meet these criteria exhibit the clinical syndrome of IC. Listed below are few criteria for diagnosis of IC as developed by NIDDK.

• Presence of urinary urgency and frequency
• A negative urine culture
• Pelvic /perineal pain
• Absence of genitourinary infections, neoplastic diseases, history of radiation or chemical cystitis ⁶

The NIDDK criteria are available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1476008.