Interstitial Cystitis and Chronic Pelvic Pain: Present Views on Definition, Clinical Presentation and Management

Interstitial cystitis (IC) is a clinical syndrome defined by chronic symptoms of urgency, frequency, and/or pain associated with the bladder and unexplained by any other reasonable causation. The presence of IC is usually difficult to detect, both because of the intermittent and progressive nature of the symptoms and because the disease is easily mistaken for other urologic and gynaecologic disorders. The intravesical potassium sensitivity test helps to identify the presence of IC by detecting the abnormal bladder epithelial permeability that is present in most individuals with IC. Treatments for IC have ranged from pharmacological treatments that anaesthetize the bladder to antihistamines or drugs that reintegrate urothelial permeability, pain medications including tricyclic antidepressants. New options have been tried in cases refractory to more usual treatments, such as oral pentosanpolisulfate, and intravesical administration of different medications: dimetilsulfoxide (RIMSO), heparin, hyaluronic acid, BCG. More recently, detrusor infiltration with botulinum toxin by cystoscopy, and sacral neuromodulation have been tried. Some time and more extensive experience will be needed to evaluate the results of these new treatment modalities. Definition and diagnosis of IC The diagnosis and management of interstitial cystitis (IC) has a long and varied history. Leading theories for its pathogenesis include deficit of urothelial permeability, increased activity of mast cells, immuno-neural mechanisms and neuroplasticity, infectious etiologies. The diagnosis of this syndrome was vague until 1987, when the US NIDDK developed criteria that were to be used in national research studies. Agarwal, O'Reilly & Dixon state "The criteria were intended to be for research purposes, to compare the patient population in various research studies, but because there were no other clinical guidelines, they were adopted by urologists worldwide for diagnosing patients"(1). The problem, though, was that not all IC patients in a typical urology practice met these strict guidelines. A patient with frequency, urgency or pain, with no evidence of petechial hemorrhages, may have been told that they had psychiatric problems. NIDDK criteria are therefore much too restrictive for clinical usage, and have resulted in many patients being left undiagnosed, and possibly untreated. A recent study (2), although confirming the research utility of the NIDDK criteria, shows that over 60 % of cases would not have been diagnosed if clinicians relied on the need to meet the NIDDK criteria to make the diagnosis; besides, IC has even been described in children (3), and should not be considered an unknown condition in men (4, 5). To the extent that treatment is delayed because of this, does patients a great disservice. The challenge to clinicians, when facing IC, is to diagnose the condition early and initiate therapy. IC is still a diagnosis of exclusion, and since patients do not typically report a full constellation of symptoms at onset, it is useful to understand how the earliest symptoms appear. It is now