Chronic bladder pain syndrome · KIMS Secunderabad
Interstitial Cystitis / Bladder Pain Syndrome — Chronic Bladder Pain That Needs a Specialist
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic bladder condition characterised by persistent pelvic or bladder pain, pressure, or discomfort, accompanied by urinary urgency and frequency — in the absence of any identifiable infection or other pathology to explain the symptoms. It is a condition of exclusion — the diagnosis is made when recurrent UTI, bladder cancer, and other specific bladder conditions have been excluded. IC/BPS is poorly understood, frequently misdiagnosed (often labelled as 'recurrent UTI' despite negative urine cultures), and can profoundly impair quality of life — patients may void 15 to 60 times per day and have persistent pelvic pain that interferes with sleep, work, and daily activities.
IC/BPS is far more common in women than men (8 to 10:1 ratio) and affects an estimated 2 to 5 million women in India — though the true prevalence is uncertain due to widespread misdiagnosis. The mechanism is not fully understood — leading hypotheses include: defective bladder urothelial lining (impaired GAG layer), neurogenic inflammation, mast cell activation, and central sensitisation of the pelvic pain nervous system. Two distinct subtypes exist: IC with Hunner lesions (the classic form — identifiable specific inflammatory lesions on cystoscopy, affecting approximately 10 to 15% of IC patients) and IC without Hunner lesions (the more common form — normal-appearing or non-specific cystoscopy, with central sensitisation as the dominant mechanism).
Symptoms — the diagnostic criteria
Symptom complex of IC/BPS
Bladder or pelvic pain — the essential feature. Suprapubic, pelvic, perineal, or urethral pain or discomfort. Characteristically worsens as the bladder fills and partially improves after voiding. Worsens with certain foods (acidic, caffeinated, spicy — the IC diet trigger pattern).
Urinary frequency — voiding 15 to 60 times per day in severe cases. Unlike OAB where frequency is driven by urgency (the patient rushes to the toilet to prevent leakage), IC frequency is driven by pain relief (the patient voids to temporarily relieve bladder pain by emptying the bladder).
Nocturia — multiple voidings per night, with pain. Severe sleep disruption.
Urgency — the urge to void to relieve pain, not from fear of leakage (distinguishing it clinically from OAB).
Dyspareunia — pain during or after sexual intercourse, from bladder filling during penetration.
Absence of infection — urine cultures are consistently negative. This is the key distinguishing feature from recurrent UTI.
Diagnosis at KIMS — exclusion and characterisation
Urine culture and sensitivity — mandatory
Three consecutive negative urine cultures on freshly voided midstream specimens are required before IC/BPS can be considered. Any positive culture requires treatment and reassessment before an IC/BPS diagnosis is made.
Bladder diary — 3 to 7 days
Records voiding frequency, volumes, and pain scores. Provides objective data on voiding pattern and the relationship between bladder filling and pain.
Cystoscopy under general anaesthesia with hydrodistension
The defining diagnostic procedure. The bladder is distended with saline under anaesthesia and then the bladder wall is inspected. Two findings: Hunner lesions (in approximately 10–15% of IC patients) — distinct inflammatory ulcers or patches on the bladder wall that bleed on distension (glomerulations at the lesion margin). Pathognomonic of classic IC (IC Type 2). Hunner lesions require specific treatment with fulguration (laser or electrocautery) or intravesical steroids. Glomerulations only (no Hunner lesions — in IC without Hunner lesions) — petechial haemorrhages scattered across the bladder wall after hydrodistension. Less specific — may be seen in other conditions. Clinical correlation required.
Potassium sensitivity test (PST — Parson's test)
Intravesical instillation of potassium chloride — patients with IC have defective urothelial permeability and experience pain with KCl instillation. A positive PST supports the diagnosis but has moderate specificity.
Treatment — multimodal and patient-specific
Dietary modification
The IC diet avoids foods that irritate the urothelium: acidic foods (tomatoes, citrus), caffeine, alcohol, carbonated drinks, spicy foods, and artificial sweeteners. A 4-week elimination diet trial identifies individual food triggers. Calcium glycerophosphate (Prelief) neutralises food acid and reduces symptom flares.
Oral medications
Amitriptyline (low-dose — for central sensitisation and neuropathic pain reduction) · Pentosan polysulfate sodium (Elmiron — aims to restore the defective GAG layer; requires 3 to 6 months before benefit) · Hydroxyzine (mast cell stabiliser — for patients with a strong allergy or mast cell component) · Cyclosporine A (for severe refractory cases — potent immunosuppression).
Intravesical therapy
Dimethyl sulphoxide (DMSO — instilled into the bladder through a catheter weekly for 6 weeks; reduces inflammation and mast cell activation) · Intravesical heparin + lignocaine + sodium bicarbonate cocktail (restores the GAG layer) · Intravesical hyaluronic acid or chondroitin sulphate (GAG layer replacement).
Hunner lesion fulguration — for IC with Hunner lesions
Laser or electrocautery ablation of identified Hunner lesions at cystoscopy provides significant symptom relief in 60 to 90% of IC Type 2 patients. Symptoms may recur when new lesions form — repeat fulguration is effective.
Neuromodulation — for refractory IC/BPS
Sacral neuromodulation (InterStim) — an implanted sacral nerve stimulator that modulates the pelvic pain pathways and reduces bladder urgency and frequency. Effective in approximately 50 to 70% of carefully selected refractory IC patients. Transcutaneous tibial nerve stimulation (TTNS) is a non-implanted alternative.
IC/BPS is a condition that requires patience — both from the patient and the treating team. No single treatment works for all patients. The KIMS approach combines dietary modification, oral medications, and intravesical therapy in a staged protocol, with cystoscopy for Hunner lesion identification and fulguration where applicable. Most patients achieve significant improvement over 3 to 12 months of multimodal therapy.
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Frequently Asked Questions — Interstitial Cystitis
No — and this is the most important and most common misconception about IC/BPS. Bladder infections (UTI, cystitis) are caused by bacteria and produce positive urine cultures — they are treated with antibiotics and resolve. IC/BPS produces identical symptoms (frequency, urgency, pelvic pain) but urine cultures are consistently negative — no bacteria are present. Many women with IC are treated with repeated courses of antibiotics for presumed recurrent UTI without ever having a positive culture — experiencing temporary improvement (from the anti-inflammatory effects of antibiotics rather than their antibacterial action) followed by symptom return. Any woman with 'recurrent UTI' and consistently negative urine cultures should be assessed for IC/BPS.
A Hunner lesion (also called a Hunner's ulcer — though it is not a true ulcer) is a distinct inflammatory lesion on the bladder wall — appearing as a red, velvety patch with radiating small vessels that blanches on hydrodistension and bleeds around the margins. Hunner lesions are found in approximately 10 to 15% of IC/BPS patients and define IC Type 2 — the classic form of IC with a specific, identifiable bladder pathology. Their clinical importance: they respond specifically to fulguration (laser or electrocautery ablation) with 60 to 90% symptom improvement — a treatment that is far more effective for Hunner lesion IC than any oral medication.
The IC dietary triggers vary between individuals, but the most commonly reported: acidic foods (tomatoes, citrus fruits and juices, vinegar), caffeine (coffee, tea, energy drinks), alcohol (particularly wine and beer), carbonated fizzy drinks, spicy foods (chilli, pepper, hot sauces), artificial sweeteners (aspartame, saccharin), and cranberry juice (despite its reputation for UTI prevention — cranberry is highly acidic and worsens IC). A 4-week elimination diet removing all common triggers, followed by systematic reintroduction of one food at a time, identifies individual triggers. Calcium glycerophosphate (an alkalinising supplement available in India) taken before trigger foods neutralises dietary acid and reduces symptom flares.
IC/BPS is a chronic condition — there is currently no cure. The goal of treatment is sustained symptom control — reducing pain, frequency, and urgency to levels that allow a normal or near-normal quality of life. Many patients achieve significant symptom improvement with multimodal treatment (dietary changes, oral medications, intravesical therapy). For IC with Hunner lesions, fulguration provides prolonged remission (often 12 to 24 months) before symptoms recur — repeat fulguration is effective. The natural history of IC/BPS is variable — some patients have spontaneous periods of remission followed by flares; a proportion improve significantly over years without ever being completely asymptomatic.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU), systematic IC/BPS evaluation (3 consecutive urine cultures, bladder diary, cystoscopy with hydrodistension under GA, Hunner lesion identification and fulguration), intravesical DMSO, heparin-lignocaine cocktail, and hyaluronic acid programme, amitriptyline and pentosan polysulfate sodium, potassium sensitivity test, dietary counselling, neuromodulation for refractory cases. NABH and NABL accredited. Call 040-4488-5000.