A 40-year-old woman comes to the office due to increasing pelvic pain and urinary urgency for the last few months. The patient initially had increasing urgency and was voiding every 1-2 hours. She now has increasing pelvic pain and pressure that requires her to void every 30-45 minutes. The patient's pelvic pain is typically relieved with voiding but returns prior to her next void. She has had no hematuria, postcoital bleeding, or urinary leakage.
The patient has fibromyalgia and type 2 diabetes mellitus. She had 2 vaginal deliveries in her late 20s. She is sexually active with a male partner and has had a tubal ligation. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. BMI is 28 kg/m². On pelvic examination, the external genitalia and vagina appear normal and well-supported. The cervix is multiparous and nonfriable, and physiologic discharge is noted throughout the vaginal vault. On bimanual examination, there is tenderness to palpation over the urethra but no cervical motion tenderness.
Laboratory results are as follows:
Urine culture and pregnancy test are negative.
Which of the following is the most likely diagnosis in this patient?

Question

A 40-year-old woman comes to the office due to increasing pelvic pain and urinary urgency for the last few months. The patient initially had increasing urgency and was voiding every 1-2 hours. She now has increasing pelvic pain and pressure that requires her to void every 30-45 minutes. The patient's pelvic pain is typically relieved with voiding but returns prior to her next void. She has had no hematuria, postcoital bleeding, or urinary leakage.
The patient has fibromyalgia and type 2 diabetes mellitus. She had 2 vaginal deliveries in her late 20s. She is sexually active with a male partner and has had a tubal ligation. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. BMI is 28 kg/m². On pelvic examination, the external genitalia and vagina appear normal and well-supported. The cervix is multiparous and nonfriable, and physiologic discharge is noted throughout the vaginal vault. On bimanual examination, there is tenderness to palpation over the urethra but no cervical motion tenderness.
Laboratory results are as follows:

Urine culture and pregnancy test are negative.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_97ec_83fc_853d_fdd89be60907_MD0002_00 This patient's urinary urgency and increasing pelvic pain and pressure relieved with voiding are due to interstitial cystitis, or bladder pain syndrome (IC/BPS). Because pain worsens with a full bladder, patients urinate more often (frequency) and at lower bladder volumes (urgency). Although the etiology is poorly understood, patients with IC/BPS likely have bladder pain from urothelial damage and increased pain sensitization, creating an abnormal pain trigger during bladder filling at normal volumes and urethral tenderness with palpation. Urinalysis is typically normal. Treatment of IC/BPS is not curative and, therefore, focuses on patient education, quality of life, and avoidance of triggers. Some oral pharmacotherapies improve symptoms; the most common treatments include amitriptyline and pentosan polysulfate sodium. Amitriptyline, a tricyclic anticholinergic, relieves bladder pain and associated depressive symptoms; however, side effects (eg, dry mouth, orthostatic hypotension) limit its use. Pentosan polysulfate sodium repairs the urothelium, has minimal side effects (eg, mild reversible hair loss), and is approved by the FDA for the treatment of IC/BPS. Bladder instillation therapy (eg, hydrodistension), intradetrusor botulinum toxin, and sacral neuromodulation are reserved for severe or refractory cases. (Choice A) Pelvic organ prolapse (eg, cystocele) creates a bulge sensation and may have associated stress urinary incontinence due to the loss of anterior vaginal wall support. Although vaginal delivery is a risk factor for prolapse, this patient has no evidence of cystocele on examination. (Choice C) Patients with a neurogenic bladder have chronic urinary retention due to peripheral neuropathy (eg, diabetes mellitus); impaired detrusor contractility and decreased sensation of bladder filling cause incomplete bladder emptying. Therefore, patients have constant dribbling from urine overflow with no associated pelvic pain. (Choice D) Nongonococcal urethritis, caused by atypical bacteria (eg, Chlamydia trachomatis, Mycoplasma genitalium), presents with urinary frequency, urethral tenderness, and sterile pyuria (ie, elevated white blood cells on urinalysis and a negative urine culture). However, patients usually have associated cervicitis (eg, postcoital bleeding, cervical motion tenderness) and pain with voiding (ie, dysuria). (Choice E) In patients with overactive bladder, or urgency incontinence, involuntary detrusor contractions cause immediate loss of urine. Although bladder spasms may cause intermittent pain, this patient has no urinary leakage. Educational objective: Interstitial cystitis causes chronic pelvic pain that increases with bladder filling and is relieved with voiding. Urinalysis is typically normal. Treatment includes patient education, avoidance of triggers, and oral pharmacotherapy (eg, amitriptyline, pentosan polysulfate sodium). __________ References: Current pharmacologic approaches in painful bladder research: an update. (http://www.ncbi.nlm.nih.gov/pubmed/29298474) Interstitial cystitis/bladder pain syndrome: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/23430074)

A 40-Year-Old Woman Comes to the Office Due to Increasing