A 47-year-old woman comes to the office due to lower abdominal pain that is relieved with urination. The pain has worsened over the past 2 months and she now urinates hourly to minimize the pain. The patient is sexually active but has avoided intercourse recently because it has become painful. She had 4 vaginal deliveries in her 30s and a tubal ligation after her last delivery. The patient has irritable bowel syndrome and takes no medications. Vital signs are normal. BMI is 27 kg/m². There is tenderness to palpation over the lower abdomen. On bimanual examination, the anterior vaginal wall is tender to palpation, but there is no cervical motion tenderness. The remainder of the pelvic examination is normal, and Valsalva does not elicit any noticeable changes. Urinalysis results are as follows: A urine culture is negative. Which of the following is the most likely diagnosis in this patient?

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Quizplus · Accepted Answer

11ec25c8_d9c7_3247_bc81_89406de9a246_MD0003_00 Interstitial cystitis (IC) (also known as painful bladder syndrome) is a chronic, painful bladder condition of uncertain etiology. Patients typically have pain that is exacerbated by bladder filling and relieved by voiding. Symptom onset is typically gradual and worsens over a period of months. Other clinical features include urinary frequency and urgency, chronic pelvic pain, and dyspareunia. IC typically presents in women age >40 and is associated with other chronic pain conditions (eg, fibromyalgia, endometriosis, irritable bowel syndrome), sexual dysfunction, and psychiatric illness (eg, depression, anxiety). The diagnosis of IC is largely clinical; however, additional laboratory testing-including a urinalysis, postvoid residual, and sexually transmitted infection screening-is performed to exclude other conditions (eg, cystitis, urinary obstruction, malignancy). Management includes bladder training, fluid management, analgesics, and avoidance of any precipitating agents (eg, caffeine, alcohol, artificial sweeteners). (Choice A) Cystocele (bladder prolapse into the anterior vaginal wall) may cause dyspareunia and urinary symptoms (eg, frequency). Although cystoceles are common in multiparous women, this patient has no changes on pelvic examination with Valsalva (ie, no prolapse). (Choice C) An overactive bladder presents with urinary urgency (an intense need to urinate) that can be accompanied by nocturia and frequency. There is no associated dyspareunia or pelvic pain relieved with voiding. (Choice D) Pelvic inflammatory disease typically presents with lower abdominal pain and dyspareunia; however, patients typically have concomitant cervical motion or adnexal tenderness, making this diagnosis unlikely. (Choice E) A urethral diverticulum, an abnormal outpouching of the urethra, can cause urethral tenderness, urinary frequency, and dyspareunia. However, it also typically presents with a tender anterior vaginal mass, purulent urethral discharge, and increased pain with voiding. Educational objective: Interstitial cystitis (painful bladder syndrome) is an idiopathic, chronic condition characterized by pain that is exacerbated by bladder filling and relieved by voiding. Additional clinical features may include dyspareunia and urinary frequency and urgency. References: Advances in diagnosis and treatment of interstitial cystitis/painful bladder syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25416849) Treating interstitial cystitis/bladder pain syndrome as a chronic disease. (http://www.ncbi.nlm.nih.gov/pubmed/25009448)

A 47-Year-Old Woman Comes to the Office Due to Lower