Interstitial Cystitis, Bladder Pain, and Chronic Pelvic Pain
These are the patients who have been told “it's all in your head,” who have been through five courses of antibiotics for negative cultures, and who arrive angry and exhausted. They are also among the most rewarding patients you will treat, because…
31 pathway steps4 pathways2 local-policy steps
Your learning progress0 of 31 chapters complete
Saved privately in this browser and shared across state tabs.
Didactics
Shared across all locations
These are the
patients who have been told “it's all in your head,” who have
been through five courses of antibiotics for negative cultures, and
who arrive angry and exhausted. They are also among the most
rewarding patients you will treat, because almost nobody has actually
listened to them or offered a coherent plan. Chronic pelvic pain is
real, it is treatable, and it requires a multimodal approach — not
another antibiotic.
Definition
— an unpleasant sensation (pain, pressure, discomfort) PERCEIVED to
be related to the bladder, associated with lower urinary tract
symptoms of more than 6 weeks' duration, in the ABSENCE of infection
or other identifiable causes. Note the emphasis: the defining symptom
is PAIN, not urgency. That is what separates IC/BPS from OAB.
Feature
IC / BPS
OAB
Driving symptom
PAIN/pressure, worsening as the bladder FILLS and relieved by
voiding
URGENCY — a fear of leaking, not pain
Why they void frequently
To relieve pain
To avoid incontinence
Nocturia
Common
Common
Incontinence
Uncommon
Common (OAB-wet)
Response to OAB drugs
Poor
Good
Diagnose
by exclusion and by pattern: negative cultures (repeatedly), a
normal urinalysis, no hematuria (if there is hematuria, work it up —
Chapter 3), and a pain pattern tied to bladder filling. Ask about
flares and triggers (foods, stress, menses, intercourse).
Exclude
the mimics: bladder cancer/CIS (irritative symptoms + hematuria
— cystoscope them, especially smokers over 40), recurrent UTI,
urethral diverticulum, endometriosis, pelvic floor dysfunction, and
bladder stones.
Examine
the pelvic floor. A large proportion of IC/BPS patients have a
hypertonic, exquisitely tender pelvic floor — and in many of them,
that is the actual primary problem. Palpate the levators; if
pressing on them reproduces their pain, you have found something
treatable.
Hunner
lesions: a distinct phenotype (~5–10%) — inflammatory
patches seen on cystoscopy with hydrodistension. They respond
specifically and dramatically to fulguration or triamcinolone
injection. Identifying them changes everything, which is why
cystoscopy has real value in refractory patients.
27.2 Treating IC/BPS — a stepwise, multimodal
plan
Set expectations
at the first visit: the goal is control and flare-reduction, not
necessarily a cure. Patients who understand this do far better than
those promised a fix.
Tier
Interventions
Behavioral / first-line
Patient education; the IC DIET — eliminate the classic bladder
irritants (coffee, tea, alcohol, carbonated and citrus drinks,
tomatoes, spicy food, artificial sweeteners, chocolate), then
reintroduce systematically to find the individual triggers;
stress management; timed voiding and bladder training; heat/cold;
avoid constipation
Pelvic floor physical therapy
MANUAL therapy by a therapist trained in internal pelvic floor
work. This is a cornerstone and is strongly recommended — and
it is often the single most effective intervention. Do NOT
prescribe Kegels: strengthening a hypertonic pelvic floor makes
it worse
Oral therapy — our practice first-line
Our two first-line oral agents are HYDROXYZINE (an
antihistamine/mast-cell stabilizer — it calms bladder mast-cell
activation, helps the urgency and the sleep, and is especially
useful in patients with an allergic or atopic history; dose at
bedtime and warn about sedation) and URO-MP (a urinary
analgesic/antispasmodic combination that directly relieves the
bladder pain, pressure, and dysuria). Start with these two.
Oral therapy — add-on
If the first-line pair is insufficient: amitriptyline (helps
pain, urgency, and sleep — a good next agent) and the
neuromodulators gabapentin or pregabalin for the centrally
sensitized patient. NOTE: we do NOT use pentosan polysulfate
(Elmiron) — see below
Procedural — and the ONLY route for intravesical therapy
At Central Ohio Urology Group, intravesical therapy is delivered only at
the time of cystoscopy with hydrodistension, performed in the
office or the ASC — we do not run standalone series of office
bladder instillations. Hydrodistension is both DIAGNOSTIC
(identifying Hunner lesions and glomerulations) and THERAPEUTIC
(relief lasting months in many patients), and the intravesical
agent is instilled at that same setting. Also at this setting:
fulguration or triamcinolone injection of Hunner lesions
(dramatically effective in that phenotype)
Advanced procedural
Intradetrusor onabotulinumtoxinA; sacral neuromodulation
(InterStim) — an excellent option given our InterStim
experience (Chapter 5)
What NOT to do — the four rules
Do NOT use Elmiron (pentosan
polysulfate). We have removed it from our armamentarium.
Long-term use causes a distinctive PIGMENTARY MACULOPATHY —
irreversible retinal damage and vision loss — and its efficacy
is marginal at best. The risk-benefit does not justify it. If a
patient arrives on Elmiron, discuss stopping it and refer for a
retinal exam.
Do NOT use cyclosporine A.
It is too toxic for a benign, non-life-threatening condition —
nephrotoxicity, hypertension, immunosuppression, and malignancy
risk. We do not use it.
Do NOT give repeated courses
of antibiotics for negative cultures. It is the most common thing
done to these patients, it does not work, and it delays real
treatment.
Do NOT perform prolonged,
high-pressure hydrodistension — it can rupture the bladder.
Do NOT dismiss them. These patients have usually been
dismissed many times, and the therapeutic alliance is a large
part of the treatment.
NEVER do a cystectomy with urinary
diversion for benign disease
This is an absolute at
Central Ohio Urology Group. Removing a bladder and building a diversion is
a major, irreversible operation with lifelong consequences —
stoma or neobladder care, metabolic derangement, stones,
infections, reoperation, and real perioperative mortality. It is
justified for CANCER. It is not justified for IC/BPS, chronic
pelvic pain, or any other benign condition.
The reason it fails is
biological, not technical: the pain in these patients is
CENTRALLY SENSITIZED (Section 27.5). Take the bladder out and a
large share of patients still hurt — except now they hurt AND
they have a urinary diversion for the rest of their lives. You
have removed the organ and left the disease.
If a desperate patient asks for it — and they will —
the answer is to intensify multimodal therapy (pelvic floor PT,
neuromodulators, hydrodistension, Botox, InterStim, pain
psychology), not to operate. Escalate the conversation to the
physician; do not let anyone talk you into this.
27.3 Chronic prostatitis / chronic pelvic pain
syndrome (CP/CPPS) in men
The male
analogue: chronic pelvic, perineal, suprapubic, penile, or
ejaculatory pain WITHOUT infection (NIH category III — Chapter 6).
It is far more common than bacterial prostatitis, and it is not a
prostate infection despite the name.
Use the UPOINT
phenotype to direct therapy — score the patient across six
domains and treat the domains that are positive — this is a
validated approach and it dramatically outperforms giving everyone
the same antibiotic:
UPOINT domain
Finding
Treatment
Urinary
LUTS, elevated PVR, obstructive symptoms
Alpha-blocker; treat the outlet
Psychosocial
Depression, anxiety, catastrophizing
Cognitive behavioral therapy, counseling — do not skip this; it
is a major driver of outcome
Organ-specific
Prostate tenderness, hematospermia
Anti-inflammatories; quercetin/pollen extract; occasionally a
limited antibiotic trial
Infection
Documented positive localization culture
Culture-directed antibiotics (this domain is the MINORITY of
patients)
PELVIC FLOOR PHYSICAL THERAPY — the highest-yield intervention
in most of these men
27.4 Chronic scrotal pain (orchialgia)
Definition:
intermittent or constant testicular pain for > 3 months that
interferes with daily activity. Roughly half have no identifiable
cause.
Evaluate:
a careful history (prior vasectomy — post-vasectomy pain
syndrome; hernia repair — ilioinguinal nerve entrapment; trauma;
infection), scrotal ultrasound to exclude a mass or other pathology,
and a urinalysis. Examine the pelvic floor and the spine —
referred pain from the ureter, hip, or lumbar spine is a classic
miss.
Manage
conservatively and patiently: scrotal support, NSAIDs, a course
of a neuromodulator (amitriptyline, gabapentin), and pelvic floor
physical therapy. A spermatic cord block is both diagnostic and
therapeutic — if a block relieves the pain, targeted microsurgical
denervation of the spermatic cord may help.
Counsel
honestly: ORCHIECTOMY IS NOT A RELIABLE CURE for chronic
orchialgia and frequently fails to relieve pain (the pain has often
centralized). Do not let a desperate patient talk you into removing
a normal testicle. This is a conversation, not a procedure.
27.5 The cross-cutting principle: central
sensitization
Chronic pelvic
pain of all types shares a common feature — the nervous system
amplifies pain signals over time, and the pain becomes decoupled from
any ongoing peripheral injury. That is why removing the organ often
fails, and why treatments that target the nervous system
(neuromodulators, physical therapy, cognitive behavioral therapy,
neuromodulation) succeed where anatomic fixes do not. Explain this to
patients. It reframes their experience from “nobody can find what's
wrong with me” to “we understand the mechanism, and we can treat
it” — and that reframing is itself therapeutic.
Clinical Pathway
Click any node to expand
These are the patients who have been told it is all in their head and who have had five courses of antibiotics for negative cultures. Chronic pelvic pain is real, it is treatable, and it needs a multimodal plan — not another antibiotic. Everything here rests on one biological fact: the pain is centrally sensitized, which is why anatomic fixes fail.
The defining symptom is PAIN, not urgency. Diagnose by pattern and exclusion, and examine the pelvic floor before you write anything.
Select a box to open its teaching details.
The definition
An unpleasant sensation — pain, pressure, discomfort — PERCEIVED to be related to the bladder, associated with lower urinary tract symptoms of more than 6 weeks' duration, in the ABSENCE of infection or other identifiable causes.
The distinction that matters
The defining symptom is PAIN, not urgency — that is what separates IC/BPS from OAB
Ch 27.1 — definition
IC / BPS
Driving symptom: PAIN/pressure, worsening as the bladder FILLS and relieved by voiding
Why they void frequently: to relieve pain
Nocturia: common
Incontinence: uncommon
Response to OAB drugs: poor
OAB
Driving symptom: URGENCY — a fear of leaking, not pain
Why they void frequently: to avoid incontinence
Nocturia: common
Incontinence: common (OAB-wet)
Response to OAB drugs: good
Ch 27.1 — IC/BPS vs OAB
What supports the diagnosis
Repeatedly negative cultures
A normal urinalysis
No hematuria — if there is hematuria, work it up (Chapter 3)
A pain pattern tied to bladder filling
History to take
Ask about flares and triggers — foods, stress, menses, intercourse
Ch 27.1 — diagnose by exclusion and pattern
Exclude
Bladder cancer / CIS — irritative symptoms plus hematuria; cystoscope them, especially smokers over 40
Recurrent UTI
Urethral diverticulum
Endometriosis
Pelvic floor dysfunction
Bladder stones
Ch 27.1 — exclude the mimics
What to do
Palpate the levators
If pressing on them reproduces their pain, you have found something treatable
Why
A large proportion of IC/BPS patients have a hypertonic, exquisitely tender pelvic floor — and in many of them that is the actual primary problem.
Ch 27.1 — examine the pelvic floor
Hunner lesions
A distinct phenotype — ~5–10% of patients
Inflammatory patches seen on cystoscopy with hydrodistension
Respond specifically and dramatically to fulguration or triamcinolone injection
Why it matters
Identifying them changes everything — which is why cystoscopy has real value in refractory patients.
Ch 27.1 — Hunner lesions
What to say
The goal is control and flare-reduction, not necessarily a cure
Pitfalls
Do NOT dismiss them. These patients have usually been dismissed many times, and the therapeutic alliance is a large part of the treatment
Ch 27.2 — treating IC/BPS
A stepwise, multimodal plan — behavioral, pelvic floor PT, our practice first-line oral pair, then procedural. Plus the four things we do not do, and the one absolute rule.
Select a box to open its teaching details.
The IC diet
Eliminate the classic bladder irritants: coffee, tea, alcohol, carbonated and citrus drinks, tomatoes, spicy food, artificial sweeteners, chocolate
Then reintroduce systematically to find the individual triggers
Also first-line
Patient education
Stress management
Timed voiding and bladder training
Heat/cold
Avoid constipation
Ch 27.2 — behavioral / first-line
What to order
MANUAL therapy by a therapist trained in internal pelvic floor work
This is a cornerstone, is strongly recommended, and is often the single most effective intervention
Pitfalls
Do NOT prescribe Kegels — strengthening a hypertonic pelvic floor makes it worse
Ch 27.2 — pelvic floor physical therapy
Local policy
Our protocol
HYDROXYZINE — an antihistamine / mast-cell stabilizer. It calms bladder mast-cell activation, helps the urgency and the sleep, and is especially useful in patients with an allergic or atopic history. Dose at bedtime and warn about sedation
URO-MP — a urinary analgesic/antispasmodic combination that directly relieves the bladder pain, pressure, and dysuria
Start with these two
Ch 27.2 — oral therapy, our practice first-line
Add-on agents
Amitriptyline — helps pain, urgency, and sleep; a good next agent
Gabapentin or pregabalin — for the centrally sensitized patient
Pitfalls
We do NOT use pentosan polysulfate (Elmiron) — see the What-not-to-do node
Ch 27.2 — oral therapy, add-on
Local policy
Our protocol
At Central Ohio Urology Group, intravesical therapy is delivered only at the time of cystoscopy with hydrodistension, performed in the office or the ASC
We do not run standalone series of office bladder instillations
What the setting delivers
DIAGNOSTIC — identifies Hunner lesions and glomerulations
THERAPEUTIC — relief lasting months in many patients
The intravesical agent is instilled at that same setting
Fulguration or triamcinolone injection of Hunner lesions — dramatically effective in that phenotype
Pitfalls
Do NOT perform prolonged, high-pressure hydrodistension — it can rupture the bladder
Ch 27.2 — procedural
Advanced procedural options
Intradetrusor onabotulinumtoxinA
Sacral neuromodulation (InterStim)
Our protocol
InterStim is an excellent option here given our practice's InterStim experience (Chapter 5)
Ch 27.2 — advanced procedural
Our protocol
Do NOT use Elmiron (pentosan polysulfate). We have removed it from our armamentarium — long-term use causes a distinctive PIGMENTARY MACULOPATHY with irreversible retinal damage and vision loss, and its efficacy is marginal at best. If a patient arrives on Elmiron, discuss stopping it and refer for a retinal exam
Do NOT use cyclosporine A. Too toxic for a benign, non-life-threatening condition — nephrotoxicity, hypertension, immunosuppression, malignancy risk
Pitfalls
Do NOT give repeated courses of antibiotics for negative cultures. It is the most common thing done to these patients, it does not work, and it delays real treatment
Do NOT perform prolonged, high-pressure hydrodistension — bladder rupture
Do NOT dismiss them
Ch 27.2 — what NOT to do
Time-critical
Our protocol
This is an absolute at Central Ohio Urology Group. Cystectomy with diversion is justified for CANCER. It is not justified for IC/BPS, chronic pelvic pain, or any other benign condition
Why it fails — biology, not technique
The pain in these patients is CENTRALLY SENSITIZED. Take the bladder out and a large share of patients still hurt — except now they hurt AND they have a urinary diversion for the rest of their lives. You have removed the organ and left the disease.
The cost of the operation
Stoma or neobladder care
Metabolic derangement
Stones
Infections
Reoperation
Real perioperative mortality
When a desperate patient asks for it — and they will
The answer is to intensify multimodal therapy — pelvic floor PT, neuromodulators, hydrodistension, Botox, InterStim, pain psychology — not to operate
Escalate the conversation to the physician; do not let anyone talk you into this
Ch 27.2 — never do a cystectomy for benign disease
The male analogue — not a prostate infection despite the name. Phenotype with UPOINT and treat only the domains that are positive.
Select a box to open its teaching details.
The definition
Chronic pelvic, perineal, suprapubic, penile, or ejaculatory pain WITHOUT infection — NIH category III (Chapter 6).
Pitfalls
It is far more common than bacterial prostatitis
It is not a prostate infection despite the name — do not treat it as one
Ch 27.3 — CP/CPPS in men
Why UPOINT
Scoring across six domains and treating the positive ones dramatically outperforms giving everyone the same antibiotic.
The six domains
U — Urinary
P — Psychosocial
O — Organ-specific
I — Infection
N — Neurologic/systemic
T — Tenderness of skeletal muscle
Ch 27.3 — UPOINT
UPOINT domains 1–3 — treat each positive domain
Findings
LUTS
Elevated PVR
Obstructive symptoms
Treatment
Alpha-blocker — treat the outlet
Ch 27.3 — UPOINT
Findings
Depression
Anxiety
Catastrophizing
Treatment
Cognitive behavioral therapy
Counseling
Pitfalls
Do not skip this — it is a major driver of outcome
Ch 27.3 — UPOINT
Findings
Prostate tenderness
Hematospermia
Treatment
Anti-inflammatories
Quercetin / pollen extract
Occasionally a limited antibiotic trial
Ch 27.3 — UPOINT
UPOINT domains 4–6 — treat each positive domain
Finding
A documented positive localization culture
Treatment
Culture-directed antibiotics
Pitfalls
This domain is the MINORITY of patients — most men with CP/CPPS should not be getting antibiotics
Ch 27.3 — UPOINT
Findings
Pain beyond the pelvis
Fibromyalgia
IBS
Treatment
Amitriptyline
Gabapentin
Pregabalin
Ch 27.3 — UPOINT
Findings
Pelvic floor spasm and trigger points on exam
Treatment
PELVIC FLOOR PHYSICAL THERAPY — the highest-yield intervention in most of these men
Ch 27.3 — UPOINT
What to say
The nervous system amplifies pain signals over time and the pain becomes decoupled from any ongoing peripheral injury. That is why treatments targeting the nervous system — neuromodulators, physical therapy, CBT, neuromodulation — succeed where anatomic fixes do not.
Why bother
It reframes his experience from "nobody can find what's wrong with me" to "we understand the mechanism, and we can treat it" — and that reframing is itself therapeutic.
Ch 27.5 — central sensitization
Orchialgia — evaluate for the classic misses, manage conservatively and patiently, and never let a desperate patient talk you into an orchiectomy.
Select a box to open its teaching details.
The definition
Intermittent or constant testicular pain for > 3 months
That interferes with daily activity
Expectation
Roughly half have no identifiable cause
Ch 27.4 — chronic scrotal pain
Ask about
Prior vasectomy — post-vasectomy pain syndrome
Hernia repair — ilioinguinal nerve entrapment
Trauma
Infection
Ch 27.4 — evaluate
Orders
Scrotal ultrasound — exclude a mass or other pathology
Urinalysis
Ch 27.4 — evaluate
Examine
The pelvic floor
The spine
Pitfalls
Referred pain from the ureter, hip, or lumbar spine is a classic miss
Ch 27.4 — evaluate
Conservative management
Scrotal support
NSAIDs
A course of a neuromodulator — amitriptyline, gabapentin
Pelvic floor physical therapy
Ch 27.4 — manage conservatively
How to use it
A spermatic cord block is both diagnostic and therapeutic
If a block relieves the pain, targeted microsurgical denervation of the spermatic cord may help
Ch 27.4 — manage conservatively
Time-critical
Counsel honestly
ORCHIECTOMY IS NOT A RELIABLE CURE for chronic orchialgia and frequently fails to relieve pain — the pain has often centralized
Do not let a desperate patient talk you into removing a normal testicle
This is a conversation, not a procedure
The underlying reason
Chronic pelvic pain of all types is centrally sensitized — which is exactly why removing the organ often fails.