Significant comorbidities are missed in interstitial cystitis workups

August 15, 2007

Patients with apparent interstitial cystitis need thorough workups, and they're not always getting them.

Those findings from the University of Missouri, Columbia Regional Hospital, echo those published 3 years ago by re-searchers at William Beaumont Hospital, where urologists found a 1% rate of transitional cell carcinoma misdiagnosed as IC. While the Columbia Hospitals study found that some of these malignancies and comorbidities were found to be concomitant disease, all should have been caught. Thus, Durwood E. Neal, Jr, MD, told the audience at AUA, patients with apparent IC need to be evaluated thoroughly, not only to rule out alternative diagnoses, but also to identify coexisting medical conditions.

"This certainly applies to any patient with a chronic condition for which there may be nonspecific findings or even a paucity of objective evidence," said Dr. Neal, the study's author, who is professor and chief of urology at the University of Missouri, Columbia Regional Hospital.

"This is perhaps much higher than one would see in a population of patients who did not have a preceding illness," Dr. Neal noted.

Seventy percent of the patients had had hematuria, but most had not undergone urine cytologies or other urinalyses for bladder cancer.

Kenneth M. Peters, MD, who led the study at William Beaumont Hospital in Royal Oak, MI (J Urol 2004; 172:478-80), cautioned against arriving at an IC diagnosis too quickly.

"In our case, only 50% had hematuria, there was no smoking history in the majority of women, and some were young-38 years old," said Dr. Peters, chief of urology at Wiliam Beaumont. "It's so easy to diagnose IC these days based on a questionnaire of symptoms, but we've still got to be clinicians and work patients up, instead of just labeling them."

The Columbia team also found about a 5% incidence of renal ureteral calculi that were previously undiagnosed.

"I thought that was interesting," said Dr. Peters, "because I just this year had two patients come to me with a diagnosis of IC treated for 6 months. They both had distal ureteral stones that we treated and their symptoms went away."

Who needs an intensive workup?

These findings raise the question: How much of a workup should be done on a patient with apparent IC?

"Does this mean that we should be getting some imaging on every IC patient, like CT scans or ultrasound, or should we just do it on those who have hematuria?" asked session co-chair Rodney Anderson, MD, of Stanford University, Stanford, CA.

At Columbia, all patients in the study underwent a complete history and physical and a review of their records; completed a voiding diary; underwent pelvic imaging, such as computed tomography, ultrasonography, or magnetic resonance imaging; had laboratory studies, including a complete blood count, complete metabolic panel, and urinalysis with culture; cystoscopy and hydrodistention at 70 cm H2O under anesthesia and biopsies; and retrograde pyelography, if indicated.

"Perhaps it's overkill," Dr. Neal said, "but the difficulty I have as a referral base is that most of the time, I don't see these patients first, and for the majority of them, I make sure I do some sort of imaging study. We include CT, ultrasound and, in very rare cases, MRI. But I think [patients] ought to at least have a pelvic ultrasound to make sure I'm not missing some mass that's compressing the bladder."

His study poses an additional question: How often should evaluations for IC patients be repeated?

"Does one need to re-look in their bladder 1 year, 2 years, 5 years hence?" Dr. Neal asked. "I don't know that that's a question we can answer at this time."