Interstitial cystitis/bladder pain syndrome (IC/BPS) is a likely underdiagnosed chronic pain syndrome consisting of pelvic pain lasting longer than 6 weeks plus lower urinary tract symptoms in the absence of infection or other identifiable cause. It is more common after 40 years of age. The etiology is unclear, but some patients have inflammatory findings in the bladder known as Hunner lesions. Due to its variable presentation, there is no standardized evaluation for diagnosis of IC/BPS. The history should include pain and urinary symptoms; associated comorbid disorders, including autoimmune and mental health conditions; and symptoms suggestive of other causes (eg, infection). Cystoscopy is not required but should be considered for patients with refractory symptoms and when Hunner lesions are suspected, such as in those older than 50 years or with comorbid autoimmune disorders and/or bladder-centric presentation (eg, predominance of urgency, frequency, low urine volumes). Treatment is often multimodal, including behavior modifications, stress management, and nonpharmacologic therapy (eg, pelvic floor physical therapy). Oral pharmacotherapy can be considered, but no guidelines exist on preferred agents. Referral for procedural treatments can also be considered for refractory cases. Patients should understand that no treatments are definitively successful, and recurrences and flare-ups often occur.

Case 4. DO is a 39-year-old patient who reports more than 1 year of intermittent pain in her pelvis along with urinary urgency and frequency. She has visited emergency departments and urgent care facilities several times but has never been diagnosed with a urinary tract infection. She is frustrated and wants to know how to stop these symptoms.