History: 45 year old female presented with a 7 month history of urgency and frequency of urination. The patient noted voiding every 45 min to 1 hour during the daytime but only once at night. The patient described that as soon as she empties her bladder, she feels the needed to empty again. Sometimes, she had the sensation of incomplete bladder emptying and needed to push to relieve that sensation. There was a history of chronic constipation. One of the patients previous doctors said that she had "irritable bowel-syndrome". The patient occasionally complained of lower back discomfort and stated that the force of her urinary stream was variable. The patient noted that stress caused a significant worsening in symptoms. There was no recent history of bladder infection. Antibiotics were prescribed and failed to result in symptom improvement. Ditropan(r) (another medication to reduce bladder contraction) was given and resulted in a further reduction in the force of the urine stream.

Physical examination: Mild tenderness of the lower abdomen was detected. Pelvic examination showed no abnormalities of the gynecological organs. The patient perceived no pain when the bladder was pressed. Significant tenderness was elicited when pushing against the muscles of the pelvic floor.

Laboratory testing:
  • Urinalysis: negative
  • Urine culture: negative
  • Urine cytology: negative
  • Uroflow Exam (a test whereby the patient is asked to urinate into a special container. The flow rate is measured throughout the voiding interval): The study demonstrated a "start-stop-start-stop" pattern of voiding. The pattern was typical of a patient who urinates by pushing urine out.
  • Bladder Scan: Residual urine 80cc
  • 48 Hour Voiding diary: showed multiple daytime voids raging from every 15 minutes to two hours apart. Volumes varied from 1 ounce to 14 ounces.
At this point, it is clear that this patient has pelvic floor problems that account for most of her symptoms. Her urinary difficulties are present mainly during the day. She rarely voids at night and she is capable of voiding large quantities at times. Her urinary flow rate is poor and the constipation is probably making the whole problem worse. The pelvic examination shows little bladder tenderness but the pelvic floor muscles are tender. Now heres the big question. Should a hydrodistention of the bladder to be performed to better prove that IC is or is not present?
Doctor might consider hydrodistention if therapy directed to the pelvic floor muscles fails.
This illustrative case give you an idea of the thinking process that goes into a patient evaluation. Bear in mind that not all practitioners use this game plan. That doesnt mean that they are necessarily right or wrong. The goal, of course, no matter how you get there is to make as accurate a diagnosis as possible; and thereby get the patient on a treatment course thats most likely to yield positive results.