Bladder pain syndrome / interstitial cystitis — structured oral station (12 minutes)

Opening prompt — "Take a focused history from this patient."

Model response — say it in this order: ^[1][2]

• "I would start with the pain: where exactly is it, what does it feel like, does it worsen as the bladder fills and is it relieved by voiding — that pattern is the diagnostic fingerprint of bladder pain syndrome."
• "I would quantify frequency, nocturia and urgency with a bladder diary, and ask about pain on voiding and on filling."
• "I would ask about dyspareunia, post-coital pain, vulval pain and bowel symptoms — BPS often clusters with other chronic pain syndromes and with pelvic-floor dysfunction."
• "I would review what has been tried, what was attributed to UTI, and the timing of the first symptoms."
• "I would screen for associated conditions: fibromyalgia, IBS, migraine, autoimmune disease, and for impact on sleep, work, mood and sexual function."^[1]

Examiner is listening for: pain-related-to-bladder-filling pattern, frequency quantification, exclusion of mimics, and the impact question. ^[2]

Probe 1 — "Her urine cultures are repeatedly negative. What now?"

• "BPS/IC is a diagnosis of exclusion. I would first repeat the urine culture to confirm it is genuinely sterile, send urine cytology to look for atypical cells, and arrange cystoscopy with hydrodistension under general anaesthesia with bladder biopsies."
• "I would also take a careful sexual and menstrual history, examine for vulvodynia and pelvic-floor muscle spasm, and consider whether the picture is endometriosis with bladder involvement — a tender anterior fornix nodule or cyclical pain would change my workup."
• "If she has microhaematuria, the threshold for cystoscopy is non-negotiable — we must exclude bladder cancer before settling on BPS."^[1][3]

Probe 2 — "On cystoscopy with hydrodistension at 80 cm H2O for two minutes, you see glomerulations (more than 10 per quadrant in three quadrants) and no Hunner lesion. What is the diagnosis and what is your first step in management?"

• "This is non-Hunner bladder pain syndrome, ESSIC type 2B or 2C depending on biopsy. It is the more common phenotype, accounting for the great majority of cases."
• "First step in management is always behavioural: trigger avoidance (caffeine, alcohol, citrus, tomatoes, vinegar, spicy food), bladder training, stress management and pelvic-floor physiotherapy given the tight pelvic floor."
• "I would then start amitriptyline 25 mg nocte, titrated by 25 mg weekly to 50–75 mg, with counselling on anticholinergic effects."^[1]

Probe 3 — "She has had amitriptyline, hydroxyzine, pentosan polysulfate and intravesical DMSO, and remains symptomatic. Cystoscopy now shows a reddened mucosal patch with a central scar on the posterior wall. What next?"

• "That is a Hunner lesion — and in this setting I would arrange transurethral fulguration or laser ablation of the lesion as the next step. Fulguration of Hunner lesions gives initial response near 90% with relief beyond 3 years in 40%, the majority responding to repeat resection."^[7]
• "If she remains symptomatic, I would discuss cyclosporine A at 3 mg/kg/day in two divided doses under specialist supervision, with renal function, blood pressure and C2 (2-hour post-dose) monitoring. Cyclosporine is the most effective oral agent in Hunner-lesion BPS, but the toxicity profile means it is reserved for refractory disease."^[1][5]

Probe 4 — "She asks what pentosan polysulfate actually does and why you would not start it first."

• "PPS is a synthetic glycosaminoglycan analogue thought to repair the urothelial barrier. It does work, but the response is partial and delayed — typically 6 months or longer before benefit."^[8]
• "With long-term use beyond 5 years, PPS carries a small but important risk of pigmentary maculopathy, which is why we monitor the eyes annually from year 5."^[8]
• "Behavioural therapy and amitriptyline are cheaper, faster, and have stronger evidence for first-line use."^[1]

Probe 5 — "She is distressed and asks whether she will ever get better."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, and be honest: "Bladder pain syndrome is a chronic condition — most patients improve, but it tends to flare and remit over years."
• "The good news is that there is a structured ladder of treatments, and most patients find something that helps. We will start with the safest options first and work together over the coming months."
• Acknowledge the diagnostic delay she has already endured, validate her experience, name a contact for flares, and offer written information and pelvic-floor physiotherapy referral.^[1][2]