Whether or not the US NIDDK criteria are used to diagnose interstitial cystitis, the presence of erythema and Hunner’s ulcer under anesthesia with water dilatation remains one of the most important pieces of evidence for the diagnosis of interstitial cystitis. This article will briefly describe the methods and clinical implications of cystoscopy and hydrodilation under anesthesia for the diagnosis of interstitial cystitis.
Before performing hydrodilation under anesthesia, the patient’s history should be thoroughly understood and other exclusionary tests should be essentially completed according to NIDDK criteria, and cystoscopy and hydrodilation under anesthesia should be the last invasive test for interstitial cystitis.
Usually lumbar or intravenous anesthesia (without assisted breathing) is used. The truncated position is performed with routine sterile towel laying. The perfusion solution is saline and the perfusion bottle should be 80 cm above the patient’s pubic symphysis. Cystoscopy is performed first, and observation should avoid mucosal injury as much as possible to avoid affecting the judgment of mucosal bleeding thereafter. The observations include any abnormalities in the cystourethra, such as the presence of mucosal masses, mucosal hemorrhage, mucosal white spots, mucosal ulcers, bladder and urethral diverticula, and pus exudation from the cumulative urethra. Observe for any ureteral abnormalities. After perfusion over 400 ml, the liquid drip rate should be mainly observed, if the liquid drip rate becomes significantly slower or stops, it means that the pressure in the bladder is close to or reaches 80 cm water column, keep this pressure for 3 minutes and drain the bladder. Observe again the mucosal situation in the bladder, bleeding spots usually appear in the more extended parts such as anterior wall, top, posterior wall, left and right lateral walls, etc. If more than three sites show an average of more than 10 blebs, it is positive for erythema. The presence of characteristic ulcers is also diagnostic of interstitial cystitis if present. A random mucosal biopsy should also be taken after observation. The purpose of random biopsy is to exclude extensive carcinoma in situ and to understand the presence or absence of chronic inflammatory manifestations of the bladder. Although the pathological manifestation of chronic inflammation is not a diagnostic basis for interstitial cystitis, the finding of mucosal mast cell infiltration may suggest that the etiology of interstitial cystitis in this patient may be related to allergy or autoimmunity, and antihistamines may be effective in such patients. Biopsy is also required for characteristic ulcers, and Hunner’s ulcer pathology has a characteristic presentation with a large infiltration of mast cells and other inflammatory cells.
Symptomatic relief occurs in approximately 60% of patients after hydrodilation under anesthesia, but this relief is temporary, ranging from a few days to 3 months, with a return to prehydrodilation symptoms. Those who also suffer from pelvic floor pain often complain of relief of bladder pain when holding urine after hydrodilation, but there is generally no significant improvement in pelvic floor pain symptoms, mainly pain around the perineum and vaginal urethra.
Hydrodilation under anesthesia is primarily used for the diagnosis of interstitial cystitis and is not recommended as a long-term regular treatment due to the severity of damage to the interstitial bladder, although it may bring temporary symptomatic relief.
The following clinical information is available for your reference, but all rights to the information are reserved! Figure 1: Initial filling of the bladder, a thinning of the mucosa can be observed, as demonstrated by the submucosal vessels that are well defined. However, not all thinning mucosa is interstitial cystitis and needs to be combined with the presence or absence of erythema. Figure 2: This is a typical erythema, with scattered hemorrhagic erythema visible at the bottom left of the figure and hemorrhagic spots that have fused into a sheet at the top right. Figure 3: Typical microscopic presentation of erythema