Could It Be Something Else? A Guide to Conditions That Mimic IC/BPS

Why every diagnosis should begin by ruling out other causes of bladder pain, urgency, and frequency.

Before a diagnosis of IC/BPS can be made, physicians should first rule out the many other conditions that can produce similar urinary symptoms. IC/BPS remains a diagnosis of exclusion, meaning that other possible causes of bladder pain, urgency, frequency, and pelvic discomfort should be carefully evaluated before the diagnosis is confirmed. Unfortunately, whether due to limited time during office visits, outdated training, or limited experience with pelvic pain disorders, some clinicians may overlook alternative diagnoses.

The consequences can be significant. Patients may be told they have a lifelong, incurable bladder condition when another medical disorder is actually responsible for their symptoms. In many cases, that underlying condition is treatable—and sometimes even curable. A missed diagnosis can delay appropriate treatment for months or even years, leading to unnecessary pain, anxiety, ineffective or expensive and costly therapies, and ongoing frustration.

Every patient deserves a careful, comprehensive evaluation. Yet both patients and physicians can sometimes be eager to find a quick answer. Patients may hesitate to discuss sensitive issues, such as prior trauma, bowel or sexual symptoms, or mental health concerns, while physicians may not always have sufficient time to explore every possibility. The more complete the information you provide, the more likely your healthcare provider will be able to identify the true source of your symptoms.

Before your appointment, take time to prepare a detailed medical history, including when your symptoms began, what makes them better or worse, previous infections or surgeries, medications, injuries, trauma, and any bladder, bowel, pelvic floor, gynecologic, or sexual symptoms you have experienced. Rather than relying on educated guesses, your physician should gather objective information through a thorough history, physical examination, urine testing, and other diagnostic studies when appropriate. An accurate diagnosis is built on evidence—not assumptions.

In this article, we’ll review the many disorders that can mimic IC/BPS, explain the symptoms and clinical features that help distinguish them, discuss the tests and examinations that may aid in diagnosis, and identify the clinical clues that suggest another condition should be investigated before a diagnosis of IC/BPS is made. It is based upon a recently published proposal from the International Society for the Study of Bladder Pain Syndrome.(1)

Some of these conditions may actually coexist with IC/BPS rather than replace the diagnosis. Identifying and treating each contributing condition often provides much better symptom relief than treating the bladder alone.

Please know that most people with urinary frequency, urgency, and bladder pain do not have cancer or another life-threatening illness. These conditions are listed because they should be considered and ruled out during a thorough evaluation. Fortunately, many of them are uncommon, and some are easily treated once identified.

UROLOGICAL CONFUSABLE DISEASES

Chronic bacterial cystitis and prostatitis – Patients who have active bacterial infections are usually excluded from the diagnosis of interstitial cystitis. Rather, they have bacterial cystitis. Recurring infections can occur in women with estrogen atrophy/GSM, as well as in patients who have weakened immune systems, both of which should be explored further if a patient is struggling with persistent infections. Patients who appear to improve with antibiotic treatment may also fall into this group. What makes it different from IC/BPS? UTI’s are strongly associated with urethral burning during urination, and can cause fever and chills.
Suggested Tests: Urine, semen and prostatitic secretion cultures and, perhaps, Next Gen DNA urine testing to identify rare, more complex and drug resistent infections.

Chronic fungal infection – US researchers found overgrowth of candida in some, but certainly not all, patients. The more fungus present, the greater the pain. Why are IC patients vulnerable to fungal infections? Most IC patients have been given antibiotics for their urinary symptoms, some for long periods of time. Antibiotics kill the good bacteria that normally keep fungus in check. If flares are triggered by eating sugar and carbohydrates, fungal infection should be investigated.
Suggested Tests: Fungal urine culture, urine microscopy to see fungal buds, Next Gen DNA urine testing

Genitourinary tuberculosis – While rare in the USA, patients can be exposed when travelling to South-East Asia, the Western Pacific and Africa. Tuberculosis travels through the blood stream to the kidneys and eventually into the bladder where it can cause extreme frequency, painful urination and blood in the urine. Generally, there is no observable bacterial growth in urine cultures though pus is often found. They may have other symptoms suggestive of TB (i.e. coughing, etc.)
Suggested Tests: PCR urine testing for TB, QuantiFERON Gold TB blood test, cystoscopy and biopsy

Bladder Cancer – These patients may have significant blood in the urine, as well as a frequent and/or painful urination. The biggest risk factors for bladder cancer are a history of smoking and/or family members with a history of cancer. What makes it different from IC/BPS? IC is not associated with the growth of tumors in the bladder.
Suggested Tests: Urine cytology, cystoscopy and bladder biopsy

Inflammatory cystitis of identifiable cause (radiotherapy, ketamine, cyclophosphamide, BCG, eosinophilic cystitis, other drug-related cystitis) – These patients struggle with injury to the bladder, usually from chemicals or radiation, resulting in severe urinary symptoms and pain. Ketamine, for example, is very damaging to the tissues of the kidneys and bladder which, over time, may lead to bladder removal. What makes it different from IC/BPS? Chemical injury is not a disease.
Suggested Tests: Clinical history, ketamine urine testing, cystoscopy and bladder biopsy, upper tract imaging for hydronephrosis.

Overactive Bladder – Often confused with IC/BPS, these patients struggle with urinary frequency and sudden urgency that has them running to the restroom to avoid leakage. In contrast, IC patients run to the restroom to reduce pain. In OAB, bladder muscles contract too early or too often, often the result of nerve damage, stones or UTI. Thus, antispasmodic medications are the treatment of choice. What makes it different from IC/BPS? IC patients urgency and need for restroom access is driven by pain while OAB patients are driven by the worry of incontinence.
Suggested tests: Bladder diary, urodynamics if needed.

Bladder outlet obstruction in men and women (anatomical or functional obstruction) – These patients have a blockage that stops or slows the flow of urine. In men, this is often caused by an enlarged prostate (benign prostatic hyperplasia). In women, it can be the result of scar tissue or, perhaps, pelvic organ prolapse. Symptoms can include trouble starting urination, a weak stream, a slow stream, urinary frequency and/or feeling as if your bladder is full even after you’ve just emptied your bladder. What makes it different from IC/BPS? Typical IC does not involve any obstruction in the bladder though tight pelvic floor muscles could make it more difficult to relax and release urine.
Suggested tests: post void residual sonagram, urodynamics, preferably video to observe what the obstruction could be.

Prostate Cancer – Prostate cancer begins when cells in the prostate begin to grow abnormally. Patients may have blood in their urine and in their semen. They may have trouble starting urination and often wake up more frequently at night. If the cancer is more aggressive, they may struggle with incontinence, erectile dysfunction, weakness, pain, feeling very tired and losing weight.
Suggested tests: rectal examination, blood testing for PSA levels, MRI of the prostate and a biopsy, if suspected.

Neurogenic lower urinary tract dysfunction – These patients may have a neurological disease (i.e. multiple sclerosus, parkinson’s, spinal cord injury, etc.) that is also affecting their bladder and triggering urinary symptoms. Patients may struggle with either an overactive bladder (frequency, urgency, night time urination, incontinence) or an underactive bladder (hesitancy, slow urine stream, incomplete emptying, retention). Some may be unable to empty their bladder without the assistance of a catheter. What makes it different from IC/BPS? Neurogenic bladder is caused by nerve damage and/or dysfunction that can affect how the bladder functions.
Suggested tests: clinical examination, urodynamics, MRI of the brain and spine.

Bladder Stones – These patients struggle with mineral stones that develop in their bladder (not kidneys), often the result of injury to the bladder or excessive urinary retention that allows minerals in urine to concentrate and crystallize. Symptoms can include pain and/or blood in their urine as the sharp edges of the stone injure nearby tissue. In some cases, the stone may be so large that it cannot pass through the urethra, causing persistent irritation to the bladder wall.
Suggested tests: cystoscopy, CAT scan

Foreign body in the bladder (mesh, sutures, surgical clips) – We’ve had several patients discover that their bladder symptoms were the result of manmade objects found in their bladder. Polypropylene mesh was often used to repair pelvic organ prolapse and hernias but was discovered to migrate through the tissue, including into the vagina, bladder and urethra. If a patient has a prior history of pelvic surgery (i.e hysterectomy), a suture or surgical clip may have penetrated the bladder wall.
Suggested tests: cystoscopy, CAT scan

Distal ureteric stone – These patients have a kidney stone lodged in a ureter, resulting in intense pain. They may have a history of kidney stones.
Suggested tests: microscopic hematuria on a dipstick, cat scan.

Urethral diverticulum – If you struggle with urethral symptoms, a diverticulum should be ruled out. These are small pouches that extend from the urethra, often the result of excessive straining, where they may hold urine and/or infection. Symptoms include pain with urination, dribbling after urination, recurring UTI and pain with intimacy.
Suggested tests: pelvic examination, MRI of the urethra.

GYNECOLOGICAL

Sexually transmitted infection (chlamydia, gonorrhea, herpes, HPV) – Sexually transmitted diseases can be the underlying cause of urinary symptoms. Please don’t be offended if your doctor orders STD testing. This is is completely normal, regardless of the age of the patient, to rule these out. These patients may struggle with urethral pain, a discharge from their urethra or vagina, vaginal itching, observable skin lesions.
Suggested tests: urine and vaginal swabs or PCR testing

Vaginal Infection (ureaplasma, mycobacteria, corynmebacterium, candida) – It’s not unusual for vaginal infections to infect the bladder, simply by proximity. Patients may struggle with urethral pain, urethral or vaginal discharch, vaginal itching and discomfort.
Suggested tests: urine, semen or vaginal swabs and/or PCR testing

Pelvic Congestion Syndrome – Women who struggle with a sensation of heaviness in their pelvis that builds and worsens throughout the day but then resolves at night may have blood pooling in the pelvis, the result of swollen veins. They may also struggle with typical urinary symptoms and pain with intimacy. Thankfully, this can be easily treated by an interventional radiologist.
Suggested tests: pelvic ultrasound or MRI

Pelvic Organ Prolapse – Pelvic organs (bladder, vagina, uterus, etc.) are held in place by the pelvic floor muscles. When these muscles are weakened through straining and childbirth, the organs can drop out of position. In a worse case scenario, they might even hang outside of the vagina. If you feel a hard lump at the entrance your vagina when standing, that could be a sign of a prolapse. Please note that when you lay down, such as on a examination table, the prolapse may reverse. Make sure that you tell your doctor that you feel something when you are standing or sitting.
Suggested test: pelvic examination

Estrogen Atrophy – The loss of estrogen directly affects the vagina, vulva, urethra and bladder. Known as genitourinary syndrome of menopause (GSM), skin becomes dry and more vulnerable to irritation, particularly to acidic foods. This is not a disease process. It occurs with aging, after total hysterectomy and/or the use of estrogen suppression medications for endometriosis or hormone driven cancers (lupron, tamoxifen, etc.). What makes it different from IC/BPS? It’s not that different. GSM is a well known cause of bladder wall thinning and increased sensitivity and is found in many IC patients who developed symptoms as their estrogen levels dropped.
Suggested tests: visual examination

Endometriosis – These women may have a history of very painful cramping and heavy bleeding with menstruation. Unfortunately, endometrial tissue can not only attach to the outside of the bladder, it can penetrate into the bladder cavity (deep infiltrating endometriosis) causing sharp, burning pain during urination, intense urinary symptoms and pelvic pain.
Suggested tests: MRI, pelvic ultrasound or a diagnostic laparoscopy

Gynecological malignancy (cervical, uterine, ovarian cancer) – The first sign to look for is abnormal spotting and bleeding, as well as pelvic pain. It is vital that you seek medical attention quickly. The earlier cancer is diagnosed, the easier it is to treat. Sadly, millions of women have shared this journey.
Suggested tests: Ultrasound, MRI

Pelvic Inflammatory Disease (PID) – Usually the result of an untreated sexually transmitted disease (i.e. chlamydia, gonorrhea) that has spread to the uterus, fallopian tubes and/or ovaries. Patients may have pelvic pain, heavy vaginal discharge with a bad smelll, bleeding between periods, pain with intimacy and fever, chills or burning during urination.
Suggested tests: vaginal swab for a culture

Vulvodynia – Vulvodynia is one of the chronic overlapping pain conditions that some IC patients struggle with. It can feel like a severe yeast infection with pain so severe that wearing pants and/or underwear is painful. After ruling out infection and atrophy, the general consensus is that the nerves in the vulvar skin have become very sensitive and easy to trigger. Sometimes, it can be the result of chemical irritation to soaps, fabric softeners, bubble baths, spermicide and menstrual pads. Lichen sclerosus is a more severe skin condition that cause thin, white, patchy skin that may require more aggressive steroid treatment. If it is not treated, it can leave to scarring, changes in the skin and an increased risk of skin cancer.
Suggested tests: Visual examination of the vulva, Qtip test

COLORECTAL

Colon Cancer – If you notice changes in bowel movements, blood in your stool, weight loss and abdominal pain, you should be screened for colon cancer, especially if you have a family history of colorectal cancer.
Suggested tests: stool test for blood, colonoscopy

Inflammatory Bowel Disease/Diverticulitis – Inflammatory bowel disease can trigger pelvic pain and discomfort, as well as fecal urgency, incontinence, diarrhea, blood in stool, fevere or weight loss. Please note that Elmiron®, an older medication often prescribed for IC/BPS, has a strong association with inflammatory bowel disease and polyposis (the abnormal growth of bowel polyps) with multiple research studies demonstrating that stopping the medication often results in total bowel healing.
Suggested tests: colonoscopy

Irritable Bowel Syndrome – IBS is another chronic overlapping pain condition often found in patients with IC/BPS and widespread pain. Patients can suffer from diarrhea, constipation or they may alternate with both. Again, we believe that sensitive nerves may be the underlying cause, as well as foods which irritate nerves in the bowel.
Suggested tests: colonoscopy

MUSCULOSKELETAL

Pelvic floor dysfunction (tight, hypertonic muscles) – Research now suggests that 87% of IC patients struggle with tight pelvic floor muscles. In many cases, a pelvic injury was the triggering event for their pelvic pain and urinary symptoms, such as falling on the tailbone, a difficult birth, riding bicycles, etc. Tight muscles can cause pain in the belly, back and perineum, as well as pain after urination, reduced urine flow, difficulty starting urination and pain with intimacy. The often unseen complication of tight pelvic floor muscles is the development of ischemia, reduced blood flow to the bladder and surrounding tissues because muscles are squeezing blood vessels. Pelvic examinations are now encouraged at the very first urology appointment for IC/BPS with immediate referrals to a qualified pelvic floor physical therapist for treatment if tight muscles are found.
Suggested test: pelvic examination

Abdominal wall hernia – In recent years, we have seen newly diagnosed IC patients with a history of weight lifting and the development of hernias. Hernias are caused when intense pressure is placed on weak muscles, resulting in a rupture. If you feel a soft lump in your belly or groin that shows up when you stand, cough or lift things, that then goes away when you lie down, that could be a hernia. It’s also possible that the pelvic floor muscles sustain damage at the same time that the hernia develops.
Suggested test: physical examination

Arthritis in the hips – These patients may have pain in their hip, groin and buttock, tenderness, swelling and stiffness when they try to walk. This can stress the pelvic floor muscles, resulting in pain and discomfort.
Suggested test: X-ray or MRI

Osteitis Pubis – Can you hear a clicking sound when moving? Do you have pain when running, kicking, twisting or doing situps? Do you feel sore when you press over the pubic bone? Osteitis pubis is an inflammation of the pubic symphysis, the joint where the pubic bones meet directly below your bladder.
Suggested test: MRI

Degenerative disc disease/nerve compression/cauda equina – Compressed discs in the spine can put pressure on the nerves that affect the bladder and bowel. If you experience severe lower back pain, numbness in the groin and inner thighs or you have sudden bladder or bowel incontinence, this can be very serious. You may have difficulty starting urination, a weak urine stream or urinary retention. You may not feel the urge to empty your bladder. Other symptoms can include leg pain, weakness, sciatic and/or trouble lifting the front of your foot while walking. Some men may be unable to become erect and/or lose all feeling during sex. These are urgent and require immediate medical consultation. Don’t wait! The goal is to protect the nerves before permanent nerve damage occurs.
Suggested test: MRI

Conclusion

Your doctors should be working to identify the underlying cause of your symptoms—not simply treat the symptoms themselves. While treatments that reduce pain, urgency, and frequency are valuable, they are most effective when directed at the condition actually responsible for those symptoms. In some cases, more than one condition may need to be identified and treated before meaningful improvement occurs.

Once a diagnosis is entered into a medical record, future healthcare providers may unconsciously assume that it is correct. This is known as diagnostic momentum. While previous diagnoses are often accurate, they should never prevent a clinician from reconsidering the diagnosis when symptoms change, treatment fails, or new information becomes available. It’s not uncommon for doctors to miss or misidentify Hunner’s lesions.

Receiving a diagnosis of IC/BPS should never mean the diagnostic process has ended. Medicine is a process of gathering evidence, testing ideas, and adjusting when new information emerges. If your symptoms change, worsen, or fail to improve despite treatment, it is reasonable to revisit your diagnosis and ensure that no contributing condition has been overlooked. An accurate diagnosis is the cornerstone for effective treatment.