Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) diagnosis is often challenging due to subtle mucosal lesions. We hypothesized that cystoscopy under general anesthesia (with hydrodistension) would outperform local anesthesia in lesion grading accuracy and subtype identification, and bladder capacity changes would correlate with lesion severity. This study aimed to compare grading/subtype diagnostic differences between the two anesthesia methods and analyze capacity variations, providing evidence for optimized clinical diagnostic strategies.

This retrospective study enrolled 52 female patients clinically highly suspected of BPS/IC at our hospital from 2024 to 2026. All patients underwent sequential cystoscopy under local anesthesia and general anesthesia (with bladder hydrodistension) before final BPS/IC diagnosis. General anesthesia cystoscopy results served as the "gold standard". Lesions were graded 0–4 (Grade 4 subdivided into 4H [Hunner lesions] and 4N [mucosal fissures without obvious Hunner lesions]). Upgrade rates and missed diagnosis rates were calculated. Bladder capacity under general anesthesia and capacity increment (general minus local anesthesia) were recorded. Statistical analyses included one-way analysis of variance (ANOVA) and least significant difference (LSD) post-hoc test, with independent samples t-test for combined group comparisons (α=0.05).

Of 52 patients, 65.4% (34/52) had lesion grade upgrading from local to general anesthesia, and 34.6% (18/52) had no change (6 Grade 4, 12 Grade 2–3). Upgrade rates were 100% (12/12) for Grade 0, 100% (5/5) for Grade 1, 52.9% (9/17) for Grade 2, 66.7% (8/12) for Grade 3, and 0% (6/6) for Grade 4. General anesthesia detected 18 Grade 4 lesions (12 4H, 6 4N), with 66.7% (12/18) missed under local anesthesia (4N: 100%, 4H: 50%). Bladder capacity under general anesthesia was Grade 1–2 (549.1±135.1ml, n=23), Grade 3 (574.5±197.6ml, n=11), Grade 4 (372.8±119.8ml, n=18); ANOVA showed intergroup differences (F=9.59, P=0.0003), with Grade 4 smaller than Grade 1–2 (P=0.0002) and Grade 3 (P=0.0001). Capacity increment was Grade 1–2 (236.7±161.2ml), Grade 3 (276.3±219.4ml), Grade 4 (83.7±154.1ml); Grade 4 increment was significantly smaller than combined Grade 1–3 (t=3.47, P=0.0011).

The high upgrade rate (100%) of Grade 0–1 lesions under local anesthesia confirms its limitations in identifying early BPS/IC lesions, likely due to pain-induced underfilling. The 100% missed diagnosis rate of 4N lesions and 50% of 4H lesions highlights the necessity of general anesthesia for precise subtyping—hydrodistension under general anesthesia eliminates pain, exposing subtle mucosal fissures and small Hunner lesions. Bladder capacity differences reflect pathological changes: severe lesions (Grade 4) involve deeper mucosal/muscular damage, reducing distensibility, while non-severe lesions (Grade 1–3) retain relatively normal bladder elasticity.

Cystoscopy under local anesthesia significantly underestimates BPS/IC lesions. General anesthesia cystoscopy is indispensable for diagnosing suspected BPS/IC with negative local anesthesia findings and achieving precise subtyping. Bladder capacity increment (with Grade 4 showing smaller values than Grade 1–3) can serve as an auxiliary indicator for severity assessment, guiding clinical diagnosis and treatment decisions.

Continence 19S (2026) 102764
DOI: 10.1016/j.cont.2026.102764