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. 2025 Jul 3;45(1):26–31. doi: 10.1002/nau.70103

Interstitial Cystitis/Bladder Pain Syndrome in Men

Madeline Snipes 1,2,✉, Wyatt Whitman 1,2, Michel Pontari 3, Jennifer Anger 4, Michael Samarinas 5, Rajesh Taneja 6
PMCID: PMC12748021  PMID: 40605567

ABSTRACT

Aims

In April 2025, the Wake Forest Institute for Regenerative Medicine hosted a Global Consensus meeting on interstitial cystitis/bladder pain syndrome (IC/BPS) in Winston‐Salem, NC. The goal of this meeting was to establish attainable targets in phenotyping, diagnosis, and biomarkers for IC/BPS. Our subcommittee focused on developing a consensus document addressing IC/BPS in men.

Methods

Narrative review.

Results

Within this document, we discuss prevalence, clinical characteristics, evaluation/investigation, and treatment of IC/BPS in men. The is limited literature specifically addressing IC/BPS within the male population, as IC/BPS has traditionally been considered a disease of women. Thus, prevalence data varies widely. Diagnosis of IC/BPS in men is fraught with difficulty, as there is much overlap with other chronic pelvic pain syndrome, specifically chronic prostatitis. Key clinical features specific to IC/BPS are pain with bladder filling and relief with voiding. Painful ejaculation may be indicative of pelvic floor dysfunction. Physical exam, including extensive pelvic exam with analysis of pelvic floor tenderness, is critical in correct diagnosis. Ultrasound +/− urodynamics may be used to rule out obstructive disease, and urinalysis +/− culture must be used to rule out infection. There are no treatments specific to men with IC/BPS.

Conclusions

We have described the prevalence, clinical characteristics, evaluation, and treatment of IC/BPS in men. There is a significant need for more sex‐specific research of IC/BPS with consideration for hormonal and anatomical factors that may differentiate the disease in men.

Clinical Trial Registration

No new data were generated for this manuscript; no clinical trial was conducted.

Keywords: bladder‐capacity, chronic pelvic pain syndrome, chronic prostatitis, diagnosis, Hunner lesion, treatment

1. Introduction

In April 2025, the Wake Forest Institute for Regenerative Medicine hosted a Global Consensus meeting on interstitial cystitis/bladder pain syndrome (IC/BPS) in Winston‐Salem, North Carolina. The goal of this meeting was to establish attainable targets in definition, diagnosis, phenotyping, and treatment of IC/BPS. Our sub‐committee focused on developing a consensus document regarding IC/BPS in men. Our committee chair was Dr. Rajesh Taneja, committee members were Drs. Michel Pontari, Jennifer Anger, and Michael Samarinas, and junior researchers were Drs. Madeline Snipes and Wyatt Whitman.

2. Prevalence of IC/BPS in Men

IC/BPS has been conventionally considered a disease of women; however, the recently published literature indicates an increasing percentage of men being diagnosed with IC/BPS. Additionally IC/BPS has been traditionally thought of as a rare diagnosis, but recent studies indicate that the disease may be more widespread than we once thought [1]. The prevalence of IC/BPS in men has been described variously because of the differences in definition used and the methodology employed. The confusion is further compounded as the prevalence is calculated in managed care systems, where the screened population is a subset of the general population that is visiting the health care facility. Conversely, some studies, such as household surveys, may cover a wider cross section of the population. In a recent review of the literature, Anger et al. pointed out that while the range of prevalence data of IC/BPS in women is almost 150‐fold, it is about 500‐fold for similar data in men [2]. Interestingly, though prevalence appears to differ by region, studies have demonstrated no variation in symptom prevalence by race or ethnicity; however, it is important to note that most of the research has been conducted on white women [3].

In 2007, an NHIS study estimated that the prevalence of IC/BPS was 500 per 100 000 population, with 60 per 100 000 men, for a total of 82 832 men visiting the health facilities [4]. A study investigating the prevalence of IC/BPS in the United States Veterans Affairs (VA) population found a prevalence of 0.23% in men within VA patients, estimating a 0.66% prevalence of IC/BPS in US men overall [2]. Utilizing a health care‐based survey of over 5 million cases, Anger et al arrived at prevalence value of 1.08% in Women and 0.66% in men, a ratio of (F:M), 1.6:1. This is close to prevalence data obtained from existing population‐based surveys. In contrast, the Boston Area Community Health (BACH) survey conducted over 2002–2005 revealed a prevalence of IC/BPS in 2.6% in women as compared to men as 1.3%, with a ratio (F:M) 2:1 [4].

IC/BPS definitions and diagnostic criteria vary by region and likely affect prevalence data. The prevalence as calculated by Clemens et al. in a managed health care system, in which 10 000 patients were screened, was much lower at 0.045%–0.197% in women and between 0.008% and 0.041% in men, depending upon whether a sensitive or specific definition of IC/BPS was utilized. The ratio (F:M) thus obtained was 5:1 and 4.8:1 respectively for the definitions used [3, 5]. A RAND epidemiological study from the general population of over 100 000 US households revealed a prevalence of 2.7% (high specificity) and 6.5% (high sensitivity) for women and 1.9% (high specificity) and 4.2% (high sensitivity) for men. This female to male ratio stood at (F:M) 1.42:1 and 1.54:1, depending upon the definition used. Using the high specificity definition, it may be estimated that about 2 107 727 men were suffering from IC/BPS in the U.S around the time of publication of that study [4].

From recently presented data at theninth annual international conference of Global Interstitial cystitis Bladder pain Society (GIBS), the demographic analysis of IC/BPS patients treated in a tertiary care center in India revealed the ratio (F:M) to be 0.95:1. These patients were strictly defined as per the bladder pain increasing on filling without evidence of infection or another disease, and all had undergone cystoscopy [6].

The following are the gaps in the above cited literature

  • 1.

    The self‐reported symptoms and diagnosis of IC/BPS should be confirmed by further investigations as per the standard of care for these patients.

  • 2.

    The prevalence data should be segregated based on whether the survey population was healthcare registered individuals or general population.

3. Clinical Features of IC BPS in Men

The diagnosis of IC/BPS in men can be more difficult as men may think that their symptoms are linked to prostate. This contrasts with women, who perceive their symptoms to be related to bladder, as they do not have a prostate [7]. Men with IC/BPS are frequently diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), bladder outlet obstruction, and epididymitis. Reports have indicated that up to 48% of men with IC/BPS have been previously diagnosed with prostatitis [8]. Hanash and Pool reported that 55% of 123 men diagnosed with IC/BPS had previously undergone transurethral resection of the prostate (TURP) for bladder outlet obstruction [9]. CP/CPPS is defined by the NIH as “the presence of genitourinary pain in the absence of uropathogenic bacteria detected by standard microbiological methodology” [10]. Given these broad and overlapping definitions and symptoms, it is not surprising that IC/BPS in men is believed to be significantly underdiagnosed and often misdiagnosed [11, 12]. Bias of the treating physician may certainly contribute to this since IC/BPS is a diagnosis conventionally associated with women.

In a recent study, it was shown that the urological symptoms are more severe in men with IC/BPS compared to women with IC/BPS and men with CPPS [3, 8, 12, 13]. The most prominent symptoms of IC/BPS in men include suprapubic pain, frequency, and nocturia [14]. The symptoms are aggravated when the bladder is full and alleviated with micturition, “causing a sense of forced voiding” [15]. The patients develop intense pain and/or discomfort when asked to withhold urination, rather than the urgency or fear of leakage described by men with bladder outlet obstruction, who are also likely to report hesitation and incomplete bladder emptying [16]. Moreover, many IC/BPS patients experience significant sleep disturbance, waking up from pain rather than full bladder sensation. In men, pain associated with IC/BPS has also reported in the low back, perineum, scrotum, in addition to the suprapubic region. Pain described as pricking or burning may signify neuropathic origin of pain.

Pain with bladder filling and pain perceived by the patient to be originating from the bladder is the defining symptom of of IC/BPS, while pain that commences with urination can associated with an inflamed prostatic urethra (CP/CPPS) [17]. Painful ejaculation is less specific and may be seen in both conditions [13, 18]. In the NIH sponsored Multidisciplinary Approach to the study of Pelvic pain study (MAPP), men could enter the study with a diagnosis of either CP/CPPS or IC/BPS. Together, both conditions were put under the umbrella term of Urologic Chronic Pelvic Pain Syndrome (UCCPS). Approximately 75% of male participants with UCPPSreported painful bladder filling and/or painful urinary urgency [19]. These bladder‐associated symptoms are usually observed with IC/BPS; however, most of the male participants with UCPPS in MAPP I were originally diagnosed with CP/CPPS [19]. Prevalence of CP/CPPS is reported to be 9% of urological visits, indicating that the male IC/BPS population is quite large if we assume that many of these are misdiagnosed [20, 21].

During physical examination, suprapubic tenderness is common with IC/BPS diagnosis, along with anterior rectal tenderness, and tenderness in perineal body [21]. Tenderness in the prostate on digital rectal examination is not common in CP/CPPS and is mainly associated with acute bacterial prostatitis [21]. Careful mapping of trigger points and widespread pain is important for understanding the pathophysiology and consequent therapeutic benefit [4].

CP/CPPS is further classified by the presence or absence of leukocytes into inflammatory and noninflammatory subtypes, Although to date there have been no clinically significant differences noted between the two subtypes. Recent data suggest the existence of phenotypic subtypes within IC/BPS [22, 23]. Several studies have identified an association between low bladder capacity and worse severity scores on validated symptom and pain questionnaires (i.e., Interstitial Cystitis Problem Index [ICPI], Interstitial Cystitis Symptom Index [ICSI], Pelvic Pain and Urgency/Frequency [PUF] Patient Symptom Scale), leading to the designation of a bladder‐centric phenotype [24]. The bladder‐centric phenotype is associated with more severe pelvic pain and increased presence of Hunner lesions in the bladder epithelium [21, 22, 24]. It has been postulated that a non‐bladder‐centric phenotype (associated with non‐low bladder capacity and negative HL‐status) has increased co‐occurrence with non‐urologic comorbidities, such as fibromyalgia, neuropathies, irritable bowel syndrome, and mental health disorders [25].

Mental health disorders are important to consider in IC/BPS patients, with a significant percentage of patients experiencing comorbid depression, anxiety, or other disorders. In a case‐control study investigating rates of mental health disorders in patients with pelvic pain, 23% of women with IC/BPS and 13% of men with CP/CPPS had a history of a mental health diagnosis, compared to 3% and 4% of controls, respectively. This study, though it did not include men specifically with IC/BPS, demonstrates the significant increase in mental health conditions in the pelvic pain population [26]. Sexual dysfunction has been reported in 60% of men with IC/BPS, which may be due to neurologic abnormalities and/or the impact of pain in the pelvic region on patients' mental states [11, 17].

Evidence suggests that male IC/BPS patients score significantly lower than women on ICSI and ICPI, but there was no reported significant difference between sexes on Genitourinary Pain Index (GUPI) and AUA SI [14]. The GUPI should be used for evaluating symptoms in men with IC/BPS as there are specific questions on pain with bladder filling and or relieved by bladder emptying [19]. Other evaluation tools that may help clinicians assess overall symptomatology include the Michigan Body Map for mapping widespread pain, Patient Health Questionnaire‐9 (PHQ‐9) to assess depression, and PROMIS anxiety questionnaire. Previous studies have demonstrated significantly higher levels of reported depression and anxiety in women with IC, with women reporting a greater desire for psychosocial support than men [14]. GUPI is a validated score for assessing the possibility for bladder pain and pain during sexual activity, but it does not include the sexual dysfunction associated with IC/BPS [14, 23]. The Apollo Clinical Scoring system is a recently validated clinical scoring system that includes a sexual dysfunction domain for both men and women [24].

There are various phenotyping systems being investigated including the ongoing MAPPII study [22]. Other non‐urology clinical features of men with IC may include comorbidities commonly associated with the disease including but not limited to irritable bowel syndrome, migraines, autoimmune disease, fibromyalgia, depression, and anxiety [26, 27, 28]. Over one‐third (38%) of the MAPP I participants with UCPPS were found to have at least one of the three common nonurological chronic overlapping pain conditions (COPCs) that were evaluated—IBS (22%), fibromyalgia (4%), CFS (3%) or multiple COPCs (10%). The conditions may have some cause and/or effect relationship with IC/BPS. Allergies in the form of seasonal hay fever, asthma or multiple drug allergies may have some causal relationship with the IC/BPS and hence must be asked about.

The following should be incorporated in future research:

  • 1.

    Phenotyping based on etiopathogenic mechanism will be able to help in cause directed therapy resulting in optimizing clinical results.

  • 2.

    Uniform Clinical scoring system needs to be utilized for future meaningful integrated research.

4. Investigations in Men With IC/BPS

IC/BPS is a clinical diagnosis of exclusion with no specific diagnostic tests; however, there are several evaluations clinicians may conduct that should lead to a correct diagnosis. Beginning with the least invasive options, the bladder diary provides us with an idea of patients' voided volumes and frequencies and may serve as the baseline assessment of functional capacity. This is an easy method that allows providers to quantify patient responses to treatment. Disparity in day and night frequency may indicate a non‐bladder‐centric disease, contrasting bladder‐centric disease in which functional bladder capacity is consistent throughout a 24‐h period.

The basic lab investigation includes urinalysis, which is mandatory to exclude infection and microscopic hematuria which could indicate bladder cancer. If urinalysis indicates presence of microscopic hematuria, further workup to include imaging is indicated.

A mid‐stream urine culture should be sent to exclude a urinary tract infection. Not all bacteria produce nitrates, and therefore a dip negative nitrate test does not rule out a urinary tract infection [29]. If there is suspicion of NIH category II chronic bacterial prostatitis, microbiologic localization cultures should be used. The four‐glass test according to Meares and Stamey is recommended using first voided urine, midstream urine, expressed prostatic secretion, and urine collected after prostatic massage [30]. The more recently described two glass test, VB2 and VB3, is easier to use and just as accurate [31].

Estimation of residual urine with bladder ultrasound and uroflowmetry tracing is useful to exclude bladder outlet obstruction. Further investigation with video urodynamics may be required to exclude a primary or coexisting lower tract dysfunction such as bladder neck obstruction [32]. In men above 50 years of age, a PSA level may be obtained with informed consent. However, if PSA is elevated, it should not be ascribed to any possible inflammatory condition of the bladder or prostate and needs to be evaluated for prostate cancer as in any other population [33].

If symptoms appear to vary with change in posture, or in the setting of low back pain with radiation down the legs to suggest radiculopathy from sacral nerve involvement, MRI of lumbosacral spine or pelvis should be done to exclude neurologic pathology.

Though there is evidence of urinary biomarkers, specifically TNF‐alpha, and eotaxin, they do not currently play a definitive role in the diagnosis of the disease [34, 35].

5. Treatment of IC/BPS in Men

As with all IC/BPS patients, men who are diagnosed should be educated about the disease, and appropriate strategies for management of stress, diet and exercise should be provided. Furthermore, there arises a role for a multimodal, multidisciplinary approach, often combining oral treatment options with instillations or other more invasive treatment options. Additionally, many patients can benefit from lifestyle modifications as well as psychological support, as numerous patients concomitantly suffer from psychological distress, depression, and sexual dysfunction [14, 20]. Further, consideration should be given to specialist referrals, particularly in men with overlapping chronic pain syndromes, such as gastroenterology, rheumatology or neurology.

Cystoscopy is diagnostic in patients with IC/BPS, as it is the only way to diagnose or exclude Hunner lesions. It has been proposed and practiced as per ESSIC guidelines, Japanese guidelines, and GIBS guidelines to be part of initial investigation and management [36, 37, 38, 39]. Recently, AUA guidelines in 2022 have recommended cystoscopy earlier during the course of management to facilitate identification of Hunner lesions [38]. It is well‐documented that IC/BPS patients experience pain on bladder filling and, therefore, may be unable to tolerate cystoscopy under only local anesthesia. The methodology followed during the procedure may influence the outcome of both diagnosis and treatment. A standardized methodology for diagnostic and therapeutic cystoscopy has been described [39]. General or spinal anesthesia also gives an opportunity to perform therapeutic hydrodistension, ablation of any Hunner's lesions, and intravesical treatments such as triamcinolone injection.

Oral nonspecific medications include Alpha blockers, Hydroxyzine, Amitriptyline, gabapentinoids, and urinary alkalizers. In the past, there was concern about urinary retention with using anticholinergic agents due to a concern for increased residual urine. However, more recent clinical trials have indicated that both anticholinergic medications as well as beta three agonists can be used safely in males without significant risk of urinary retention [40, 41].

Oral pentosan polysulphate is the only oral medication approved by the FDA for treatment of IC/BPS. Though it has been shown to have mixed results and likely has some role in the treatment of bladder‐centric disease, caution must be used given its association with retinopathy in long term use [38, 42, 43].

Men with pelvic floor overactivity may require an extensive pelvic floor relaxation physical therapy. Oral skeletal muscle relaxants like cyclobenzaprine and clonazepam have been used as well. Valium suppositories have been used in Europe for treatment of spastic pelvic floor in women [44, 45].

Intravesical agents have been tried with varied benefit. There is no male‐specific data regarding the roles of botulinum toxin, neuromodulation, and other therapies for IC/BPS treatment in men [38, 46, 47].

6. Risk of Bias in Male‐Specific Data

  • Underrepresentation of male patients in most studies.

  • Small sample sizes make statistical analysis unreliable.

  • No separate analysis for men versus women, making it unclear if treatment responses differ.

7. Investigating New Therapeutic Targets

  • Emerging therapies such as:
    • ∘
      Intravesical Hyaluronic Acid or Chondroitin Sulfate to repair the bladder lining.
    • ∘
      Novel neuromodulation techniques to regulate bladder pain perception. In a recent review of use of neuromodulation in IC/BPS patients, none of the three series of IC/BPS patients included men [45].
    • ∘
      Botulinum toxin has been used with no specific gender specific data [46].
    • ∘
      Stem cell therapy for bladder regeneration has been studied, needs further studies.
    • ∘
      Intravesical platelet rich plasma is still being used in research setting [47].

8. Challenges in Male BPS Research

  • Lack of gender‐specific trials.

  • Potential overlapping diagnosis with CP/CPPS.

9. Future Research Directions

  • More male‐specific trials are needed.

  • Consideration of hormonal and anatomical factors in male BPS treatment.

  • Studies should analyze sex‐based differences in treatment response.

  • Consider studying traditionally utilized tests, such as the Intravesical Lidocaine Test and Potassium Sensitivity Test, within male IC/BPS populations [48, 49].

Author Contributions

R.T. developed an outline for the manuscript; R.T. organized meetings between authors; M.S. and W.W. conducted literature review and drafted manuscript; M.S., M.P., J.A., M.S., and R.T. edited and revised manuscript; R.T. approved final manuscript.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

The authors would like to thank Gopal Badlani, Steve Walker, and Robert Evans for organizing the Global Consensus on IC/BPS meeting held in Winston‐Salem, North Carolina on April 23–24, 2025, providing an opportunity for leaders in the field of IC/BPS to gather and hold meaningful discussions to progress the IC/BPS field.

Data Availability Statement

The authors have nothing to report.

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