Contemporary Non-Operative Management of Bladder Pain Syndrome: A Narrative Review for General Urologists

Background: Bladder pain syndrome (BPS) is a chronic, debilitating condition defined by the International Continence Society as bladder-related pelvic pain accompanied by urinary symptoms in the absence of identifiable pathology. Its heterogeneous presentation, unclear pathophysiology, and variable treatment response make management challenging for general urologists. This review aims to provide a practical narrative review of current understanding of BPS, with particular emphasis on diagnosis, phenotyping, and non-operative management strategies relevant to the general urologist. Methods: A narrative literature review was undertaken using PubMed/MEDLINE, Embase, Google Scholar, and major international guideline documents to identify evidence relating to the diagnosis and non-operative management of BPS. Publications from January 2015 to December 2025 were reviewed, with selected landmark earlier studies included, where clinically relevant. Priority was given to guidelines, systematic reviews, randomised trials, and cohort studies. Owing to heterogeneity in study design, patient phenotypes, and reported outcomes, findings were synthesized narratively. Results: BPS represents a heterogeneous spectrum, including Hunner-lesion and non-Hunner phenotypes, with proposed mechanisms involving urothelial dysfunction, chronic inflammation, immune dysregulation, and central sensitisation. Diagnosis remains one of exclusion, relying on careful history, examination, symptom scoring, and selective investigations. Non-operative management is stepwise and multidisciplinary, combining lifestyle modification, pelvic floor therapy, oral agents and intravesical therapy. Available evidence suggests that symptom improvement is often modest but clinically meaningful in selected patients, supporting an individualized, phenotype-informed approach to care with realistic patient counselling. Conclusions: Bladder pain syndrome remains a chronic, multifaceted disorder with profound impact on quality of life, requiring clinicians to approach patients with empathy while recognising the physical, psychological, and social burden of the condition. Effective management requires early recognition, thoughtful phenotyping, exclusion of confusable conditions, and realistic expectation-setting within a multidisciplinary framework. For the general urologist, a structured and compassionate non-operative approach can improve symptom control, support shared decision-making, and help guide timely escalation when required.