Kristin A. Greco, MD
Ahmer V. Farooq, DO
BASICS
DESCRIPTION
• Suprapubic pain describes a pain located in the midline of the abdomen, above the pubic symphysis and below the umbilicus.
• Multiple organ systems can cause suprapubic pain including urologic, gastrointestinal, gynecologic, and other rare causes.
RISK FACTORS
• History of urinary tract infections (UTIs)
• BPH as it may cause urinary retention
• Urolithiasis
• Immunocompromised patients have increased susceptibility to infections
• Pelvic radiation treatment
• Chronic pain syndromes
• Strenuous athletic activity
PATHOPHYSIOLOGY
• The pathophysiology of suprapubic pain is dependent on the etiology and various reproductive, GI, urologic, and neuromuscular disorders may cause pain in this area. This section will focus on urologic pathophysiology.
• Suprapubic pain resulting from the urinary tract is usually associated with inflammation or obstruction such as in UTI or acute urinary retention.
– Bacterial cystitis causes a sharp and stabbing pain that is worse at the end of micturition. The pain is often referred to the distal urethra and is associated with the symptoms of frequency and urgency of urination.
UTI also causes intermittent suprapubic discomfort secondary to inflammation of the urothelium. This is often more severe with a full bladder and improves when the bladder is relieved of distention.
– Acute urinary retention causes suprapubic pain by overdistention of the bladder (1). In contrast, chronic, slowly progressing urinary retention is usually asymptomatic despite large residual volumes.
• Malignancies in the urinary tract generally do not produce pain unless they cause obstruction or extend into adjacent nerves. Pain can be a late manifestation of malignancy.
• Prostatitis typically causes pain in the perineum, but this pain is frequently referred to the suprapubic area. Pain is secondary to inflammation with resulting edema and distention of prostatic capsule.
• Interstitial cystitis or painful bladder syndrome (IC/PBS) is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6-wk duration, in the absence of infection of other identifiable causes.
– The pathophysiology of this disorder is currently under investigation. It is associated with other chronic systemic pain syndromes.
ASSOCIATED CONDITIONS
• BPH with urinary retention
• IC/PBS
• Prostatitis
• UTI
• Urolithiasis
DIAGNOSIS
HISTORY
• History taking in the patient presenting with suprapubic pain should be broad and consider all possible organ systems involved. A thorough history can lead the clinician to appropriate diagnostic tests in this patient
• Associated urinary symptoms such as frequency, urgency, dysuria, nocturia, and ability to empty the bladder
• Onset and duration of suprapubic pain
• Perineal pain
• Gross hematuria or hematospermia
• History of urinary retention
• Benign prostatic hypertrophy (BPH)
• Urolithiasis
• History of pelvic malignancy
• Trauma
• Radiation treatment for cancer
• History of diarrhea or bowel disease
• Last menstrual period and possibility of pregnancy
• History of STI/STD
• Dyspareunia
PHYSICAL EXAM
• Abdominal exam:
– Palpable bladder suggests urinary retention
– Suprapubic tenderness is common with inflammation and infection of the genitourinary system
– Umbilical discharge with urachal abnormality
• Pelvic exam:
– Chandelier sign (tenderness with movement of the cervix) with PID
– Cervical discharge
– Pelvic masses
• Rectal exam:
– Tender, swollen, or boggy prostate during palpation may indicate prostatitis
– Evidence of masses or blood with GI tract disease
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis and culture:
– Pyuria, nitrite, and bacteria with infection
– pH, crystals/calcium, uric acid, oxalate, citrate, 24-hr excretion with urolithiasis
• CBC: Leukocytosis with left-shift; nonspecific infection and inflammation
• Urine cytology for malignancy
• Pregnancy testing in women
Imaging
• Plain x-ray: Important for evaluation of bowels, urolithiasis, or foreign body.
• CT pelvis: Useful for diagnosing GI etiology, urolithiasis, or pelvic masses. Has no role in uncomplicated infections of the GU tract.
• US bladder: Assess postvoid residual volume, calculi, or mass.
• Pelvic US for gynecologic causes. Transvaginal US is best for uterine or ovarian evaluation.
Diagnostic Procedures/Surgery
• Cystoscopy:
– Evaluate for bladder tumor, stone, outlet obstruction, urethral stricture and IC/PBS (may see inflammatory lesions or Hunner’s ulcers).
– Contraindicated during acute GU infection such as UTI or prostatitis.
• Mears–Stamey 4-glass test for prostatitis evaluation.
• Urodynamics:
– Assess bladder capacity, bladder contraction, pressure, and outlet obstruction. Not indicated for acute suprapubic pain.
Pathologic Findings
Based on the specific entity
DIFFERENTIAL DIAGNOSIS
• Urologic:
– UTI
Cystitis
Prostatitis, acute bacterial
Pyelonephritis
– Urinary Retention
– Urolithiasis (bladder or distal ureter)
– Prostatitis including acute bacterial, chronic nonbacterial, inflammatory and noninflammatory (NIH CP/CPPS III A and B)
– Bladder perforation
– IC/PBS
– Malignancy (bladder, prostate)
– Urachal abnormality
• Gastrointestinal:
– Acute appendicitis
– Colitis
– Diverticulitis
– Inflammatory bowel disease
• Gynecologic:
– Dysmenorrhea
– Endometriosis
– Malignancy (uterine, ovarian)
– Miscarriage
– Mittelschmerz
– Ovarian cyst (hemorrhagic or ruptured)
– Ovarian torsion/ovarian vein thrombosis
– Pelvic Inflammatory disease
– Pregnancy (including ectopic)
– Uterine fibroids
• Other:
– Trauma
– Sexual abuse
– Osteitis pubis
– Abdominal wall myofascial pain
– In athletes (2):
Sports hernia (athletic pubalgia, Sportsman’s hernia)
Adductor strain
Muscle tears
Avulsion injuries
Stress fractures
Tears of acetabular labrum
TREATMENT
• The focus of this discussion is on urologic pathologic processes.
• Some common urologic conditions and interventions are noted below. Other conditions are beyond the scope of this section.
MEDICATION
First Line
• Acute uncomplicated UTI in women (3,4):
– Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days is appropriate due to minimal resistance and propensity for collateral damage.)
– Trimethoprim–sulfamethoxazole (160/800 mg [1 double-strength tablet] twice daily for 3 days) given its efficacy in numerous clinical trials.
• Complicated UTI: Treat for 7–14 days with culture-specific antibiotics.
– Risk factors that make a UTI complicated include:
Indwelling catheter
Immunosuppression
Male sex
Urinary retention
Functional or anatomical abnormality of the urinary tract
History of urinary tract surgery
• Prostatitis
– Antibiotics empirically for 2 wk. If cultures are positive or the patient has improved clinical symptoms then continue antibiotics for 4–6 wk. Antibiotics with excellent prostatic penetration include fluoroquinolones (so they should not be used with concomitant UTI).
• BPH/urinary retention
– α-Blockers, such as tamsulosin, may be used. 5α-reductase inhibitors, such as finasteride can be added if the prostate gland is estimated to be over 40 g.
• Bladder calculi
– Often require surgical removal. Medical therapy can be considered for uric acid stones.
• Interstitial cystitis/painful bladder syndrome (IC/PBS) (5)
– 1st-line treatment is behavioral modifications, counseling and stress management, and coping techniques.
– 2nd-line treatment includes manual physical therapy techniques that resolve pelvic, abdominal and hip muscular trigger points, and lengthen muscle contractures.
– Amitriptyline, cimetidine, hydroxyzine or pentosan polysulfate may be used as 2nd-line oral medications.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• BPH/urinary retention
– Transurethral catheterization to relieve acute obstruction; if unable to perform then suprapubic catheter should be considered.
– Transurethral resection of prostate or other ablative procedure (laser, microwave) if appropriate.
• Bladder calculi
– Remove transurethrally and fragment manually with lithotrite or with Holmium laser
– Open cystolithotomy rarely needed
• IC/PBS
– 3rd-line treatment of IC/PBS can involve cystoscopy under anesthesia with short-duration, low-pressure hydrodistention
– If Hunner’s lesions are present, then fulguration with laser or electrocautery and/or injection of triamcinolone should be performed.
• Bladder cancer
– Superficial tumors:
TURBT ± intravesical BCG
– Invasive tumors: Radical cystectomy with urinary diversion
ONGOING CARE
PROGNOSIS
Good prognosis with treatment of a clearly identified problem. Patients with IC/PBS often have a chronic course with flares that can last days to weeks to months. These patients require a multimodal treatment approach.
FOLLOW-UP
Patient Monitoring
• Patient monitoring and follow-up is dependent on the specific pathologic process.
• Assessment of postobstructive diuresis following relief of urinary obstruction includes measurement of serum electrolytes.
• Urine culture following treatment of complicated UTI should be performed to ensure adequate treatment. This is not needed for uncomplicated UTI in women.
REFERENCES
1. Selius BA, Subedi R. Urinary retention in adults: Diagnosis and initial management. Am Fam Physician. 2008;77(5):643–650.
2. Weber MA, Rehnitz C, Ott H, et al. Groin pain in athletes. Rofo. 2013;185(12):1139–1148.
3. Wagenlehner FM, Wullt B, Perletti G. Antimicrobials in urogenital infections. Int J Antimicrob Agents. 2011;385:3–10.
4. Hummers-Pradier E, Kochen MM. Urinary tract infections in adult general practice patients. Br J Gen Pract. 2002;52:752–761.
5. Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187–193.
ADDITIONAL READING
Edwards JL. Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2008;77(10):1403–1410.
See Also (Topic, Algorithm, Media)
• Bladder Calculi
• Cystitis, General
• Interstitial cystitis (IC)/Painful Bladder syndrome (PBS)
• Osteitis Pubis
• Prostate, Benign Hyperplasia/hypertrophy (BPH)
• Prostatitis, General
• Stamey Test (Meares–Stamey Test)
• Urethra Stricture, Male
• Urethral Stenosis/Stricture, Female
• Urinary Retention, General
CODES
ICD9
• 592.9 Urinary calculus, unspecified
• 599.0 Urinary tract infection, site not specified
• 789.09 Abdominal pain, other specified site
ICD10
• N20.9 Urinary calculus, unspecified
• N39.0 Urinary tract infection, site not specified
• R10.8 Other abdominal pain
CLINICAL/SURGICAL PEARLS
• Multiple organ systems can cause suprapubic pain including urologic, gastrointestinal, gynecologic, neuromuscular and other rare causes.
• Bacterial cystitis typically causes a sharp and stabbing pain that is worse at the end of micturition. This is secondary to inflammation of the urothelium.
• Acute urinary retention causes suprapubic pain by overdistention of the bladder.
• CT imaging can be useful for diagnosing GI etiology, urolithiasis or pelvic masses, but CT has no role in uncomplicated infections of the GU tract.
• Cystoscopy can be used to evaluate for bladder tumor, stone, outlet obstruction or urethral stricture.
• 1st-line treatment for interstitial cystitis/painful bladder syndrome (IC/PBS) involves behavioral modifications, counseling and stress management and coping techniques.