From the Guidelines
Painful, tender suprapubic sites are commonly associated with urinary tract infections (UTIs), and urinalysis is a crucial diagnostic tool for evaluating these symptoms, as recommended by the European Association of Urology guidelines 1. When a patient presents with suprapubic pain and tenderness, a urinalysis should be performed immediately to check for pyuria (white blood cells), hematuria (red blood cells), nitrites (suggesting bacterial presence), and leukocyte esterase (indicating inflammation). Some potential diagnoses for a painful, tender suprapubic site include:
- Urinary tract infections (UTIs)
- Cystitis
- Urolithiasis (bladder stones)
- Interstitial cystitis
- Bladder distention from urinary retention
- Pelvic inflammatory disease
- Gynecological conditions like endometriosis or ovarian cysts in women The diagnostic value of urinalysis lies in its ability to quickly differentiate infectious from non-infectious causes, guiding appropriate initial management and determining the need for additional testing, as supported by the American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guideline 1. Urinalysis, including assessment of white and red blood cells and nitrite, is recommended for routine diagnosis of UTIs, and a urine culture and antimicrobial susceptibility testing should be performed in all cases of pyelonephritis 1. In patients with recurrent UTIs, evaluation of the upper and lower urinary tracts with imaging and cystoscopy is considered good clinical practice to identify sources of infection 1. For uncomplicated UTIs, empiric treatment with fluoroquinolones or cephalosporins can be initiated while awaiting culture results, as recommended by the European Association of Urology guidelines 1. Patients should increase fluid intake and avoid bladder irritants like caffeine and alcohol. Persistent symptoms despite treatment warrant further investigation with imaging studies such as ultrasound or CT scan to rule out structural abnormalities, stones, or masses.
From the Research
Diagnoses for a Painful, Tender Suprapubic Site
- Urinary tract infection (UTI) is a possible diagnosis for a painful, tender suprapubic site, as it can cause symptoms such as dysuria, urgency, and frequency 2, 3
- Interstitial cystitis is another possible diagnosis, characterized by excessive urgency and frequency of urination, suprapubic pain, and negative urine cultures 4
- Other conditions that may cause suprapubic pain include bacterial cystitis, urethritis, neoplasia, vaginitis, and vulvar vestibulitis 4
Role of Urinalysis in Evaluation
- Urinalysis is an important diagnostic tool in evaluating a painful, tender suprapubic site, as it can help identify the presence of a UTI or other conditions 2, 3
- Dipstick urinalysis can be used as a screening test, but results must be interpreted in the context of the patient's symptoms and pretest probability 3
- Urine culture is the gold standard for detecting UTI, but may not be necessary in all cases, particularly if the patient has a low pretest probability of UTI 3
- Microscopic urinalysis may be comparable to dipstick urinalysis as a screening test, but bacteriuria is more specific and sensitive than pyuria for detecting UTI 3
Considerations in Specific Populations
- In older women, UTIs may present differently, and dipstick urinalysis may be less sensitive, but nitrites may be more sensitive and specific for UTI 3
- In pregnant women, urine culture is the test of choice, and positive dipstick testing is likely specific for asymptomatic bacteriuria, but treatment should be initiated based on symptoms and risk of UTI 3
- In preterm infants, suprapubic aspiration (SPA) may be more painful than urine catheterization (UC), and had a tendency to be associated with a higher rate of procedure failure 5