What are the treatment options for suprapubic pain and dysuria (burning on urination)?

Treatment of Suprapubic Pain and Dysuria

For suprapubic pain with burning on urination, the primary concern is to diagnose and treat the underlying cause, with uncomplicated urinary tract infections requiring antibiotics like trimethoprim-sulfamethoxazole, while chronic conditions like interstitial cystitis/bladder pain syndrome require a stepwise multimodal approach starting with oral pentosan polysulfate sodium. 1, 2, 3

Initial Diagnostic Considerations

The combination of suprapubic pain and dysuria requires differentiation between several key conditions:

• Acute bacterial cystitis presents with these symptoms plus positive urine culture and responds to antibiotics 1, 4
• Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by suprapubic pain related to bladder filling, urinary urgency and frequency, with negative urine cultures 1, 4, 3
• Other conditions to exclude include urethritis, neoplasia, vaginitis, vulvar vestibulitis, and in rare cases eosinophilic cystitis or enterovesical fistula 1, 4, 5, 6

Important caveat: Many IC/BPS patients use the term "pressure" rather than "pain" to describe their symptoms, so asking specifically about pressure and discomfort is critical 1

Treatment Algorithm for Acute Bacterial Cystitis

If urine culture is positive or clinical suspicion is high for uncomplicated UTI:

• Trimethoprim-sulfamethoxazole is indicated for urinary tract infections due to susceptible organisms including E. coli, Klebsiella, Enterobacter, and Proteus species 2
• Initial episodes of uncomplicated UTI should be treated with a single effective antibacterial agent 2
• Culture and susceptibility testing should guide therapy when available 2

Treatment Algorithm for Interstitial Cystitis/Bladder Pain Syndrome

When urine cultures are negative and symptoms are chronic (pain is the hallmark symptom):

First-Line Oral Therapies

• Pentosan polysulfate sodium is the only FDA-approved oral therapy for IC/BPS and should be considered first-line 3
• Antihistamines can be used as oral therapy 1, 3
• Tricyclic antidepressants are effective oral options 1, 4, 3

Second-Line Intravesical Therapies

• Dimethyl sulfoxide (DMSO) is the only FDA-approved intravesical therapy for IC/BPS 3
• Hydrodistention can be both diagnostic and therapeutic 1, 4
• Intravesical heparin or combination agents may be considered 1, 4
• Intravesical pentosan polysulfate sodium is an alternative route of administration 3

Adjunctive Measures

• Dietary modifications should be implemented, as pain often worsens with specific foods or drinks 1, 3
• Support group referral should be offered to all IC/BPS patients given the significant psychological and quality of life impacts 4

Special Considerations for Male Patients

In men presenting with suprapubic pain and dysuria:

• Consider both IC/BPS and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) as the clinical characteristics overlap significantly 1
• The diagnosis of IC/BPS should be strongly considered when pain is perceived to be related to the bladder 1
• Some men meet criteria for both conditions and may benefit from combined treatment approaches 1
• Early symptoms may begin with mild dysuria or urgency and progress to severe frequency, nocturia, and suprapubic pain 1

When to Suspect Rare Causes

• Eosinophilic cystitis should be considered in children or young adults with acute hematuria, dysuria, and suprapubic pain with sterile cultures and focal bladder lesions on imaging 5
• Enterovesical fistula from colorectal malignancy should be suspected with recurrent UTIs unresponsive to antibiotics, especially with associated weight loss and tenesmus 6
• IC/BPS as manifestation of Sjögren's syndrome may require immunosuppressive therapy such as low-dose cyclosporine when standard treatments fail 7

Critical Pitfalls to Avoid

• Do not dismiss patients who deny "pain" but describe "pressure" or "discomfort" - these are equivalent descriptors in IC/BPS 1
• Do not assume all dysuria with suprapubic pain is simple UTI - negative cultures should prompt consideration of IC/BPS 1, 4, 3
• Do not expect any single treatment to reliably benefit most IC/BPS patients - treatment response is variable and often requires trial of multiple therapies 1
• Do not use prolonged antibiotic therapy without documented infection, as this delays appropriate diagnosis and treatment of IC/BPS 1