What are the causes of pubic pain and dysuria when the bladder is full?

Causes of Pubic Pain and Dysuria When the Bladder is Full

The most common cause of pubic pain and dysuria with bladder fullness is interstitial cystitis/bladder pain syndrome (IC/BPS), a chronic condition where pain worsens with bladder filling and improves with urination, though urinary tract infection and sexually transmitted infections must be ruled out first. 1

Primary Pathophysiologic Mechanism

In IC/BPS, the urothelium releases excessive prostaglandins when stretched during bladder filling, which sensitizes sensory nerves and bladder smooth muscle, amplifying pain signals beyond normal physiologic limits. 2 This represents an exaggerated version of normal bladder filling sensation that becomes pathologic. 2

Differential Diagnosis by Likelihood

Most Common: Interstitial Cystitis/Bladder Pain Syndrome

• Pain that worsens with bladder filling and improves with urination is the hallmark of IC/BPS. 1
• Patients typically describe suprapubic pain, pressure, or discomfort (many deny "pain" and use "pressure" instead). 3, 1
• Pain may extend throughout the pelvis including urethra, vagina, rectum, lower abdomen, and back. 3
• Symptoms must persist for at least 6 weeks in the absence of infection or other identifiable causes. 1
• Urinary frequency (92% of patients) and urgency (84% of patients) are nearly universal, but patients void to relieve pain rather than prevent incontinence. 1
• Pain often worsens with specific foods or drinks. 3, 1

Must Rule Out First: Infectious Causes

• Urinary tract infection is the most common cause of dysuria overall and must be excluded with urinalysis and urine culture. 1, 4
• Urethritis from N. gonorrhoeae or C. trachomatis should be considered, especially in sexually active individuals. 5
• Gram-stained urethral smear showing >5 polymorphonuclear leukocytes per oil immersion field suggests urethritis. 5

In Males: Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• CP/CPPS shares nearly identical clinical characteristics with IC/BPS, with pain in the perineum, suprapubic region, testicles, or tip of the penis that worsens with urination. 3, 5
• IC/BPS should be strongly considered in men whose pain is perceived to be bladder-related. 3, 1, 5
• Some men meet criteria for both conditions and require combined treatment approaches. 3, 1, 5

Less Common Causes

• Bladder inflammation from any source increases urothelial prostaglandin release, contributing to pain during filling. 2
• Diabetic bladder dysfunction can cause overdistension with delayed pain sensation followed by severe discomfort. 2
• Bladder tumors, obstructive conditions, and other urologic diseases must be considered. 6

Critical Diagnostic Approach

Basic laboratory testing with urinalysis and urine culture is mandatory to document symptoms and exclude infection. 1

• Cystoscopy should be performed when Hunner lesions are suspected, as this is the only reliable way to diagnose their presence. 1
• Urodynamics are not recommended for routine clinical use as there are no agreed-upon diagnostic criteria for IC/BPS. 1
• If vaginal discharge is present, investigate cervicitis and other causes rather than assuming urinary tract infection. 4
• For persistent urethritis or cervicitis with negative initial testing, Mycoplasma genitalium testing is recommended. 4

Critical Pitfalls to Avoid

• Do not treat with antibiotics when no infection is documented, as this leads to antibiotic resistance and disruption of protective flora. 1
• Do not dismiss patients who describe "pressure" rather than "pain"—this is extremely common in IC/BPS. 3, 1, 5
• Pain that occurs with minimal bladder filling, persists after voiding, or is described as pressure should raise concern for IC/BPS rather than simple bladder fullness. 2
• The condition is often misdiagnosed or diagnosis is delayed due to the wide spectrum of symptoms. 1
• Do not use research or clinical trial definitions in clinical practice, which can lead to misdiagnosis or treatment delays. 1