What is the appropriate evaluation and management for a patient with suprapubic tenderness on light palpation that occurs during urination?

Evaluation and Management of Suprapubic Tenderness During Urination

Suprapubic tenderness on light palpation during urination requires immediate evaluation for bladder injury, urinary tract infection, or inflammatory bladder conditions, with retrograde cystography being the diagnostic test of choice if trauma is suspected, and urinalysis with culture if infection is the primary concern.

Initial Clinical Assessment

Key Diagnostic Indicators to Evaluate

Suprapubic tenderness during urination is a critical clinical finding that warrants systematic evaluation. The following features must be assessed:

• Trauma history: Any recent pelvic trauma, pelvic fracture, or penetrating injury to the lower abdomen, perineum, or buttocks should raise immediate concern for bladder rupture 1
• Urinary symptoms: Assess for gross hematuria (present in >90% of traumatic bladder ruptures), inability to void, low urine output, or urinary retention 1
• Associated findings: Look for abdominal distension, elevated BUN/creatinine (suggesting peritoneal urine absorption), or signs of systemic infection 1
• Catheter status: Determine if the patient has or recently had (within 48 hours) an indwelling urinary catheter, as this significantly increases risk of catheter-associated UTI 1

Diagnostic Approach

If Trauma or Bladder Injury is Suspected

Retrograde cystography is the mandatory diagnostic test for suspected bladder injury 1. The technique requires:

• Retrograde, gravity filling of the bladder with contrast medium
• Minimum 300 mL instillation or until patient tolerance to achieve maximal bladder distension
• Minimum two views: one at maximal fill and one post-drainage 1
• Critical pitfall: Simply clamping a Foley catheter to allow IV contrast accumulation is inadequate and results in missed injuries 1

Plain film and CT cystography have similar sensitivity and specificity (95% and 100% respectively) 1. CT cystography is preferred when available as it can simultaneously evaluate other injuries 1.

If Infection is Suspected

For patients without trauma history presenting with suprapubic tenderness and urinary symptoms:

• Obtain urinalysis and urine culture before initiating antimicrobial therapy 1
• Look for signs of catheter-associated UTI if applicable: new onset fever, altered mental status, flank pain, costovertebral angle tenderness, acute hematuria, pelvic discomfort, dysuria, or suprapubic pain 1
• Consider interstitial cystitis/painful bladder syndrome in patients (particularly women) with chronic symptoms (>6 months), urinary frequency, urgency, and negative cultures 2, 3

Management Based on Diagnosis

Traumatic Bladder Injury

Intraperitoneal bladder rupture requires immediate surgical repair 1. These are typically large "blow-out" injuries in the bladder dome that will not heal with catheter drainage alone and risk peritonitis and sepsis if left unrepaired 1.

Uncomplicated extraperitoneal bladder rupture can be managed conservatively with:

• Urethral catheter drainage (suprapubic catheter not routinely necessary) 1
• Clinical observation and antibiotic prophylaxis 1
• Healing occurs within 10 days in >85% of cases 1
• Surgical repair is indicated only for complex injuries (bladder neck involvement, associated pelvic fractures requiring fixation, or rectal/vaginal injuries) 1

Urinary Tract Infection

For complicated UTI with systemic symptoms, initiate empiric broad-spectrum antibiotics 1:

• Combination therapy: amoxicillin plus aminoglycoside, OR second-generation cephalosporin plus aminoglycoside, OR IV third-generation cephalosporin 1
• Avoid fluoroquinolones for empirical treatment in urology patients or those with recent fluoroquinolone use (within 6 months) 1
• Tailor therapy based on culture results and continue for 7-14 days (14 days for men when prostatitis cannot be excluded) 1

For catheter-associated UTI, treat according to complicated UTI guidelines and obtain urine culture before starting antimicrobials 1.

Interstitial Cystitis/Painful Bladder Syndrome

This diagnosis of exclusion should be considered in patients with chronic suprapubic pain, urinary urgency/frequency, and negative cultures 3, 4. Management includes:

• Pentosan polysulfate sodium: The only FDA-approved oral therapy for interstitial cystitis 3
• Dimethyl sulfoxide: The only FDA-approved intravesical therapy 3
• Additional options include antihistamines, tricyclic antidepressants, and dietary modifications 3
• Multimodal therapy is typically required to break the cycle of chronic inflammation 5

Critical Pitfalls to Avoid

• Never perform blind urethral catheterization if urethral injury is suspected (blood at meatus, perineal hematoma, high-riding prostate). Obtain retrograde urethrography first 1
• Do not rely on passive contrast filling during CT for bladder evaluation—active retrograde instillation is mandatory 1
• Do not assume microscopic hematuria excludes significant injury in trauma patients, especially with pelvic fractures 1
• Do not delay surgical repair of intraperitoneal bladder rupture—conservative management is contraindicated and risks life-threatening complications 1