What are the possible causes of suprapubic tenderness and the appropriate initial work‑up?

Suprapubic Tenderness: Causes and Initial Work-Up

Suprapubic tenderness most commonly indicates bladder pathology—particularly interstitial cystitis/bladder pain syndrome, urinary tract infection, or bladder injury in trauma settings—but you must systematically rule out gynecologic, gastrointestinal, and musculoskeletal causes before settling on a diagnosis.

Urologic Causes (Most Common)

Interstitial Cystitis/Bladder Pain Syndrome

• Suprapubic pain related to bladder filling that extends throughout the pelvis is the hallmark presentation 1, 2
• Suprapubic tenderness to palpation is the most common physical finding, present in the majority of male patients with interstitial cystitis 2
• Bladder base tenderness on pelvic examination is present in 34% of women with pelvic pain versus only 3% of controls (OR = 16.3) 3
• Anterior vaginal wall tenderness (AVWT) has 95% sensitivity for interstitial cystitis and 85% positive predictive value 4
• Associated symptoms include severe dysuria, urinary frequency, and in men, painful ejaculation in 60% of cases 2

Bladder Trauma

• Bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims, with gross hematuria present in 77-100% of cases 5
• Suprapubic fullness and urinary retention are key clinical findings in traumatic bladder injury 5
• Retrograde cystography (CT or conventional) is critical to determine presence and type of injury (intraperitoneal vs. extraperitoneal) 5

Urinary Tract Infection/Cystitis

• Acute cystitis presents with suprapubic pain, dysuria, frequency, and urgency 6
• Urinalysis and urine culture are essential initial diagnostic steps 6

Urethral Pathology

• Urethral diverticulum, periurethral masses (Skene gland cyst/abscess), and urethral stricture can cause suprapubic discomfort 6
• Blood at the urethral meatus suggests urethral injury in trauma settings 5

Gynecologic Causes

Pelvic Inflammatory Disease (PID)

• Empiric treatment should be initiated when uterine, adnexal, or cervical motion tenderness is present, even with minimal findings 5, 7
• Suprapubic tenderness may accompany lower abdominal pain, abnormal discharge, and fever >38.3°C 5
• Tubo-ovarian abscess demonstrates thick-walled adnexal mass with suprapubic and pelvic tenderness 5

Ovarian Pathology

• Ovarian cysts account for one-third of gynecologic causes of postmenopausal pelvic pain 5, 8
• Ovarian torsion presents with sudden severe unilateral pain that may radiate to suprapubic region 5, 7
• Ovarian neoplasm accounts for 8% of acute pelvic pain cases in postmenopausal women and must be prioritized given malignancy risk 5, 8

Endometriosis

• Deep infiltrating endometriosis can cause suprapubic pain, particularly with bladder involvement 5
• Pain that begins before menstruation and worsens with deep dyspareunia is characteristic 9

Uterine Pathology

• Degenerating fibroids are the second most common cause of acute pelvic pain in perimenopausal/postmenopausal women 5
• Cervical stenosis with endometritis can present with suprapubic discomfort 5

Gastrointestinal Causes

• Diverticulitis presents with left lower quadrant/suprapubic tenderness, fever, and altered bowel habits 8
• Inflammatory bowel disease can manifest as chronic suprapubic/pelvic pain 8
• Appendicitis may cause suprapubic pain in retrocecal or pelvic locations 5

Musculoskeletal Causes

• Pelvic myofascial pain can mimic bladder pathology and cause suprapubic tenderness 8, 1
• Abdominal wall trigger points are independently associated with suprapubic tenderness (OR = 3.44) 3
• Pelvic floor muscle tension is strongly associated with suprapubic tenderness (OR = 8.22) 3
• Pelvic girdle pain from lower back or pelvic disorders can refer pain to the suprapubic region 8

Initial Diagnostic Work-Up Algorithm

Step 1: History and Targeted Physical Examination

• Obtain detailed pain characteristics: onset (sudden vs. gradual), quality, radiation, timing relative to voiding/menses, and aggravating factors 1, 6
• Document urinary symptoms: frequency, urgency, dysuria, hematuria, and relationship of pain to bladder filling 1, 2
• In reproductive-age women, obtain menstrual history and assess for dyspareunia 9
• Palpate for suprapubic tenderness, abdominal wall trigger points, and assess for costovertebral angle tenderness 2, 3
• In women, perform bimanual examination to assess for bladder base tenderness, anterior vaginal wall tenderness, cervical motion tenderness, and adnexal masses 3, 4
• In men, perform digital rectal examination to assess for anterior rectal wall tenderness and prostate abnormalities 2

Step 2: Laboratory Testing

• Obtain urinalysis with microscopy and urine culture to evaluate for infection, hematuria, and pyuria 6, 2
• In reproductive-age women, obtain quantitative serum β-hCG immediately to exclude pregnancy-related emergencies 5, 7, 9
• Consider complete blood count and inflammatory markers (ESR, CRP) if infection or inflammatory process suspected 5

Step 3: Initial Imaging

• Transvaginal ultrasound combined with transabdominal approach is the initial imaging study of choice for suspected gynecologic or bladder pathology in women 5, 8
• Color and spectral Doppler should be routinely incorporated to evaluate vascularity and distinguish cysts from solid masses 5, 8
• In trauma settings with gross hematuria, perform retrograde cystography (CT or conventional) to diagnose bladder injury 5
• If urethral injury is suspected (blood at meatus, inability to void, perineal hematoma), perform retrograde urethrography before catheterization 5

Step 4: Advanced Imaging When Initial Work-Up Is Nondiagnostic

• MRI pelvis with gadolinium-based IV contrast is the problem-solving examination of choice when ultrasound is inconclusive 8, 9
• CT abdomen and pelvis with IV contrast is indicated when life-threatening non-gynecologic diagnoses are suspected (appendicitis, diverticulitis, bowel obstruction) or when rapid diagnosis is required 5
• CT has 89% sensitivity for urgent abdominal diagnoses but should not be first-line for suspected gynecologic pathology due to radiation exposure 5, 7, 9

Step 5: Specialized Diagnostic Procedures

• Cystoscopy with hydrodistention under anesthesia is diagnostic for interstitial cystitis, revealing glomerulations and reduced bladder capacity 2
• Laparoscopy may be required for definitive diagnosis of endometriosis, ovarian torsion, or tubo-ovarian abscess when imaging is equivocal 5, 7

Critical Pitfalls to Avoid

• Never assume suprapubic tenderness is solely bladder-related without systematically evaluating gynecologic, gastrointestinal, and musculoskeletal systems 8, 1, 6
• Never omit pregnancy testing in reproductive-age women before imaging or initiating treatment 7, 9
• Never use CT as first-line imaging for suspected gynecologic or bladder pathology; ultrasound offers equal or superior accuracy without radiation 7, 9
• Never delay empiric antibiotic therapy for suspected PID while awaiting culture results, as postponement can cause permanent reproductive damage 5, 7, 9
• Never dismiss anterior vaginal wall or bladder base tenderness as nonspecific; these findings have high sensitivity and positive predictive value for interstitial cystitis 3, 4
• Never assume normal arterial Doppler flow excludes ovarian torsion; venous flow abnormalities are more sensitive 7, 9
• In trauma settings, never attempt urethral catheterization before retrograde urethrography if urethral injury is suspected 5
• Never overlook musculoskeletal causes; pelvic floor tenderness and abdominal wall trigger points are independently associated with suprapubic pain 3