Suprapubic / Pelvic Pain
Suprapubic or pelvic pain is discomfort localized to the lower abdomen below the umbilicus, commonly arising from urinary, gynecological, gastrointestinal, or musculoskeletal pathology affecting the pelvic organs or structures.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute uncomplicated cystitis (UTI) [1] | Dysuria + frequency + urgency + suprapubic pain; +ve urine dipstick (LE, nitrite) | 「小便有冇痛？去得密唔密？急住去？」(Dysuria + storage LUTS) |
| Dysmenorrhoea / Mittelschmerz | Cyclical pain related to menstrual cycle; midcycle for Mittelschmerz | 「個痛同你嚟M有冇關係？」 | |
| Serious Not To Miss | Ectopic pregnancy | Missed period + unilateral pelvic pain + vaginal bleeding; +ve β-hCG | 「月經有冇遲咗？有冇可能懷孕？」 |
| Pelvic inflammatory disease (PID) [4] | Lower abdominal pain + fever + vaginal discharge + cervical motion tenderness | 「有冇發燒？有冇分泌物？同伴侶親密有冇痛？」 | |
| Ovarian torsion | Sudden severe unilateral pelvic pain + N/V; adnexal tenderness | 「係突然間好痛定慢慢嚟？有冇作嘔作悶？」 | |
| CA bladder [3] | Painless gross haematuria in ≥50yo; smoking history | 「有冇食煙？小便有冇血？」 | |
| Acute appendicitis (pelvic) [5] | Periumbilical → suprapubic; anorexia; may have no RIF signs if pelvic appendix | 「最初痛邊度？而家轉咗去邊？有冇食唔落嘢？」 | |
| Pitfalls | Endometriosis [4] | Chronic cyclical pelvic pain + dysmenorrhoea + dyspareunia + subfertility | 「嚟M嗰陣特別痛？痛咗幾耐？有冇影響到生育？」 |
| Interstitial cystitis | Chronic suprapubic pain + storage LUTS; sterile urine; Dx of exclusion [6] | 「呢個痛有冇成幾個月？尿液驗過有冇菌？」 | |
| Ureteric / bladder stone [7] | Colicky pain, haematuria, stone at VUJ → storage LUTS | 「個痛有冇一陣陣嘅？小便有冇血？」 | |
| Subluxation of pubic symphysis (pregnant) [8] | Suprapubic pain worse on weight-bearing in pregnancy | 「你而家有冇懷孕？行路或者轉身有冇痛多啲？」 | |
| Masquerades | Depression / somatisation | Chronic pain, low mood, sleep disturbance, functional impairment | 「最近心情點？瞓得好唔好？」 |
| Constipation | Infrequent stool, bloating, suprapubic discomfort relieved by defecation | 「大便正唔正常？幾耐去一次？」 | |
| Drug side-effect (e.g. NSAID → AIN) | Recent drug use + renal impairment | 「最近有冇食新藥或者止痛藥？」 | |
| Trying to Tell Me Something? | Fear of STD / unwanted pregnancy | Recent unprotected sex, new partner, anxiety | 「有冇咩嘢令你特別擔心？」 |
| Domestic / sexual violence | Evasive about mechanism, frequent visits, injury pattern | 「你喺屋企安唔安全？」(Ask if suspicion arises) |
Suprapubic / Pelvic Pain — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, ID, set agenda | 「你好，我係X醫生，今日由我同你傾吓。請問我可以點稱呼你？」「今日有咩唔舒服想同我講？」 | Rapport, patient-centred opening, interpersonal marks |
| 0:30–2:00 | HPI — SOCRATES + urinary/GYN Sx | 「呢個痛幾時開始？」「痛嘅位置係邊度？有冇去到其他地方？」「個痛係咩嘢感覺？脹住痛、刺痛、定係一陣陣絞痛？」「有冇嘢令到佢痛啲或者舒服啲？」「有冇痛到去腰後面？」「小便有冇痛？有冇血？有冇急住想去？去得密唔密？」「有冇陰道分泌物或者唔正常出血？」 | Captures symptom analysis, storage LUTS, red flags — core Case Report marks |
| 2:00–3:00 | Red flags + systemic review | 「有冇發燒、作悶、嘔？」「有冇食唔落嘢、瘦咗？」「最後一次月經幾時？有冇可能懷孕？」「有冇性生活？」 | Rules out ectopic pregnancy, PID, malignancy — "serious not to miss" marks |
| 3:00–4:00 | PMHx, drug Hx, allergy, FHx, social Hx | 「以前有冇咩大病或者做過手術？」「而家有冇食緊咩藥？有冇藥物敏感？」「屋企人有冇類似嘅問題？」「你做咩嘢工作？有冇食煙飲酒？」 | Completeness of history; drug Hx esp NSAIDs, antibiotics |
| 4:00–5:00 | ICE + hidden agenda | 「你自己覺得可能係咩問題？」（Idea）「你最擔心係咩嘢？」（Concern）「你嚟睇醫生最希望醫生幫到你咩？」（Expectation）「有冇咩嘢令你特別擔心先嚟睇醫生？」（Hidden agenda） | ICE marks — often 3 separate marks on CRF. Hidden agenda: fear of STD, pregnancy, cancer, impact on work/relationship |
| 5:00–5:30 | Summarise back to patient | 「等我總結吓：你話…痛咗…日，仲有…你最擔心…我聽得啱唔啱？」 | Shows active listening, earns interpersonal marks |
| 5:30–6:00 | Explain plan + safety net + close | 「根據你講嘅情況，我會想幫你做個檢查同驗下小便。如果痛加劇、發高燒、或者暈倒，記住即刻去急症室。有冇嘢想問？」 | Safe closure, safety-net earns marks, appropriate referral if needed |
Uncovering the hidden agenda: The presenting symptom (suprapubic pain) may mask concerns about STD exposure, unplanned pregnancy, domestic/sexual violence, or fear of cancer. Always ask 「有冇咩嘢令你特別擔心先決定嚟睇醫生？」 — the RFC is often NOT "pain" but "fear of something serious."
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始痛？係突然間定慢慢嚟？」 | Acute → UTI, stone, torsion; Chronic → endometriosis, interstitial cystitis | Sudden severe → ruptured cyst, torsion, ectopic |
| Character | What does the pain feel like? | 「個痛係咩嘢感覺？脹痛、刺痛、定絞住痛？」 | Colicky → stone, obstruction; Dull/constant → UTI, PID, endometriosis | Colicky + haematuria → ureteric/bladder stone |
| Radiation | Does the pain go anywhere else? | 「個痛有冇去到腰、大髀內側、或者背脊？」 | Loin → pyelonephritis/stone; Thigh → ureteric stone at VUJ | Radiation to loin → upper tract involvement |
| Dysuria | Pain or burning when urinating? | 「小便有冇痛？有冇㷫㷫哋嘅感覺？」 | UTI cardinal symptom [1] | UTI, urethritis, STD |
| Frequency/Urgency | How often? Feel urgent? | 「去得密唔密？有冇急住忍唔住？」 | Storage LUTS (FUN) [2] | UTI, overactive bladder, bladder stone |
| Haematuria | Any blood in urine? | 「小便有冇血？有冇變紅色或者茶色？」 | Red flag for CA bladder, stone, glomerular disease [3] | Painless gross haematuria ≥50 → suspect bladder CA [3] |
| Vaginal discharge/bleeding | Any abnormal discharge or bleeding? | 「有冇唔正常嘅陰道分泌物或者出血？」 | PID, STD, ectopic, endometriosis, fibroid | Purulent discharge + fever → PID |
| LMP / Pregnancy | When was last period? Could you be pregnant? | 「最後一次月經幾時？有冇可能懷孕？」 | Must exclude ectopic pregnancy in all women of reproductive age | +ve → ectopic, threatened miscarriage |
| Dysmenorrhoea/Dyspareunia | Pain with periods or intercourse? | 「嚟M嗰時特別痛？同伴侶親密嗰時有冇痛？」 | Endometriosis — cyclical pelvic pain + dyspareunia + subfertility [4] | Deep dyspareunia → endometriosis, PID |
| Sexual Hx / STD risk | Are you sexually active? New partner? Condom use? | 「有冇性生活？有冇新伴侶？有冇用安全套？」 | PID, STD (Chlamydia, Gonorrhoea) | Multiple partners, no condom → PID, urethritis |
| Fever / Systemic | Any fever, chills, vomiting? | 「有冇發燒、打冷震、作悶嘔？」 | Upper UTI, PID, appendicitis, tubo-ovarian abscess | High fever + rigors → pyelonephritis, urosepsis |
| Bowel symptoms | Any diarrhoea, constipation, blood in stool? | 「大便正唔正常？有冇肚瀉、便秘、或者有血？」 | IBS, pelvic appendicitis, diverticulitis | Pelvic appendix → suprapubic pain with diarrhoea, no RIF signs [5] |
| Urinary retention | Difficulty passing urine? Feel bladder still full? | 「小便有冇困難？去完之後覺唔覺得仲有？」 | Acute retention of urine (AROU) [1] | Palpable suprapubic mass, BPH in older male |
| Red flag: weight loss | Any unintentional weight loss? | 「有冇無啦啦瘦咗？」 | Malignancy | CA bladder, ovarian CA, cervical CA |
| PMHx | Past medical history, surgeries? | 「以前有冇咩大病？有冇做過手術？有冇糖尿、腎病？」 | DM → complicated UTI; prior GYN surgery → adhesion pain | DM, immunosuppression → complicated UTI |
| Drug Hx | Current medications? NSAIDs? Antibiotics recently? | 「而家有冇食緊藥？有冇食止痛藥或者抗生素？」 | NSAIDs → AIN; recent antibiotics → resistant UTI | Drug-induced interstitial nephritis |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safety before prescribing | Penicillin allergy → avoid Augmentin |
| Social / Functional impact | How does this affect your daily life/work? | 「呢個問題有冇影響你返工或者日常生活？」 | Biopsychosocial model; functional impact | Time off work, relationship strain |
| Psych screen | Feeling stressed or low mood? | 「最近心情點？壓力大唔大？」 | Depression masquerade; chronic pain ↔ mood | Somatisation, depression amplifying pain |
Case Report Form Answer Builder
Suprapubic pain for [duration].
Include: onset, character, severity, radiation, aggravating/relieving factors, associated urinary symptoms (dysuria, frequency, urgency, haematuria), vaginal discharge/bleeding, fever, LMP, sexual history, bowel symptoms, constitutional symptoms. Note timeline and progression.
| Likely RFC Examples | How to Phrase |
|---|---|
| Pain affecting daily activities | "Suprapubic pain interfering with work/daily activities" |
| Worried about infection | "Concern about urinary tract infection" |
| Fear of serious disease | "Fear of sexually transmitted infection / cancer" |
| Urinary symptoms | "Troublesome urinary frequency and dysuria" |
Best single answer: Pick the one that matches what the patient actually said when you asked ICE. Often the RFC is the concern (e.g. fear of cancer/STD) rather than just the pain itself.
| Component | Likely Examples | Exact Wording for CRF |
|---|---|---|
| Idea | "I think I might have a urine infection" / "Maybe it's something gynaecological" | Patient thinks she has a urinary tract infection |
| Concern | "I'm worried it could be something serious like cancer" / "I'm afraid I caught an STD" | Patient is worried about STD / cancer |
| Expectation | "I want antibiotics" / "I want a scan to make sure everything is okay" | Patient expects urine test and antibiotics / reassurance scan |
Acute uncomplicated cystitis (lower UTI) — supported by: suprapubic pain + dysuria + frequency/urgency + ± haematuria, in a young woman without systemic features.
Minimum evidence: storage LUTS (FUN) + suprapubic tenderness + positive urine dipstick (LE/nitrite).
(Adjust if stem suggests male patient, pregnant woman, or chronic/cyclical pattern — then consider acute prostatitis, complicated UTI, or endometriosis respectively.)
| DDx | One Key Discriminator |
|---|---|
| Pelvic inflammatory disease | Fever + bilateral lower abdominal tenderness + cervical motion tenderness + vaginal discharge; sexually active with risk factors |
| Endometriosis | Cyclical pelvic pain related to menses + dyspareunia + possible subfertility; chronic course |
| Ureteric / bladder stone | Colicky pain + haematuria; may have VUJ stone causing irritative LUTS; confirmed on imaging |
| Domain | Problem |
|---|---|
| Biological | Recurrent UTI risk / underlying anatomical or hormonal factor (e.g. post-menopausal atrophic vaginitis) |
| Psychological | Anxiety about STD or cancer; embarrassment discussing sexual history; low mood if chronic pain |
| Social/Functional | Time off work/school; impact on sexual relationship; financial cost of repeated consultations |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Acute cystitis (UTI) | Suprapubic tenderness on palpation | Press gently over suprapubic area with patient supine, knees slightly flexed | Inflamed bladder wall → localised tenderness; consistent with lower UTI [1] |
| PID | Cervical motion tenderness (cervical excitation) | Bimanual vaginal exam — gently move the cervix side to side | Pathognomonic of peritoneal inflammation around adnexa; positive = suspect PID [4] |
| Endometriosis | Tender nodularity in pouch of Douglas on vaginal/rectal exam | Bimanual/rectal exam during menstruation | Deep infiltrating endometriotic deposits cause palpable nodules [4] |
| Ureteric/bladder stone | Renal angle / loin tenderness on percussion | Ballotte gently over the costovertebral angle (renal punch) | Obstruction → hydronephrosis → renal capsule distension → CVA tenderness [7] |
| Acute urinary retention | Palpable, dull suprapubic mass (distended bladder) | Palpate and percuss suprapubic region; mass arising from pelvis, dull to percussion, cannot get below it | Full bladder palpable above pubic symphysis; dull percussion = fluid-filled viscus [1] |
| Ectopic pregnancy | Adnexal tenderness ± cervical motion tenderness + tachycardia/hypotension if ruptured | Bimanual exam + vitals | Tenderness + haemodynamic instability = ruptured ectopic — surgical emergency |
| Pelvic appendicitis | Obturator sign (RLQ pain on internal rotation of flexed right hip) [5] | Patient supine — flex right hip and knee to 90°, then internally rotate hip | Pelvic appendix irritates right obturator internus muscle; NO classic RIF tenderness [5] |
Top Traps That Lose Marks
- Forgetting pregnancy test in ALL women of reproductive age — always ask LMP and possibility of pregnancy. Missing ectopic pregnancy = exam fail and clinical disaster.
- Not asking sexual history — STD-related urethritis and PID mimic UTI. Students lose marks by being embarrassed to ask.
- Labelling everything as UTI without considering GYN causes — endometriosis, PID, ovarian pathology can all present with suprapubic/pelvic pain.
- Ignoring pelvic appendicitis — can present with suprapubic pain, no RIF signs, + bladder/rectal symptoms [5].
- Not eliciting ICE — three easy marks lost if you don't ask all three components explicitly.
- Writing "abdominal pain" instead of "suprapubic pain" as chief complaint — be specific.
- Forgetting to ask about haematuria — painless gross haematuria ≥50yo must consider CA bladder [3].
Must-Not-Miss Red Flags — Urgent Referral
- Haemodynamic instability (tachycardia, hypotension) + pelvic pain → suspect ruptured ectopic or tubo-ovarian abscess → A&E immediately
- High fever + rigors + loin pain → pyelonephritis / urosepsis → urgent referral
- Painless gross haematuria ≥50yo → urgent urology referral to exclude CA bladder [3]
- Unilateral sudden severe pain + vomiting → ovarian torsion → emergency surgery
- Positive pregnancy test + pain + bleeding → ectopic pregnancy until proven otherwise
Safety-Net Line for Closing
「如果你痛到好犀利、發高燒、暈暈地、或者小便完全去唔到，一定要即刻去急症室。」 ("If the pain becomes very severe, you develop high fever, feel faint, or cannot pass urine at all, go to A&E immediately.")
High Yield Summary
What to ASK: Dysuria, frequency, urgency, haematuria, vaginal discharge/bleeding, LMP/pregnancy possibility, sexual history, fever, bowel symptoms, drug history, ICE.
What to WRITE on CRF:
- CC: "Suprapubic pain × [duration]"
- Most likely Dx: Acute cystitis (if classic LUTS) — support with suprapubic tenderness + urine dipstick
- DDx: PID, endometriosis, ureteric/bladder stone
- RFC: Often a concern (STD, cancer, fertility) rather than just the pain
- ICE: Write all three components explicitly
- Physical sign: Suprapubic tenderness (for cystitis); cervical motion tenderness (for PID)
What NOT to MISS: Ectopic pregnancy (LMP!), PID (sexual Hx!), pelvic appendicitis (migratory pain!), CA bladder (haematuria ≥50yo!), ovarian torsion (sudden severe + N/V!).
Active Recall - Family Medicine Clinical Test
[1] MBBS Final MB (Medicine) (Felix PY Lai).pdf — Suprapubic pain differential diagnosis (p.627, p.624) [2] MBBS Final MB (Pediatrics) (Felix PY Lai).pdf — LUTS classification FUN DISH (p.393) [3] MBBS Final MB (Surgery) (Felix PY Lai).pdf — CA bladder clinical manifestation, painless haematuria (p.822) [4] GC 195. Lower and diffuse abdominal pain RLQ problems; pelvic inflammatory disease; peritonitis and abdominal emergencies.pdf [5] Adrian Lui Pediatrics Notes.pdf — Pelvic appendix: suprapubic discomfort, bladder symptoms, obturator sign (p.246–247); Ryan Ho GI.pdf (p.149); MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.731, p.733) [6] Ryan Ho Urogenital.pdf — Approach to dysuria, interstitial cystitis (p.121); Ryan Ho Fundamentals.pdf (p.346) [7] MBBS Final MB (Surgery) (Felix PY Lai).pdf — Ureteric/bladder stones, VUJ stone causing storage LUTS (p.792) [8] CFB (OG01) Physiology of Pregnancy and Minor Ailments.pdf — Subluxation of pubic symphysis (p.40)
Subfertility
Subfertility is the failure of a couple to conceive after 12 months of regular unprotected intercourse, indicating reduced but not necessarily absent reproductive capacity.
Tinnitus
Tinnitus is the perception of sound, such as ringing, buzzing, or hissing, in the ears or head without an external acoustic stimulus.