Bladder Pain

Bladder pain has several possible causes, the most common of which include urinary tract infections (UTIs), interstitial cystitis (also known as bladder pain syndrome), and bladder cancer. The pain is felt in the middle of the pelvis or lower abdomen, where the bladder is situated.

Bladder pain may be accompanied by frequent urination, painful urination, blood in the urine, and other urinary symptoms. The treatment can vary by the underlying cause but may include diet, medications, bladder retraining, specialist procedures, and, occasionally, surgery.

This article describes the symptoms and causes of bladder pain, including how the condition is diagnosed and treated. It also explains when it is time to see a healthcare provider, including a specialist in urinary tract diseases known as a urologist.

Symptoms of Bladder Pain

The bladder is a hollow, muscular organ roughly the size of large grapefruit. It functions as a reservoir for urine. The kidneys pass urine to the bladder through narrow tubes (ureters). The bladder is flexible and expands and contracts as it is filled and emptied.

When it is time to urinate, a muscular passageway called the bladder neck will widen, releasing urine into a tube called the urethra, through which urine exits the body. Smooth (involuntary, not consciously controlled) muscles in the bladder wall will simultaneously contract to clear the bladder fully.

In addition to nerves that regulate bladder contractions, a group of nerves called bladder afferents are responsible for sensations such as bladder fullness. These nerves also signal pain when the bladder is irritated or injured by infection or disease.

Bladder pain can vary in intensity but is often characterized by pain or pressure in the middle of the pelvis or lower abdomen. Accompanying those symptoms may be:

• A sudden strong urge to pee (urinary urgency)
• The need to pee frequently (urinary frequency)
• Pain, burning, or stinging while urinating (dysuria)
• Difficulty starting a urine stream (urinary hesitancy)
• Waking up at night to pee (nocturia)
• Blood in the urine (hematuria)
• Bladder leakage (urinary incontinence)
• Inability to empty the bladder (urinary retention)
• Abdominal cramping or spasms

The combination of symptoms you experience may offer clues as to the underlying cause.

Causes of Bladder Pain

Bladder pain can sometimes be linked to a specific disease or infection. At other times, the cause may be ambiguous or idiopathic (meaning of unknown origin).

When you have bladder pain, three common causes a healthcare provider will likely investigate are urinary tract infections (UTIs), interstitial cystitis (IC), and bladder cancer.

Urinary Tract Infections

UTIs are those that affect any part of the urinary tract, including the urethra, bladder, ureters, and kidneys. When the bladder is affected, it is known as cystitis.

Cystitis is almost always caused by bacteria that migrate from the urethra to the bladder. The bacteria most commonly linked to cystitis include:

• Escherichia coli (E. coli)
• Klebsiella pneumoniae
• Proteus mirabilis

Females are more affected by cystitis because of their anatomy, including the shorter length of the female urethra and its closer position to the anus.

The vast majority of cases in younger females are related to sexual intercourse. In fact, the term "honeymoon cystitis" was coined to describe the frequency of UTIs in this population.

The use of urinary catheters is also linked to cystitis, particularly in males. An enlarged prostate can also contribute by decreasing the flow of urine, which would otherwise flush bacteria out of the male urethra.

Interstitial Cystitis

Interstitial cystitis (IC) is a poorly understood condition commonly referred to as bladder pain syndrome. It is characterized by chronic (persistent or recurring) pain that occurs in the absence of an infection or disease.

The cause of IC is unknown, though it often runs in families and may be influenced by genetics. The condition is diagnosed by excluding all other possible causes of bladder pain, including infections, overactive bladder (OAB), neurogenic bladder, endometriosis, and cancer.

IC may be diagnosed if a cause cannot be found and symptoms persist.

IC commonly occurs alongside other conditions that cause chronic pain, such as:

• Chronic fatigue syndrome
• Fibromyalgia
• Irritable bowel syndrome (IBS)
  
• Migraine

Emotions and psychological factors are also linked to an increased risk of IC. These include alcohol use disorder, a history of depression, post-traumatic stress disorder (PTSD), and sexual trauma. For unclear reasons, females are more affected by IC than males.

Bladder Cancer

While bladder cancer is the least likely cause of bladder pain, it is by far the most common cancer affecting the urinary tract. In 2022, an estimated 81,180 cases were reported in the United States, accounting for roughly 4% of all cancer diagnoses.

In addition to urinary symptoms, bladder cancer can cause persistent fatigue, bone pain, loss of appetite, swollen feet, one-sided lower back pain, and unintended weight loss when the disease is advanced.

While the underlying cause of bladder cancer is poorly understood, there are several factors that place a person at increased risk, including:

• A family history of bladder cancer: Having a first-degree family member with bladder cancer (such as a parent or sibling) doubles your risk of the disease.
• Being over age 55: In the United States, the average age of diagnosis of bladder cancer is 73.
• Being male: Males are at a threefold increased risk of bladder cancer compared to females.
• Smoking: Cigarette smoking triples the risk of bladder cancer compared to nonsmokers.
• Chronic bladder irritation: This includes recurrent UTIs, kidney or bladder stones, or the prolonged use of urinary catheters.
• Actos (pioglitazone): This diabetes drug is linked to bladder cancer, the risk of which increases with the size of the dose.
• Cytoxan (cyclophosphamide): The prolonged use of this widely prescribed chemotherapy drug can also increase the risk of bladder cancer.
  

How to Treat Bladder Pain

The treatment of bladder pain varies by the underlying cause. While some of the treatments are used solely to ease pain, the primary focus is to resolve or manage the underlying condition.

Urinary Tract Infection

As an infection predominantly caused by bacteria, a UTI is commonly treated with a course of oral antibiotics. These drugs are taken by mouth once or twice daily for anywhere from one to seven days, depending on the severity of the infection.

Common antibiotics used to treat urinary tract infections include:

• Nitrofurantoin
• Trimethoprim/sulfamethoxazole (TMP-SMX)
• Fosfomycin
• Cipro (ciprofloxacin)

Antibiotics are tailored to bacterial sensitivities seen in a urine culture. If your infection is more complex, has migrated up to the kidney (pyelonephritis), or you have compounding medical problems (like diabetes) you may be on antibiotics for longer.

Interstitial Cystitis

As a condition with an unclear cause, IC treatment is largely tailored to treat urinary symptoms associated with chronic bladder pain. This may involve a combination of lifestyle changes, over-the-counter (OTC) and prescription medications, and specialist-driven procedures, including:

• Diet: Certain foods can trigger IC symptoms and may need to be avoided, including caffeine, alcohol, spicy or acidic foods, citrus, artificial sweeteners, and monosodium glutamate (MSG).
• Smoking cessation: Tobacco smoke can also trigger IC symptoms and contribute to the risk of bladder cancer. The Affordable Care Act (ACA) fully covers many smoking cessation aids.
• Stress reduction: IC symptoms are linked to stress and may benefit from stress-reduction techniques like exercise, improved sleep, and mind-body therapies like meditation or yoga.
• Bladder retraining: This involves going to the bathroom on a set schedule when the bladder is full rather than running to the toilet with a half-empty bladder at the first sign of pain. This can be self-taught or done formally through a pelvic floor therapist.
• OTC pain relievers: These include Tylenol (acetaminophen) and nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and Advil or Motrin (ibuprofen).
• Elmiron (pentosan polysulfate): This is the only drug approved for the treatment of IC by the Food and Drug Administration (FDA).
• Off-label medications: Drugs like Elavil (amitriptyline), Vistaril (hydroxyzine), and Sandimmune (cyclosporine) are sometimes used off-label to treat chronic bladder pain.
• Botox (onabotulinumtoxin A) injection: Botox injected directly into the bladder wall may provide relief for up to six months by relaxing the bladder muscles.
• Transcutaneous electrical nerve stimulation (TENS): This therapeutic procedure delivers low-voltage electrical pulses through the skin to help ease chronic pain.
• Bladder stretching: This involves filling the bladder with fluids through a urinary catheter. The stretching appears to provide relief by increasing bladder flexibility and size.
• Bladder instillation: Also called a bladder wash, this involves the delivery of steroids or other substances into the bladder through a urinary catheter to ease inflammation and pain.
• Bladder fulguration: This involves a device called a resectoscope that is fed through the urethra to remove scar tissues from the bladder wall, relaxing tissues and increasing bladder volume.
• Surgery: When other treatment options fail, surgeries like orthotopic neobladder (which creates a new bladder using a section of the intestines) or cystectomy (which removes the bladder) may be considered.
  

Bladder Cancer

Bladder cancer treatment has a relatively high success rate. According to the National Cancer Institute, bladder cancer has a five-year survival rate of 77.1%—meaning that nearly 4 of every 5 people diagnosed will live for at least five years. Many go on to live for years longer.

The treatment varies by how advanced the cancer is (as determined by the cancer stage), including whether cancer cells have spread (metastasized) to other parts of the body.

If the cancer stage is early and the tumor has not metastasized, the treatment will typically involve:

• Transurethral resection: This is the surgical removal of the tumor through the urethra.
• Immunotherapy or chemotherapy drugs: These are delivered directly to the bladder through a urinary catheter to kill off residual cancer cells or prevent future cancer.
• Intravesical therapy: This is a technique in which immunotherapy or chemotherapy drugs are delivered directly to the bladder through a urinary catheter.

For cancer that is advanced and has breached the bladder wall, the treatment may involve:

• Cystectomy: This includes partial cystectomy and radical (complete) cystectomy.
• Neoadjuvant chemotherapy: This is chemo given before surgery to shrink the tumor.
• Adjuvant chemotherapy: This is chemo given after surgery to destroy any remaining cancer cells.
• Chemotherapy with radiation: This is used to slow disease progression in people with late-stage disease or those who cannot have surgery.
  

Complications of Bladder Pain

Ignoring persistent or severe bladder pain places you at risk of complications—mainly because there is no way to know the underlying cause is without a proper diagnosis. This is true whether a UTI, IC, or cancer is involved.

Urinary Tract Infection

If bladder pain is caused by a UTI, leaving it untreated can cause permanent urinary tract injury and potentially severe complications, including:

• Kidney or bladder stones: Caused by hardened mineral deposits in the urine
• Acute pyelonephritis: A severe and potentially obstructive kidney infection
• Acute prostatitis: The infection and inflammation of the prostate gland
• Acute kidney injury (AKI): Also known as acute kidney failure
• Urosepsis: A potentially deadly immune response to a disseminated (widespread) urinary tract infection

Interstitial Cystitis

One major complication of untreated bladder pain is fibrosis, or the scarring of tissues due to ongoing irritation and inflammation. The scarring can lead to the contraction and hardening of the bladder wall as well as a reduction in the size of the bladder. These changes can further perpetuate IC symptoms.

Because the internal volume of the bladder is decreased, even smaller amounts of urine can place extreme pressure on the bladder wall, triggering pain.

Bladder Cancer

If bladder pain is caused by cancer, the more serious concern is the risk of metastasis. While most bladder cancers are slow-growing and diagnosed in the early stages, one of every eight cases is diagnosed when cancer has already spread to nearby or distant organs.

If bladder cancer metastasizes, the five-year survival rate drops from 77.1% to 7.7%.

Are There Tests to Diagnose the Cause of Bladder Pain?

The diagnosis of bladder pain typically starts with a review of your symptoms, medical history, and family history. The physical exam would involve palpation (touch) to feel for any abnormalities or areas of pain in the lower abdomen. A stethoscope may be used to listen for bowel sounds.

A pelvic exam or a digital rectal exam (DRE) might also be involved in the initial workup.

Based on the initial findings, your healthcare provider will order additional tests and procedures to narrow the possible causes, including:

• Urinalysis: This test analyzes the chemical makeup of your urine. It can detect signs of infection and disease based on the presence of blood cells, pus, proteins, and other substances.
• Urine culture: If a UTI is suspected, a urine culture can "grow," isolate, and identify the specific bacteria so that the right antibiotic is prescribed.
• Bladder ultrasound: This noninvasive, handheld imaging tool can create detailed images of the bladder using reflected sound waves.
• Cystoscopy: This involves the insertion of a long, thin scope (cystoscope) through the urethra to view the inside of your bladder.
  
• Uroflowmetry: This is a series of tests that evaluate how well the bladder is working, including how fast urine flows, how much urine is released, and how long it takes to release it.
• Computed tomography (CT): This imaging technology composites multiple X-rays to create a three-dimensional visualization of the bladder and adjacent structures.

If there are indications of bladder cancer, other tests may be ordered, including:

• Magnetic resonance imaging (MRI): The imaging technology uses powerful magnetic and radio waves to create highly detailed images of soft tissues, such as those of the bladder.
• Urine cytology: This is the examination of urine under a microscope to look for abnormal cells, including cancer cells.
• Fluorescence cystoscopy: This is a form of cystoscopy in which a fluorescent dye is delivered to the bladder via a urinary catheter to check for signs of cancer.
• Bladder biopsy: Performed during cystoscopy, a biopsy is used to obtain tissue samples or abnormal growths for evaluation in the lab.

When to See a Healthcare Provider

As an isolated symptom, bladder pain cannot signal if you have a serious or nonserious condition. Even if you have no other symptom but pain, it is still worth having if looked at—in part because it could be something entirely unrelated to the bladder (such as an inguinal hernia, bowel obstruction, or even the early stages of acute appendicitis).

It is important to see a healthcare provider immediately if:

• Bladder pain is severe.
• You have a high fever with chills.
• Your urine is cloudy and foul-smelling.
• There are blood or blood clots in your urine.
• You are unable to empty the bladder completely.