Bladder tenderness as a physical sign for diagnosing cystitis in women

There are few semiotic signs for the diagnosis of cystitis. The costovertebral angle tenderness (CVAT) and vaginal exam have a likelihood ratio (LR) close to 1 [1]. Some patients experience a different pain when their bladder is compressed during the vaginal exam. The objectives of this study are to verify the accuracy of bladder tenderness for making the diagnosis of cystitis, and if a past history of cystitis, or recent sexual intercourse, are risk factors for current cystitis. One hundred and ninety female volunteers ≥ 15 years old, with or without urinary symptoms, were analyzed. The exclusion criteria were recent use of antibiotics and pregnancy. After a standard questionnaire, a clean catch midstream urine sample was obtained. Then, bladder tenderness was performed using the index finger inside the vagina. It was slid over the upper third of the anterior wall of the vagina, compressing the bladder against the opposite hand placed on the suprapubic area. If the patient experienced any kind of pain, the test was positive; otherwise, it was negative. Urine analysis and culture were standard. The prevalence of urinary infection was 13.68% in the sample (positive urine culture was ≥ 105 CFU/mL). In asymptomatic women, the prevalence of cystitis was 9.1%. A past history of cystitis and recent sexual intercourse were not significant as a risk factor for current cystitis—RR = 1.9 (95%CI 0.47–7.57); 1.6 (95%CI 0.58–4.41) respectively. The kappa index was 0.85 for interobserver difference. The main results are in Tables 1 and 2. Combining either the history of dysuria or frequency with the presence of bladder tenderness the positive LR is around 2 and a negative LR to 0.6. It means that the post-test probability of cystitis is 23%, while a negative test reduces the post-test probability to 9%. Notably, only the presence of nitrites in urine gives a high enough post-test likelihood to justify treatment before culture results are obtained. Compared to the literature, CVAT has a LR of 1.7 [2], and bladder tenderness with frequency has a LR of 2. The usefulness of bladder tenderness can be seen in a patient with pelvic pain and no symptoms of cystitis, or in locations with minimal resources. A negative test has a negative predictive value between 90% and 82%. Therefore, bladder tenderness may be used as a physical test to discriminate the source of pelvic pain and not as a complementary examination, such as urine analysis.

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