What is urethral syndrome

Urethral syndrome is also known as “frequency and dysuria syndrome” or symptomatic abacteriuria or “urethral stenosis” ¹⁾. Urethral syndrome is defined as “symptoms suggestive of a lower tract urinary infection but in the absence of significant bacteriuria with a conventional pathogen” with three provisos concerning symptomatology and the definition of significant bacteriuria and conventional pathogens. Urethral syndrome is characterized by urinary frequency, dysuria, and suprapubic discomfort without any objective finding of urological abnormalities ²⁾. The urethral syndrome is a very common condition; about half the patients visiting their general practitioner by reason of frequency and/or dysuria do not have significant bacteriuria ³⁾. Both infective causes (such as lactobacilli and sexually-transmitted pathogens) and non-infective causes (such as trauma, allergies, anatomical features and co-existing medical conditions) have been suggested as causes ⁴⁾. Urethral syndrome has many of the same symptoms as urethritis or prostatitis, which is an infection and inflammation of the urethra or prostate, respectively.

Urethral syndrome is also characterized by sterile urine culture results and urinary frequency that is typically worse during the day than during the night. The dysuria and constant suprapubic discomfort is partially relieved by voiding. Patients with urethral syndrome may also report difficulty in starting urination, a slow stream, and a feeling of incomplete emptying of the bladder.

Most patients diagnosed with urethral syndrome are women, typically aged 30-50 years. Urethral syndrome is more common in females than in males, and is more common in white women in westernized societies than in women of other races or groups ⁵⁾. Patients diagnosed with urethral syndrome are typically 13-70 years of age. Vaginal discharge and vaginal lesions must be excluded. The patient’s history is important, as the diagnosis of urethral syndrome is one of exclusion.

As a result of the unrelenting symptoms, many patients with urethral syndrome have concomitant depression, anxiety, or other secondary psychological morbidities caused by the condition; the coexistence of neurosis has prompted many physicians to categorize urethral syndrome as a psychosomatic illness

Many patients with urethral syndrome seek out multiple physicians in order to secure symptom relief and are at risk for polypharmacy and narcotic abuse.

Finding the proper treatment for urethral syndrome has been difficult, because no specific organism has ever been found and specific mechanical obstructions have never been validated ⁶⁾. The goal of treatment in urethral syndrome is to relieve the discomfort and urinary frequency. This often involves a trial-and-error approach that uses behavioral, dietary, and medical therapy.

Many women have undergone urethral dilation but its true value has never been proven. Chronic antibiotic administration, biofeedback techniques, skeletal muscle relaxants, and psychological counseling have also been advocated ⁷⁾.

Treatment options include antibiotics in the case of acute urethral syndrome, since it is not possible to distinguish between urinary tract infection (UTI) and the urethral syndrome in the consulting room ⁸⁾. For those with chronic urethral syndrome, treatment depends upon whether attacks are associated with bacteriuria or if urological investigations reveal any abnormalities.

Female urethral syndrome

Symptoms of urethritis may include retropubic pressure, dyspareunia (painful sexual intercourse), urinary frequency, painful urination (dysuria), itch (pruritus), and burning urination ⁹⁾.

Urethral syndrome male

The clinical presentation of both prostatitis and the urethral syndrome are very similar. The symptoms include nocturia (condition in which you wake up during the night because you have to urinate) and irritative voiding complaints such as urinary frequency, dysuria, urgency, and urgency incontinence. Lower abdominal pain, lower back pain, genital pain and pain associated with intercourse can often be associated with these syndromes. Some instances of microscopic hematuria, terminal or initial hematuria, post-void dribble, hesitancy, feeling of incomplete emptying and interrupted stream are also associated with this complex of symptoms ¹⁰⁾.

The urethral syndrome also known as urethral stenosis commonly presents with voiding difficulties, perineal and lower abdominal discomfort, or painful sexual encounters ¹¹⁾. The diagnosis is made when voiding symptoms are present without any demonstration of an infectious process ¹²⁾. A true mechanical obstruction is rarely demonstrated ¹³⁾. According to Bodner, “there is no reason to assume that a similar entity does not incur in men, possibly as prostatodynia” ¹⁴⁾.

Does urethral syndrome go away?

Symptoms of urethral syndrome usually improve slowly as the patient ages, but the problem may be lifelong.

How long does urethral syndrome last?

Symptoms of urethral syndrome usually improve slowly as the patient ages, but the problem may be lifelong.

Urethral syndrome causes

The cause of urethral syndrome is unknown ¹⁵⁾. Historically, urethral stenosis was believed to cause urethral syndrome. Currently theorized causes include hormonal imbalances, inflammation of Skene glands and the paraurethral glands (the “female prostate”), a reaction to certain foods, environmental chemicals (e.g., douches, bubble bath, soaps, contraceptive gels, condoms), hypersensitivity following urinary tract infection, and traumatic sexual intercourse.

Urethral syndrome is much more common in men than women and there is usually no obvious cause found. Some possible triggering factors include;

• Sexual intercourse – many contraceptive gels and condoms are irritative. Sexual activity e.g, rough intercourse, prolonged oral sex, intercourse in a heavily chlorinated hot tub or in a shower using bath soap as a lubricant may be the etiology of urethral irritation.
• Vaginal douches and feminine hygiene products
• Spermicides, tampons and stress in general
• In women who have gone through the menopause, lack of female hormones may cause a thinning of, and inflammation of the tissues around the opening of the vagina.

Historically, urethral stenosis was thought to be the cause of urethral syndrome. A diagnosis of urethral stenosis, along with the serial urethral dilations historically used to treat the condition, is appropriate in only a very small minority of patients. In addition, serial urethral dilations have fallen out of favor as a ubiquitous treatment in all patients with urethral syndrome.

Contraceptive methods (many contraceptive gels and condoms are irritative) and sexual activity (e.g., rough intercourse, prolonged oral sex, intercourse in a heavily chlorinated hot tub or in a shower using bath soap as a lubricant may be the cause of urethral irritation) may elicit urethral syndrome. A history of sexual abuse has been linked with pelvic floor muscle dysfunction.

Prolonged driving in vehicles with limited shock-absorbing mechanisms (e.g., buses, trucks), horseback riding, and long-distance biking can result in urethral irritation. These are more commonly the etiology in men with urethral syndrome than in women. Women may acquire symptoms from wearing tight thong underwear or blue jeans (especially when worn without underwear).

Diuretics can cause urinary frequency, as can lithium if secondary diabetes insipidus develops. Cholinergic cold and sinus preparations increase the tone of the bladder neck and proximal urethra and can cause symptoms in some individuals.

Prior medical conditions are also important, especially pelvic surgery or radiation therapy.

Regardless of the initial pain-causing event, patients with urethral syndrome have both involuntary spasms and voluntary tightening of the pelvic musculature during the painful episode, which, in addition to any residual irritant or reinjury, starts a vicious circle of worsening dysfunction of the pelvic floor musculature. In many cases, the original cause of the pain has healed, but the pelvic floor dysfunction persists and is worsened by the patient’s anxiety and frustration with the condition.

Urethral syndrome symptoms

Patients diagnosed with urethral syndrome are typically female and aged 13-70 years. The patient reports suprapubic discomfort, dysuria, and urinary frequency. The history is important, and the diagnosis of urethral syndrome is one of exclusion. A history of smoking or gross hematuria should hasten further evaluation to rule out bladder tumor or carcinoma in situ. Most patients focus on urinary symptoms, but other aspects of the patient’s history and symptoms must also be evaluated.

Common urethral syndrome symptoms

• Urinary Frequency – Patients may feel the need to urinate as often as twice an hour or more. The urinary frequency associated with urethral syndrome is typically every 30-60 minutes during the daytime, with minimal increased frequency of urination at night (nocturia).
• Lower abdominal pain or suprapubic pain – The discomfort and pain associated with urethral syndrome is not as severe as interstitial cystitis or urethritis (infection and inflammation of the urethra) and is not severe enough to disturb sleep
• Dysuria (painful urination) – Dysuria in patients with urethral syndrome is often described as a sensation of constant urethral irritation rather than the searing discomfort with urination that is reported by patients with an active lower urinary tract infection.
• Pain around the genital area generally.

Urinary symptoms

Urinary symptoms in urethral syndrome are as follows:

• The urinary frequency associated with urethral syndrome is typically every 30-60 minutes during the daytime, with minimal nocturia
• The suprapubic discomfort is neither constant nor as severe as in interstitial cystitis; the pain may be relieved by voiding; at night, the pain is not severe enough to disturb sleep
• Dysuria in patients with urethral syndrome is often described as a sensation of constant urethral irritation rather than the searing discomfort with urination that is reported by patients with an active lower urinary tract infection.

Other pelvic symptoms

Associated bowel symptoms, menstrual complaints, and dyspareunia (painful intercourse) may suggest pelvic floor muscle dysfunction. Irregular or excessive menstruation may indicate a gynecologic abnormality and may warrant referral for gynecologic assessment, especially in postmenopausal women. Timing of the last menstrual cycle may also suggest pregnancy as a cause for urinary frequency.

Urethral syndrome diagnosis

A diagnosis of urethral syndrome is made after exclusion of infection and local vaginal conditions such as genital herpes and variants of vaginitis. Physical examination findings are usually unremarkable; however, genital examination may reveal a cystocele or atrophic urethritis.

Pelvic examination

Initially, the inner thighs and outer labia should be inspected for sensation (sharp vs dull end of a broken cotton-tipped swab works well). Localized hypersensitivity may indicate shingles (herpes zoster), even in the absence of cutaneous manifestations. Global hypersensitivity or hyposensitivity may suggest a neurologic condition.

An initial inspection should be performed to evaluate for ulcers or inflammation caused by herpes, yeast, or other infectious agents. Standard culture swabs and specialized swabs for viral, gonococcal, and chlamydia cultures should be available so that specimens can be obtained at the time of the examination, if indicated.

The labia and other external genitalia should be carefully inspected for erythematous patches or white, heaped-up epithelium, which may indicate condyloma or squamous cell carcinoma. Careful examination of the urethra for any lesions is important to exclude urethral prolapse, urethral caruncle, or transitional cell carcinoma. The health of the mucosal tissues should be noted; dry, thin, pale mucosa suggests atrophy, which is usually hormonal in origin.

The wall shared by the anterior vagina and the posterior urethra should be carefully palpated to exclude masses or stones. Expressed purulent material or a compressible mass detected during this maneuver suggests a urethral diverticulum.

The patient should be asked to perform a Valsalva maneuver or cough to assess for urethrocele, cystocele, or rectocele.

A speculum examination should be performed to rule out foreign bodies (eg, retained tampons), cervicitis, or other lesions. A Papanicolaou test (Pap smear) should be performed if the patient has not had one in the past year. Many patients have generalized pelvic floor dysfunction and tight pelvic musculature, causing them to experience difficulty with a speculum examination. A pediatric speculum should be available for such situations.

The presence of an intact anal wink should be confirmed as part of the pelvic/neurologic examination, and a rectal examination should be performed to assess rectal tone and the presence of any lesions that might be contributing to the patient’s symptoms, such as masses, rectal/perianal fissures, ulcers, or hemorrhoids.

Abdominal examination

The presence of any masses or tenderness should be noted. Patients with urethral syndrome may experience mild-to-moderate suprapubic discomfort, but the pain is not as dramatic as that observed in patients with interstitial cystitis. Uterine enlargement may indicate pregnancy, fibroids, or malignancy and should prompt a pregnancy test, if appropriate, and referral to a gynecologist.

Tenderness localized to the pubic symphysis may indicate osteitis pubis, particularly in patients receiving systemic steroid therapy or those with a history of radiation therapy.

Neurologic examination

Reflexes, symmetry of strength and sensation, and balance should all be assessed to evaluate for intracranial or spinal cord lesions, lumbar stenosis or disk herniation, or neurodegenerative diseases. For example, multiple sclerosis has a propensity to strike women at the same age as urethral syndrome, and vague bladder symptoms are often the initial presenting feature of this disease.

Laboratory Studies

A urine sample should be collected for urinalysis and urine culture. Urinalysis may show up to three red blood cells (RBCs) per high-power field. More pronounced microhematuria or any history of gross hematuria should prompt (1) cystoscopy to evaluate the bladder and (2) intravenous pyelography (IVP) or computed tomography (CT) scanning to assess the upper urinary tract. Elevated glucose levels on urinalysis results may suggest uncontrolled diabetes as an etiology of the urinary frequency.

Although some urologists feel that 100 colonies of bacteria per milliliter may be significant, especially when accompanied by symptoms, colony counts of 100,000/mL in a voided urine specimen (10,000/mL in men) confirms urinary tract infection and should prompt treatment with antibiotics. Repeat urine cultures may be warranted for intermediate results.

The same bacteria on multiple urine cultures, even at low colony counts, may merit therapy. Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, and Lactobacillus species may be present at low colony counts in urine cultures and usually represent vaginal colonization with these organisms. However, treatment is recommended to rule out urethral colonization, especially with Ureaplasma species.

Pap smear results may reveal cervical malignancy, and this test should be performed if the patient has not had one in the past year. Usually, this has been performed by the gynecologist who referred the patient to the urologist. If the patient has not seen a gynecologist, a referral should be made to rule out gynecologic causes of the discomfort.

A pregnancy test may be indicated in women in the appropriate age group with an enlarged uterus or history of irregular menstrual cycles. This is particularly true if radiographic evaluation is planned.

Vaginal swabs for routine and viral, chlamydial, and gonococcal culture may be indicated. Again, usually these studies have been performed by the gynecologist. Potassium hydroxide preparation of vaginal secretions helps assess for fungal infection and, as with other tests, has usually been performed by the gynecologist.

Imaging Studies

Intravenous pyelography (IVP) may be considered to help rule out other urological causes if associated symptoms and history suggest them; however, in most cases the IVP results are normal.

Cystography can be used to evaluate for vesicoureteral reflux and (if performed correctly with a double-balloon catheter to occlude both the urethral opening and bladder neck) urethral diverticula ¹⁶⁾. Magnetic resonance imaging (MRI) is emerging as possibly superior to cystography in the identification of urethral diverticula. Ackerman et al reported that MRI may be useful in the identification of pelvic floor hypertonicity (manifested as shortened levator, increased posterior puborectalis angles, and decreased puborectal distances), which may be suggestive of interstitial cystitis/bladder pain syndrome ¹⁷⁾.

In men, prostate ultrasonography to evaluate for a prostatic abscess may prove useful. Pelvic ultrasonography is used to visualize the bladder and bladder neck-trigone and to evaluate the female reproductive organs for masses ¹⁸⁾.

Procedures

Cystometrics and electromyelography of the urinary sphincter are performed to eliminate the possibility of a neurogenic unstable bladder, detrusor sphincter dyssynergia, or hyperactive pelvic floor musculature.

Cystourethroscopy with hydrodistention of the bladder under general anesthesia is diagnostic, revealing ulcerations and normal bladder capacity in patients with interstitial cystitis. It is also therapeutic in patients with interstitial cystitis. Cystoscopy under anesthesia also allows an assessment for bladder masses or stones or squamous cell metaplasia at the bladder neck-trigone.

Bladder biopsy is used to rule out carcinoma in situ. Eosinophilia and mast cells in bladder biopsy samples support the diagnosis of interstitial cystitis.

The pelvic examination is also often easier to perform with the patient under anesthesia. It should be performed in patients in whom the clinical pelvic examination was suboptimal.

Urethral dilation has been used in the past for temporary relief of urethral syndrome. This practice has largely been abandoned.

Urethral syndrome treatment

The goal of treatment in urethral syndrome is to relieve the discomfort and urinary frequency. This often involves a trial-and-error approach that uses behavioral, dietary, and medical therapy. The urologist must gain the confidence of these patients and should provide assurance and encouragement throughout therapy.

Medications include the following:

• Hormone replacement, such as conjugated estrogens (Premarin). Hormone replacement therapy improves mucosal quality in postmenopausal women and may improve resistance to external irritants.
• Anesthetics, such as phenazopyridine hydrochloride (Pyridium) and lidocaine (AneCream). Pyridium colors the urine a very noticeable orange, and care must be taken to prevent staining of undergarments. Patients who wear contact lenses should be aware that lenses can also become stained. Uristat is a nonprescription version of phenazopyridine hydrochloride (Pyridium).  Topical 1-2% lidocaine jelly has been used by some patients for external urethral irritation.
  • Urised, a blend of atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate, and benzoic acid, acts as an anesthetic and antispasmodic and inhibits bacterial growth. Tolterodine tartrate (Detrol) also acts as both an antispasmodic and anesthetic.
• Antispasmodics, such as hyoscyamine (Levsin) and oxybutynin (Ditropan XL)
• Tricyclic antidepressants (TCAs), such as amitriptyline and nortriptyline (Pamelor), which act on your nerves to help relieve chronic pain
• Muscle relaxants
• Alpha-blockers, such as doxazosin (Cardura) and prazosin (Minipress), which improve blood flow by relaxing the muscles in your blood vessels
• Botulinum toxin (BOTOX®) injections have some promise in treating urethral symptoms that occur with other conditions. However, studies have yet to be performed for its use in urethral syndrome ¹⁹⁾.

Behavioral therapy, including biofeedback, meditation, and hypnosis, has been used with some success. Biofeedback has the most promise in individuals whose symptoms are due to a failure to relax the pelvic musculature during voiding. Attempts at relaxation while undergoing electromyelography monitoring can help the patient retrain their muscles to allow them to void normally.

Dietary therapy is geared primarily at increasing urinary pH.

Palleschi and colleagues ²⁰⁾ reported significant and comparable symptom improvement with the oral phytotherapeutic product Cistiquer and intravesical gentamicin plus betametasone in a randomized study of 60 women with urethral syndrome and trigonitis. The dropout rate and the incidence of infection were higher in the intravesical treatment group.

Home remedies

Exercise and massage programs that put patients in better control of their muscles can be very helpful.

• Yoga and t’ai chi both emphasize balance, posture, and integrated movement that diminish tightness of the muscles. Through these activities, patients learn to better control and relax muscle groups and learn which muscle groups contribute to or improve their chronic pain.
  • In fact, to center the mind, t’ai chi uses a physical location in the lower abdomen/pelvis, close to the area of problems in urethral syndrome patients, called the Tan T’ien. From this state of attention develops the possibility to change, correct, and heal.
  • According to t’ai chi principles, the Tan T’ien, located approximately 2 inches below the navel and in the center of the pelvic area, is a body location that expresses the multifaceted principle that is referred to in t’ai chi as “center.” The Tan T’ien is understood to be the true body center in a sense of balance, integration, and strength.
  • T’ai chi emphasizes the ability to place the focus of the mind in the Tan T’ien in order to improve movement skills by eliminating the poor movement habit of excessive upper-body emphasis (ie, head, shoulders, arms).
• Myofascial therapy represents a philosophy of care in which the therapist facilitates the patient’s own inherent ability to correct soft-tissue dysfunction.
  • Myofascial models were described in the osteopathic literature of the 1950s. Many other contemporary treatment approaches such as connective-tissue massage, Rolfing, strain and counterstrain, and soft-tissue mobilization use the same principles.
  • This is a highly interactive stretching technique that requires feedback from the patient’s body to determine the direction, force, and duration of the stretch and to facilitate maximum relaxation of the tight or restricted tissues.
• Acupuncture and electroacupuncture have been used in China with some short-term benefits ²¹⁾. However, the lack of adequate scientific data and expertise by Western physicians in the practice of acupuncture significantly hinder its widespread practice.

Walking has a less direct effect on the pelvic musculature but is a potent antidepressant. Walking regularly for 3 months has been shown to yield improvements in depression similar to those of antidepressant medications.

Urethral syndrome diet

Intake of foods and liquids that are excreted as irritants in the urine may worsen symptoms.

Patients should avoid highly acidic foods, such as coffee, orange or cranberry juice and chocolate. These typically include spicy foods, but a more complete, although not comprehensive, list is provided below. Food reactions can be extremely individualized. Some patients may find that some of these foods worsen their symptoms, while others do not. The most recommended approach is to initiate a bland diet, excluding all of the suspect foods; then, gradually reintroduce individual foods, one per week, while noting symptoms. If symptoms worsen upon introduction of a particular food, that food should be eliminated from the diet on a long-term basis.

Alcohol and other beverages that may worsen urethral syndrome include the following:

• Beer
• Champagne
• Liquor
• Wine
• Coffee (decaffeinated, regular)
• Soda (eg, cola)
• Tea (decaffeinated, regular, iced)
• Condiments that may worsen syndromes include the following:
• Barbecue sauce
• Capers
• Chutney
• Cocktail sauce
• Corn relish
• Cranberry sauce
• Horseradish
• Hot pepper sauce
• Ketchup
• Mustard
• Pickles
• Relishes
• Roasted peppers
• Salsa
• Sauerkraut
• Sweet and sour sauce
• Tartar sauce
• Vinegar
• Worcestershire sauce

Fruits that may worsen urethral syndrome include the following:

• Apples
• Bananas
• Cantaloupe
• Grapefruit
• Grapes
• Kiwi
• Lemon
• Lime
• Mango
• Nectarines
• Oranges
• Peaches
• Pears
• Pineapple
• Plums
• Star fruit
• Strawberries
• Tomatoes (all varieties)

Juices that may worsen urethral syndrome include the following:

• Apple juice or cider
• Cranberry-apple or cranberry-grape
• Cranberry
• Mixed fruit
• Grape
• Grapefruit
• Guava
• Lemon (eg, lemonade)
• Mango
• Papaya
• Peach
• Pear
• Pineapple
• Prune
• Tamarind
• Tomato

Salad dressings that may worsen urethral syndrome include the following:

• Bleu cheese
• Caesar
• French
• Honey mustard
• Italian
• Poppy seed
• Ranch
• Thousand Island
• Vinaigrette

Snacks that may worsen urethral syndrome include the following:

• Applesauce
• Chocolate
• Gelatin (eg, Jell-O)
• Spicy crackers
• Spicy nachos
• Spicy potato chips

Vegetables that may worsen urethral syndrome include the following:

• Beets
• Cabbage
• Canned or jarred artichokes
• Peppers (green, red)
• Hot peppers (eg, jalapeño)

Miscellaneous foods that may worsen urethral syndrome include the following:

• Olive oil
• Chili
• Pizza sauce
• Marinara sauce
• Tomato sauce
• Tomato soup

A diet high in vegetables, fruits, and dairy products reduces the acidity of urine. The Interstitial Cystitis Network has developed low-acid recipes specifically for patients with interstitial cystitis and urethral syndrome (https://www.ic-network.com/interstitial-cystitis-diet/). Calcium glycerophosphate, marketed as Prelief, can be sprinkled over foods to reduce acidity. Dietary supplementation with sodium bicarbonate or potassium bicarbonate can provide relief for some patients.

Increased fluid intake is advisable. Because many drinks increase acidity, patients may be prone to dehydration. This also may be an attempt by the patient to decrease urinary frequency by decreasing urine output. In fact, more concentrated urine is more acidic and contains a higher concentration of irritants. Patients should be encouraged to drink plenty of fluid, specifically water.

Surgical care

Historically, the primary surgical procedure used to treat urethral syndrome has been urethral dilation. Previously a commonly used technique for practically all female urinary tract pain syndromes, urethral dilation is rarely performed in current practice. However, women with true urethral stenosis as the etiology of their symptoms experience significant improvement after urethral dilation.

The implantable InterStim system uses mild electrical stimulation of the sacral nerve (near the sacrum). These nerves provide the most distal common autonomic and somatic nerve supply to the pelvic floor, detrusor muscle, and lower gastrointestinal tract. In properly selected patients, InterStim therapy can dramatically reduce or eliminate symptoms.

Nd:YAG laser ablation of squamous metaplasia at the bladder neck-trigone has shown some promise in patients with urethral syndrome refractory to medical management and with findings of trigonitis. Success appears to depend on necrotic coagulation followed by reconstitution of normal functional epithelium ²²⁾.