eMedicine Specialties > Urology > Common Problems of the Urethra

Urethral Syndrome

Author: Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Coauthor(s): Subbarao V Cherukuri, MD, Consulting Staff, Department of Urology, St Joseph Regional Health Center; Christopher A Hathaway, MD, PhD, Resident Physician, Department of Surgery, Medical College of Georgia
Contributor Information and Disclosures

Updated: May 19, 2009

Introduction

Background

Urethral syndrome is a term that was first coined by Powell and Powell in 1949. As they described it, the presenting symptoms of urethral syndrome included urinary frequency and dysuria without demonstrable infection. As a diagnosis, urethral syndrome (also known as or frequency-dysuria syndrome) is controversial and may be an outdated term, partially because of the lack of consensus on specific diagnostic criteria and overlap with other diseases such as interstitial cystitis (IC) or painful bladder syndrome.

Up to one quarter of patients presenting with lower urinary tract symptoms may have urethral syndrome, which is characterized by urinary frequency, dysuria, and suprapubic discomfort without any objective finding of urological abnormalities. It 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. Vaginal discharge and vaginal lesions must be excluded. The patient’s history is important, as the diagnosis of urethral syndrome is one of exclusion.

Pathophysiology

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

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.

Frequency

United States

The exact incidence of urethral syndrome is unknown because of a lack of consensus in diagnosis.

International

The exact incidence of urethral syndrome is unknown because of a lack of consensus in diagnosis.

Mortality/Morbidity

Urethral syndrome is not a fatal condition; however, the urinary hesitancy, frequency, and dysuria characterized by the syndrome can greatly impair quality of life.

• As a result of the unrelenting symptoms, many patients with urethral syndrome have concomitant depression, anxiety, or other secondary psychologic 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.

Race

Urethral syndrome is more common in white women in westernized civilizations than in women of other races or groups.

Sex

Urethral syndrome is more common in females than in males.

Age

Patients diagnosed with urethral syndrome are typically aged 13-70 years.

Clinical

History

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.

• Urinary symptoms: Most patients focus on urinary symptoms, but other aspects of the patient’s history and symptoms must also be evaluated.
  • 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 (IC). The pain may be relieved by voiding. At night, the pain is not severe enough to disturb sleep.
  • Dysuria: The patient often describes 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.
  • The Bristol Female Lower Urinary Tract Symptoms (BFLUTS), Urogenital Distress Inventory (UDI-6), and the International Prostate Symptom Score (I-PSS) questionnaires may be useful tools.
• Other pelvic symptoms: Associated bowel symptoms, menstrual complaints, and dyspareunia 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 an etiology for urinary frequency.
• Sexual history: Contraceptive methods (many contraceptive gels and condoms are irritative) and sexual activity (rough intercourse, prolonged oral sex, and intercourse in a heavily chlorinated hot tub or in a shower using bath soap as a lubricant may be the etiology of urethral irritation) may elicit an etiology. A history of sexual abuse has been linked with pelvic floor muscle dysfunction.
• Habits: Prolonged driving in vehicles with limited shock-absorbing mechanisms (eg, 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).
• Medications and past medical history: 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.
• Neurologic symptoms: Frequent falls, limping, or other neurologic symptoms may suggest a CNS abnormality. Multiple sclerosis has a propensity to affect women at the same age as urethral syndrome, and vague bladder symptoms are often the initial presenting symptom of this disease.

Physical

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 neurological 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 vaginal wall and the posterior urethral wall 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/neurological examination, and a rectal examination should be performed to assess rectal tone and the presence of any masses, rectal/perianal fissures, ulcers, hemorrhoids, or other lesions that may contribute to the patient's symptoms.
• 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 IC. 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.
• Neurological 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 symptom of this disease.

Causes

The etiology of urethral syndrome is unknown.

• 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.
• Unfortunately, a unified alternative etiology for urethral syndrome has not been identified.
• Hormonal imbalances, reactions to certain foods, environmental chemicals (eg, douches, bubble bath, soaps, contraceptive gels, condoms), inflammation of the Skene glands and the paraurethral glands (the "female prostate"), localized trauma, hypersensitivity following urinary tract infection, and dysfunction of the pelvic floor musculature have been postulated as causes of urethral syndrome, without much statistical evidence.

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