eMedicine Specialties > Urology > Common Problems of the Urethra

Urethral Syndrome

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
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

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 As a diagnosis, urethral syndrome (also known as or frequency-dysuria syndrome) is controversial and may be an outdated term, partially because of the lack of consensus on specific diagnostic criteria and overlap with other diseases such as interstitial cystitis (IC) or painful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.

Differential Diagnoses

Other Problems to Be Considered

The distinction between urethral syndrome and mild interstitial cystitis (IC) can be particularly challenging. These lower urinary tract pain syndromes may actually simply represent different points along the spectrum of the same general disease process.

Workup

Laboratory Studies

• A urine sample should be collected for urinalysis and urine culture.
  • Urinalysis may show up to 3 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 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, urine cultures of 100,000 colonies per milliliter of urine in a voided specimen (10,000 colonies of bacteria per milliliter 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 small 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

• 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.
• MRI is emerging as possibly superior to cystography in the identification of urethral diverticula.
• 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.

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 (IC). It is also therapeutic in patients with IC. 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 IC. The pelvic examination is also often easier to perform with the patient under anesthesia, and one 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.

Treatment

Medical Care

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

• Medical therapy is discussed in detail in Medication. Medications include hormone replacement, anesthetics, antispasmodics, tricyclic antidepressants (TCAs), muscle relaxants, and alpha-blockers.
• 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.

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.^{[1 ]}

Consultations

• Most women with urethral syndrome–type symptoms initially present to a gynecologist; thus, most gynecologic abnormalities have been excluded as diagnostic possibilities before the patient reaches the urologist. However, if a female patient has not seen a gynecologist and concern exists that she may have a gynecologic abnormality as an etiology of her symptoms or as a separate disease entity, referral to a gynecologist is recommended.
• The secondary psychological impact of chronic pain syndromes can be substantial. Consultation with a psychiatrist or pain-control specialist may help in management.
• Any question of a previously undiagnosed neurological condition (eg, multiple sclerosis, Parkinson disease) should prompt a consultation with a neurologist.
• A physical therapist experienced in biofeedback can provide support and relief to some patients with urethral syndrome.

Diet

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

• Avoid highly acidic foods. 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. Suspect foods may include the following:
  • Alcohol
    • Beer
    • Champagne
    • Liquor
    • Wine
  • Beverages
    • Coffee (decaffeinated, regular)
    • Soda (eg, cola)
    • Tea (decaffeinated, regular, iced)
  • Condiments
    • 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
    • Apples
    • Bananas
    • Cantaloupe
    • Grapefruit
    • Grapes
    • Kiwi
    • Lemon
    • Lime
    • Mango
    • Nectarines
    • Oranges
    • Peaches
    • Pears
    • Pineapple
    • Plums
    • Star fruit
    • Strawberries
    • Tomatoes (all varieties)
  • Juices
    • 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
    • Bleu cheese
    • Caesar
    • French
    • Honey mustard
    • Italian
    • Poppy seed
    • Ranch
    • Thousand Island
    • Vinaigrette
  • Snacks
    • Applesauce
    • Chocolate
    • Gelatin (eg, Jell-O)
    • Spicy crackers
    • Spicy nachos
    • Spicy potato chips
  • Vegetables
    • Beets
    • Cabbage
    • Canned or jarred artichokes
    • Peppers (green, red)
    • Hot peppers (eg, jalapeño)
  • Miscellaneous foods
    • Olive oil
    • Chili
    • Pizza sauce
    • Marinara sauce
    • Tomato sauce
    • Tomato soup
• Further decrease the intake of acidic foods. A diet high in vegetables, fruits, and dairy products reduces the acidity of urine. The Interstitial Cystitis (IC) Network has developed low-acid recipes specifically for patients with IC and urethral syndrome (see The IC Chef). 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.
• Increase fluid intake. 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.

Activity

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.
• 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.

Medication

The choice of medical therapy in urethral syndrome is determined by the patient's predominant symptoms and probable etiology. Determination of the optimum regimen often involves a combination of medications chosen through a process of trial and error. All possible infectious etiologies should be evaluated and treated prior to initiation of additional medications.

Hormones

Hormone replacement therapy improves mucosal quality in postmenopausal women and may improve resistance to external irritants.

Conjugated estrogens (Premarin)

Hormone replacement therapy improves mucosal quality in postmenopausal women and may improve resistance to external irritants.

Dosing

Adult

1.25 mg PO qd through 25th day of every month

Pediatric

Not established

Interactions

May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P-450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Contraindications

Documented hypersensitivity; known or possible pregnancy; breast cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Certain patients may develop undesirable manifestations of excessive estrogenic stimulation (eg, abnormal or excessive uterine bleeding, mastodynia); may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia; caution in patients with low albumin levels or hepatic disease

Tricyclic antidepressants

In low doses, these agents are effective at relieving chronic pain by interfering with nerve activity. They are commonly prescribed for several chronic pain conditions, including irritable bowel syndrome (IBS) and fibromyalgia. Imipramine (Tofranil) and a host of others may be options to consider when prescribing TCAs for chronic pain. However, amitriptyline (Elavil) is the most extensively tested medication of this type for chronic pain.

Amitriptyline (Elavil)

In low doses, effective for relieving chronic pain by interfering with nerve activity. Commonly prescribed for several chronic pain conditions, including IBS and fibromyalgia.

Dosing

Adult

100 mg PO qd

Pediatric

Not established

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, urinary retention, pyloric or duodenal obstruction, obstructive intestinal lesions, or chronic constipation

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly persons

Anesthetics

Phenazopyridine hydrochloride (Pyridium) is a prescription pain reliever that works by soothing the bladder lining when excreted into urine. It is often prescribed for temporary pain relief after surgery, cystoscopy, or catheterization. It is not prescribed for long-term use to control interstitial cystitis (IC) symptoms because it can build up in the body and cause harmful effects. 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).

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.

Topical 1-2% lidocaine jelly has been used by some patients for external urethral irritation.

Phenazopyridine (Pyridium, Urodine, Urogesic)

Azo dye excreted in urine. Exerts a topical analgesic effect on urinary tract mucosa. Compatible with antibacterial therapy and can help relieve pain and discomfort before antibacterial therapy controls infection.
Used for symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or passage of sounds or catheters. Analgesic action may reduce or eliminate need for systemic analgesics or narcotics. Uristat is a nonprescription version of phenazopyridine (Pyridium).

Dosing

Adult

200 mg PO tid prn

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal insufficiency; yellowish tinge of skin or sclera may indicate accumulation because of impaired renal excretion (discontinue therapy); treatment of UTI with phenazopyridine should not exceed 2 d because no evidence indicates more benefit than antibiotic therapy alone following 2 d of therapy

Antispasmodics

These agents decrease the contractility of bladder muscle. Multiple formulations are marketed, including flavoxate (Urispas), hyoscyamine sulfate (Anaspaz), trospium chloride (Sanctura), solifenacin succinate (Vesicare), darifenacin hydrobromide (Enablex), oxybutynin chloride (Ditropan), oxybutynin chloride ER (Ditropan XL), Urised (blend of atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate, and benzoic acid that acts as an antispasmodic and anesthetic and inhibits bacterial growth), and tolterodine tartrate (Detrol), which is also both an antispasmodic and anesthetic.

Tizanidine HCL (Zanaflex)

Centrally acting α2-adrenergic agonist that presumably reduces spasticity by increasing presynaptic inhibition of motor neurons.
A single dose of 8 mg tizanidine reduces muscle tone in patients with spasticity for a period of several hours. The effect peaks at approximately 1-2 h and dissipates between 3-6 h. Effects are dose-related.

Dosing

Adult

4-8 mg PO q8h prn; not to exceed 36 mg/d; start at 4 mg PO once, increasing 2-4 mg q6-8h to desired effect; dose can be repeated at 6- to 8-h intervals, as needed, to maximum 3 doses in 24 hours; must taper dose gradually to discontinue

Pediatric

Not established

Interactions

Concurrent administration with CYP1A2 inhibitors (eg, fluvoxamine, ciprofloxacin) significantly decreases blood pressure, increases drowsiness, and increases psychomotor impairment; alcohol increases AUC of tizanidine by approximately 20%, causing additive CNS depressant effects

Contraindications

Documented hypersensitivity; concomitant use of tizanidine with potent inhibitors of CYP1A2 (eg, fluvoxamine or with ciprofloxacin; pharmacokinetic interaction can result in potentially serious adverse events)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Frequent adverse effects include dry mouth, somnolence/sedation, asthenia (weakness fatigue and/or tiredness), and dizziness; concurrent administration with alpha 2-adrenergic agonists or potent CYP1A2 inhibitors not recommended; occasionally causes liver injury (in occasional symptomatic cases, nausea, vomiting, anorexia, and jaundice reported); monitoring of aminotransferase levels recommended during first 6 mo of treatment (eg, baseline, 1, 3, 6 mo) and periodically thereafter, based on clinical status; avoid or use with extreme caution in patients with impaired hepatic function; sedation may occur; use with extreme caution in patients with hepatic impairment; avoid concomitant use of tizanidine with other CYP1A2 inhibitors, such as zileuton, other fluoroquinolones, antiarrythmics (amiodarone, mexiletine, propafenone, verapamil), cimetidine, famotidine, oral contraceptives, acyclovir, and ticlopidine; may prolong QT interval; bradycardia and retinal degeneration may occur; caution in renal insufficiency; avoid concomitant use with oral contraceptives (reduce starting dose and subsequent titration if administration required); to stop medication, decrease dose slowly to minimize risk of withdrawal, rebound hypertension, tachycardia, and hypertonia

Oxybutynin (Ditropan, Ditropan XL); oxybutynin transdermal (Oxytrol, Gelnique)

Decreases contractility of bladder muscle by anticholinergic action.

Dosing

Adult

Titrate from 2.5 mg to 10 mg PO tid; ER formulation may be more appropriate for those requiring higher doses. A transdermal patch and gel formulation, marketed as Oxytrol or Gelnique, respectively, are also available and may have decreased side effects.

Pediatric

Not established; doses are recommended for neurogenic bladder in pediatric patients, but urethral syndrome, not a pediatric condition

Interactions

Not established

Contraindications

Documented hypersensitivity; pyloric or duodenal obstruction, obstructive intestinal lesions, GI hemorrhage, and obstructive uropathies of lower urinary tract; narrow-angle glaucoma

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause drowsiness, vertigo, and ocular disturbances; caution in glaucoma

Flavoxate (Urispas)

Used for symptomatic relief of dysuria, urgency, nocturia, and incontinence as may occur in cystitis, prostatitis, urethritis, and urethrocystitis/urethrotrigonitis. Acts as anticholinergic and exerts direct effect on muscle. Counteracts smooth muscle spasms of urinary tract.

Dosing

Adult

100-200 mg PO tid/qid; reduce dose when symptoms improve

Pediatric

Not established

Interactions

Additive anticholinergic effects may occur with coadministration of other anticholinergic agents (eg, TCAs, amantadine, phenothiazines)

Contraindications

Documented hypersensitivity; pyloric or duodenal obstruction; obstructive intestinal lesions; GI hemorrhage and obstructive uropathies of lower urinary tract

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause drowsiness, vertigo, and ocular disturbances; caution in glaucoma

Hyoscyamine (Anaspaz)

Anticholinergic agents with antispasmodic properties used for the treatment of urge incontinence. Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which in turn has antispasmodic effects. Absorbed well by the GI tract. Food does not affect absorption. Available in sublingual form (Levsin SL), conventional tablets (Levsin), extended-release capsules (Levsinex Timecaps, Cystospaz-M), and extended-release tablets (Levbid).

Dosing

Adult

0.125 mg PO q4h; alternatively, 0.375 mg PO bid; for severe symptoms, 0.375 mg PO tid

Pediatric

Not established

Interactions

Effects decrease when used concurrently with antacids; toxicity increases when used concurrently with phenothiazines, amantadine, haloperidol, MAOIs, and tricyclic antidepressants

Contraindications

Documented hypersensitivity; obstructive uropathy; narrow-angle glaucoma; myasthenia gravis; obstructive GI tract disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly patients; some products contain sodium metabisulfite, which can cause allergic type reactions

Trospium (Sanctura, Sanctura XR)

Quaternary ammonium compound that elicits antispasmodic and antimuscarinic effects. Antagonizes acetylcholine effect on muscarinic receptors. Parasympathetic effect reduces smooth muscle tone in the bladder. Indicated to treat symptoms of overactive bladder (eg, urinary incontinence, urgency, frequency).

Dosing

Adult

20 mg PO bid; take on empty stomach at least 1 h before meals
CrCl <30 mL/min: 20 mg PO hs
An extended-release (XR) formulation is available at a dose of 60 mg PO/d
>75 years: May titrate dose downward to 20 mg PO qd based on tolerability

Pediatric

Not established

Interactions

High-fat meals decrease absorption; coadministration with drugs that compete for tubular secretion (eg, digoxin, procainamide, pancuronium, morphine, vancomycin, metformin, tenofovir) may decrease trospium elimination; coadministration with other drugs that elicit anticholinergic effects (eg, antihistamines, antispasmodics) may increase adverse effects

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anticholinergic effects may occur (eg, dry mouth, constipation, dry eyes, blurred vision); increased anticholinergic effects may occur in individuals older than 75 y; decrease dose with severe renal impairment (ie, CrCl <30 mL/min)

Solifenacin succinate (Vesicare)

Elicits competitive muscarinic receptor antagonist activity, which results in anticholinergic effect and inhibition of bladder smooth muscle contraction. Indicated for overactive bladder with symptoms of urgency, frequency, and urge incontinence.

Dosing

Adult

5 mg PO qd; if tolerated, may be increased to 10 mg PO qd

Pediatric

Not established

Interactions

CYP3A4 substrate; because of decreased clearance, do not exceed 5 mg/dose when coadministered with CYP3A4 inhibitors (eg, ketoconazole, erythromycin); CYP3A4 inducers (eg, rifampin, carbamazepine) may increase clearance; may increase risk of QT prolongation when coadministered with drugs known to prolong QT interval (eg, sotalol, thioridazine, moxifloxacin)

Contraindications

Documented hypersensitivity; severe hepatic impairment (Child-Pugh class C); uncontrolled narrow-angle glaucoma; urinary retention; gastric retention

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with renal or hepatic impairment (do not exceed 5 mg with CrCl <30 mL/min or moderate hepatic impairment [Child-Pugh class B]); caution with controlled narrow-angle glaucoma, history of prolonged QT interval, bladder outflow obstruction, or decreased GI motility; tab must be swallowed whole (not crushed) with liquid

Darifenacin (Enablex)

Extended-release product eliciting competitive muscarinic receptor antagonistic activity. Reduces bladder smooth muscle contractions. Has high affinity for M₃ receptors involved in bladder and GI smooth muscle contraction, saliva production, and iris sphincter function. Indicated for overactive bladder with symptoms of urge incontinence, urgency and frequency. Swallow whole; do not chew, divide, or crush.

Dosing

Adult

7.5 mg PO qd initially; after 2 wk may increase to 15 mg PO qd based on response
Moderate hepatic impairment (Child Pugh B) or potent CYP450 3A4 inhibitors: Do not exceed 7.5 mg PO qd

Pediatric

Not established

Interactions

CYP-450 2D6 and 3A4 substrate; potent CYP-450 3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, nelfinavir, clarithromycin, nefazodone) decrease clearance (do not exceed 7.5 mg/d); may cause additive toxicity with other anticholinergics (eg, antihistamines); coadministration with CYP-2D6 substrates that have a narrow therapeutic index (eg, flecainide, thioridazine, TCA [imipramine]) may cause toxicity of these other substrates; may increase midazolam or digoxin levels

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; severe hepatic impairment; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include xerostomia, constipation, and blurred vision; caution with significant bladder outflow obstruction, decreased GI motility, controlled narrow-angle glaucoma, or moderate hepatic impairment; may cause heat prostration due to decreased ability to sweat

Tolterodine tartrate (Detrol)

Competitive muscarinic receptor antagonist for overactive bladder. Differs from other anticholinergic types in that it has selectivity for urinary bladder over salivary glands. Exhibits high specificity for muscarinic receptors. Has minimal activity or affinity for other neurotransmitter receptors and other potential targets such as calcium channels. In clinical studies, mean decrease in urge incontinence episodes was 50% and the mean decrease in urinary frequency was 17%.

Dosing

Adult

Detrol: 2 mg PO bid
Detrol LA: 4 mg PO qd

Pediatric

Not established

Interactions

Additive effects with other anticholinergic agents; patients treated with macrolide antibiotics or antifungal agents should not receive doses of tolterodine >1 mg bid; coadministration of CYP2D6 inhibitors and, to a lesser degree, CYP3A4 inhibitors may decrease clearance

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not give doses >1 mg bid to patients with significantly reduced hepatic function; caution in renal impairment

Fesoterodine (Toviaz)

Competitive muscarinic receptor antagonist. Antagonistic effect results in decreased bladder smooth muscle contractions. Indicated for symptoms of overactive bladder (eg, urinary urge incontinence, urgency, and frequency). Available as 4- or 8-mg extended-release tab.

Dosing

Adult

4 mg PO qd; may increase to 8 mg/d; not to exceed 4 mg PO qd in severe renal dysfunction (ie, CrCl <30 mL/min) or with coadministration of drugs that decrease metabolism of fesoterodine (eg, ketoconazole, itraconazole, clarithromycin)

Pediatric

Not established

Interactions

Coadministration with other drugs that cause antimuscarinic or anticholinergic effects may exacerbate adverse effects (eg, xerostomia, constipation); coadministration with strong CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin) increases maximum concentration and AUC of fesoterodine

Contraindications

Documented hypersensitivity; urinary or gastric retention; uncontrolled narrow-angle glaucoma; severe liver impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include xerostomia and constipation; caution in myasthenia gravis, hepatic or renal impairment, controlled narrow-angle glaucoma, and decreased gastrointestinal motility; may cause anticholinergic effects (eg, dry eyes, dry throat, urinary retention); may increase heart rate

Alpha-adrenergic blocking Agents

Alpha blockade can help relieve increased muscle tone at the bladder neck and proximal urethra in men and women and provide relief of symptoms in some. Include prazosin (Minipress) and the more specific alpha-1 blockers doxazosin (Cardura), tamsulosin (Flomax), alfuzosin hydrochloride (Uroxatral), and terazosin (Hytrin).

Terazosin (Hytrin)

Reduces muscle tone at bladder neck and proximal urethra by blocking alpha receptors.

Dosing

Adult

5-10 mg PO qd

Pediatric

Not established

Interactions

Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications

Contraindications

Documented hypersensitivity, recurrent dizziness, history of priapism

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment; may cause marked hypotension following first dose and coadministration with beta-blockers; may cause somnolence (caution while driving, operating machinery, and performing any other hazardous task until confident with drug reaction); nasal stuffiness has been documented

Prazosin (Minipress)

Decreases internal sphincter tone and can improve flow of urine, improving emptying of bladder. If need to increase dose, give first dose of each increment at bedtime to reduce syncopal episodes. Although doses greater than 20 mg/d usually do not increase efficacy, a few patients may benefit from dose as high as 40 mg/d.

Dosing

Adult

Initial: 1 mg PO bid/tid
Maintenance: 6-15 mg/d PO bid/tid

Pediatric

Not established

Interactions

May worsen acute postural hypotensive reaction caused by beta-blockers; indomethacin may decrease antihypertensive activity of prazosin; verapamil may increase serum prazosin levels and may increase patient's sensitivity to prazosin-induced postural hypotension; prazosin may decrease antihypertensive effects of clonidine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal insufficiency (decrease dose); marked orthostatic hypotension, syncope, and loss of consciousness may occur with first dose; rash, pruritus, alopecia, diaphoresis, lupus erythematosus, dizziness, headache, drowsiness, lack of energy, nausea, palpitations, and weakness can occur

Doxazosin (Cardura)

Selective inhibitor of alpha1-adrenergic receptors. Blockade of alpha1-adrenergic receptors in the bladder neck decreases outflow resistance.

Dosing

Adult

1 mg PO hs initially to avoid the first-dose effect; may be increased gradually over 1-2 wk; not to exceed 8 mg/d for urodynamic effect

Pediatric

Not established

Interactions

Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment; may cause marked hypotension following first dose

Tamsulosin (Flomax)

Selective alpha1-antagonist for treatment of BPH.

Dosing

Adult

0.4 mg or 0.8 mg PO qd

Pediatric

Not established

Interactions

Cimetidine may significantly increase plasma concentrations; tamsulosin may increase toxicity of warfarin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for use as antihypertensive drug; may cause orthostasis; avoid situations that may result in injuries if syncope occurs; rule out presence of carcinoma or cancer before initiating treatment

Alfuzosin (Uroxatral)

Alpha I-blocker of adrenoceptors in prostate. Blockade of adrenoceptors may cause smooth muscles in bladder neck and prostate to relax, resulting in improvement in urine flow rate and reduction in symptoms of BPH.

Dosing

Adult

10 mg PO qd

Pediatric

Not established

Interactions

Effects may increase with coadministration of diuretics and antihypertensive medications; coadministration with potent CYP450 3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir) significantly increase C_max and AUC following a single administration of alfuzosin; moderate CYP450 3A4 inhibitors (eg, diltiazem), atenolol, and cimetidine also increased C_max and AUC following repeated exposure

Contraindications

Documented hypersensitivity; moderate or severe hepatic insufficiency (Childs-Pugh categories B and C); coadministration with potent CYP450 3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Dizziness, fatigue, and headache may occur; patients should avoid situations where injury could result if syncope occurs; rule out presence of carcinoma of prostate before beginning therapy; discontinue if angina pectoris symptoms appear or worsen; caution with severe renal insufficiency (ie, CrCl <30 mL/min); do not crush or chew tablets

Sedatives

Increased tone of pelvic floor may respond to pharmacological therapy with sedative effects.

Diazepam (Valium, Diazepam Intensol)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.

Dosing

Adult

5 mg PO qd or bid

Pediatric

Not established

Interactions

Phenothiazines, barbiturates, alcohols, and MAOIs increase CNS toxicity when administered concurrently

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Follow-up

Further Outpatient Care

• Emotional support and encouragement of patient with urethral syndrome are essential. Reevaluation for possible urinary tract infection and malignancy is also imperative whenever symptoms worsen.
• Acupuncture and electroacupuncture have been used in China with some short-term benefits^{[2 ]}; however, the lack of adequate scientific data and expertise by Western physicians in the practice of acupuncture significantly hinder its widespread practice.
• Botulinum toxin (BOTOX®) injections have some promise in treating urethral symptoms that occur with other conditions, but studies have yet to be performed for its use in urethral syndrome.^{[3 ]}

Inpatient & Outpatient Medications

• Even when an optimum medical therapy is determined, symptoms may wax and wane, requiring further adjustment of the medical regimen.

Complications

• The secondary psychological impact of chronic pain syndromes can be substantial. Consultation with a psychiatrist or pain management specialist may be helpful.

Prognosis

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

Patient Education

• Diet, exercise, and stress reduction are all important to any chronic illness. Biofeedback for pelvic relaxation may also be helpful in these patients.
• For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Cancer and Bladder Control Problems.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider other possible causes of urinary frequency and dysuria: Missed malignancy is the most common reason for litigation in such cases.
• Failure to seek consultation with a psychologist in patients who become suicidal

References

1. Costantini E, Zucchi A, Del Zingaro M, Mearini L. Treatment of urethral syndrome: a prospective randomized study with Nd:YAG laser. Urol Int. 2006;76(2):134-8. [Medline].

2. Chen YL, Ha LF, Cen J, et al. [Comparative observation on therapeutic effects of electroacupuncture and manual acupuncture on female urethral syndrome]. Zhongguo Zhen Jiu. Jun 2005;25(6):425-6. [Medline].

3. Cruz F, Silva C. Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update. Curr Opin Urol. Nov 2004;14(6):329-34. [Medline].

4. Allen TD. Commentary on dysfunctional abnormalities of the urinary tract. Urol Clin North Am. Jun 1980;7(2):357-9. [Medline].

5. Barrett DM, Wein AJ, Barrett DM, Wein AJ. Voiding dysfunction: Diagnosis, classification, and management. In: Gillenwater JY, Grayhack JT, Howards SS, eds. Adult and Pediatric Urology. Vol 1. 2^nd ed. St. Louis, Mo: Mosby-Year Book; 1073-5.

6. Bogart LM. Berry SH. Clemens JQ. Symptoms of interstitial cystitis, painful bladder syndrome and similar diseases in women: a systematic review. J. Urol. Feb. 2007;177(2):450-6. [Medline].

7. Gerstenberg TC, Lykkegaard Nielsen M, Lindenberg J. Spastic striated external sphincter syndrome imitating recurrent urinary tract infection in females. Effect of long-term alpha- adrenergic blockade with phenoxybenzamine. Eur Urol. 1983;9(2):87-92. [Medline].

8. Kaur H, Arunkalaivanan AS. Urethral pain syndrome and its management. Obstet Gynecol Surv. May 2007;62(5):348-51. [Medline].

9. Lemack GE, Foster B, Zimmern PE. Urethral dilation in women: a questionnaire-based analysis of practice patterns. Urology. Jul 1999;54(1):37-43. [Medline].

10. Schmidt RA. The urethral syndrome. Urol Clin North Am. May 1985;12(2):349-54. [Medline].

11. Sugaya K, Nishijima S, Oda M, et al. Transabdominal vesical sonography of urethral syndrome and stress incontinence. Int J Urol. Jan 2003;10(1):36-42. [Medline].

12. Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. Dec 2001;166(6):2226-31. [Medline].

13. Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain. Dec 1997;73(3):269-94. [Medline].

14. Zhang D, Xu Z. [Female prostatitis]. Zhonghua Nan Ke Xue. Jul 2004;10(7):547-8, 550. [Medline].

Keywords

urethral syndrome, frequency-dysuria syndrome, painful bladder syndrome, pelvic pain syndrome, IC, interstitial cystitis, urethral stenosis, dysuria, lower urinary tract symptoms, urinary frequency, suprapubic discomfort, psychosomatic illness, chronic pelvic pain, CPP, urinary pain, voiding pain, urinary tract infection, UTI

Contributor Information and Disclosures

Author

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Subbarao V Cherukuri, MD, Consulting Staff, Department of Urology, St Joseph Regional Health Center
Subbarao V Cherukuri, MD is a member of the following medical societies: American Urological Association and Ohio State Medical Association
Disclosure: Nothing to disclose.

Christopher A Hathaway, MD, PhD, Resident Physician, Department of Surgery, Medical College of Georgia
Christopher A Hathaway, MD, PhD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

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