History
Patients diagnosed with urethral syndrome are typically female and aged 13-70 years. Patients report 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 cancer. Most patients focus on urinary symptoms, but other aspects of the patient’s history and symptoms must also be evaluated.
Urinary symptoms
Urinary symptoms in urethral syndrome are as follows:
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The urinary frequency associated with urethral syndrome is typically every 30-60 minutes during the daytime, with minimal nocturia
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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
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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
The following questionnaires may be useful for evaluating urinary symptoms:
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International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS; derived from the Bristol Female Lower Urinary Tract Symptoms - Short Form Questionnaire) [8]
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 (eg, rough intercourse, prolonged oral sex, intercourse in a heavily chlorinated hot tub or in a shower using bath soap as a lubricant) may result in urethral irritation. 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 if they were treated with pelvic surgery or radiation therapy.
Neurologic symptoms
Frequent falls, limping, or other neurologic symptoms may suggest a central nervous system 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 Examination
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 disc 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.
