Urethral Syndrome

Updated: Nov 06, 2020
  • Author: Pamela I Ellsworth, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Overview

Practice Essentials

Urethral syndrome is characterized by urinary frequency, dysuria, and suprapubic discomfort without any objective finding of urological abnormalities. In 2002 the International Continence Society recommended use of the term urethral pain syndrome (UPS) to replace urethral syndrome. [1]  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. Pain may also be experienced in the lower back, genitals, abdomen, and suprapubic region

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. See Presentation, DDx, and Workup.

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. Diet, exercise, and stress reduction are all important, as they are in any chronic illness. Biofeedback for pelvic relaxation may also be helpful in these patients. See Treatment and Medication.

For patient education information, see Bladder Control Problems.

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Background

Urethral syndrome was originally described as urinary frequency and dysuria without demonstrable infection. As a diagnosis, urethral syndrome (also known as frequency-dysuria syndrome) is controversial, and the term (coined by Powell and Powell in 1949) may be outdated, partially because of the lack of consensus on specific diagnostic criteria and overlap with other diseases such as interstitial cystitis and painful bladder syndrome. Currently, the International Continence society recommends use of the term urethral pain syndrome (UPS). [1]  Up to one quarter of patients presenting with lower urinary tract symptoms may have urethral syndrome.

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Etiology and Pathophysiology

The etiology of urethral syndrome is unknown. Historically, urethral stenosis was believed to cause urethral syndrome. A diagnosis of urethral stenosis, along with the serial urethral dilations 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; instead, it is thought that urethral syndrome may be the result of several complex mechanisms. Currently theorized etiologies include the following [2, 3, 4] :

  • 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)
  • Estrogen deficiency
  • Low grade infection
  • Early painful bladder syndrome (interstitial cystitis)
  • Urethral, spasm
  • Urethral stenosis
  • Hypersensitivity following urinary tract infection 
  • Traumatic sexual intercourse
  • Dysfunction of the pelvic floor musculature

However, there is not much statistical evidence to support those postulated causes of urethral syndrome. [3, 2, 4]  Others hypothesize that dysfunction of the mucosal barrier layer leads to inflammatory changes in the bladder urothelium that allow solutes in the urine to seep through the epithelial layer, which results in inflammatory changes, spasm, and fibrosis. [3, 5, 6]

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.

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Epidemiology

The exact incidence of urethral syndrome is unknown because of a lack of consensus in diagnosis and overlap with other conditions. [3]  

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. [7] Patients diagnosed with urethral syndrome are typically 13-70 years of age.

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Prognosis

The urinary hesitancy, frequency, and dysuria characterized by urethral syndrome can greatly impair quality of life. As a result of the unrelenting symptoms, many patients with urethral syndrome develop depression, anxiety, or other secondary psychological morbidities; the coexistence of neurosis has prompted many physicians to categorize urethral syndrome as a psychosomatic illness.

Symptoms of urethral syndrome usually improve slowly as the patient ages, but the problem may be lifelong. Many patients with urethral syndrome seek out multiple physicians in order to secure symptom relief and are at risk for polypharmacy, narcotic abuse, and antibiotic resistance.

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Patient Education

It is important to remind patients that the treatment process is a trial and error of different therapies.  It may take time to find what works effectively for a particular patient with urethral syndrome.

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