Urethral Pain Syndrome

Updated: Dec 05, 2023
  • Author: Pamela I Ellsworth, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Practice Essentials

Urethral pain syndrome (UPS) is characterized by urinary frequency, dysuria, and suprapubic discomfort without any objective finding of urological abnormalities; urine cultures are sterile. The condition is also known as frequency-dysuria syndrome. It was historically termed urethral syndrome, but in 2002 the International Continence Society recommended replacing that term with urethral pain syndrome. [1]

Urinary frequency in UPS is typically worse during the day than during the night. The dysuria and constant suprapubic discomfort is partially relieved by voiding. Patients with UPS 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

As a diagnosis, UPS is controversial: there is lack of consensus on specific diagnostic criteria, and the condition overlaps with other diseases such as interstitial cystitis and painful bladder syndrome. Nevertheless, up to one quarter of patients presenting with lower urinary tract symptoms may have UPS.

Most patients diagnosed with UPS are women, typically ranging from age 13-70 years; most are 30-50 years old. Vaginal discharge and vaginal lesions must be excluded. The patient’s history is important, as the diagnosis of UPS is one of exclusion. See Presentation, DDx, and Workup.

The goal of treatment 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.


Etiology and Pathophysiology

The etiology of urethral pain syndrome (UPS) is unknown. Historically, urethral stenosis was believed to be the cause, but 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.

Unfortunately, a unified alternative etiology for UPS has not been identified; instead, it is thought that the 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 little statistical evidence to support those postulated causes. [3, 2, 4]  Other authors 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 UPS 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.



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

Urethral pain 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.



The urinary hesitancy, frequency, and dysuria that characterizes urethral pain syndrome can greatly impair quality of life. In many affected individuals, the unrelenting symptoms lead to depression, anxiety, or other secondary psychological morbidities; the coexistence of such morbidities has prompted many physicians to categorize urethral pain syndrome as a psychosomatic illness.

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


Patient Education

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