Urethral Syndrome Treatment & Management

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. The urologist must gain the confidence of these patients and should provide assurance and encouragement throughout therapy.  

Medications include the following:

• Hormone replacement
• Anesthetics
• Antispasmodics
• Tricyclic antidepressants (TCAs)
• Muscle relaxants
• Alpha blockers
• Mucosal protecting agents such as oral elmiron
• Local corticosteroids
• Antibiotics

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. Increased fluid intake has been suggested to decrease the potassium concentration in the urine.

A nationwide survey of Swedish clinics identified 19 methods in use for treatment of urethral pain syndrome, with local corticosteroids and local estrogens being the most common; in addition, more than half the clinics used antibiotics. The survey included public gynecology, urology, gynecologic oncology, and venereology clinics and one public general practice in every county in Sweden. ^[11]

Topical estrogen has been demonstrated to produce symptom improvement in postmenopausal women with urethral syndrome. ^[12]  

Phillip et al propose that high concentrations of potassium in the urine have toxic effects on the muscles and nerves, providing an ideal environment for the growth of microbes; consequently, they advocate for the use of bactericidal broad-spectrum antibiotics. ^[3]  These authors also note that alpha blockers have been used with variable success in urethral pain syndrome, and postulate that these agents may work by decreasing urethral spasticity, which eliminates turbulence during voiding and allows the urethral mucosa to heal and regenerate the mucosal barrier. ^[3]

Palleschi and colleagues reported significant and comparable symptom improvement with the oral phytotherapeutic product CistiQuer versus intravesical gentamicin plus betamethasone in a randomized study of 60 women with urethral syndrome and trigonitis. The dropout rate and the incidence of infection were higher in the intravesical treatment group. ^[13]

Successful treatment of urethral syndrome with 31 patients with neuropathic medicines has been reported. A group of 31 patients were given 300 mg/day gabapentin, titrated to 600 mg/day. In addition, sertraline was administered at 50 mg/day, titrated to 100 mg/day in four patients and increased to 200 mg/day in three patients. Significant improvement in symptoms and symptom-related anxiety was observed. Sertraline may also have had a positive impact by decreasing pain-related anxiety with its anxiolytic effect. ^[14]

Acupuncture and electroacupuncture have been used in China with some short-term benefits. ^[15]  However, the lack of adequate scientific data and expertise by Western physicians in the practice of acupuncture significantly hinder its widespread practice.

Botulinum toxin (OnabotulinumtoxinA) injections have shown some promise in treating urethral symptoms that occur with other dysfunctional voiding conditions. ^[16] However, studies have yet to be performed for its use in urethral syndrome.

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 (Medtronic, Minneapolis, MN) 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. Interstim is approved by the US Food and Drug Administration (FDA) for the treatement of urinary retention and symptoms of overactive bladder, including urgency urinary incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatment. 

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. ^[17]

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 or pelvic floor therapy can provide support and relief to some patients with urethral syndrome.

Intake of foods and liquids that are excreted as irritants in the urine may worsen symptoms. Oral hydration is important as concentrated urine may act as a bladder irritant.

Patients should 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. 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.

Alcohol and other beverages that may worsen syndromes include the following:

• Beer
• Champagne
• Liquor
• Wine
• Coffee (decaffeinated, regular)
• Soft drinks (eg, cola)
• Carbonated beverages
• Tea (decaffeinated, regular, iced)

Condiments that may worsen syndromes include the following:

• 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 that may worsen syndromes include the following:

• Apples
• Bananas
• Cantaloupe
• Grapefruit
• Grapes
• Kiwi
• Lemon
• Lime
• Mango
• Nectarines
• Oranges
• Peaches
• Pears
• Pineapple
• Plums
• Star fruit
• Strawberries
• Tomatoes (all varieties)

Juices that may worsen syndromes include the following:

• 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 that may worsen syndromes include the following:

• Bleu cheese
• Caesar
• French
• Honey mustard
• Italian
• Poppy seed
• Ranch
• Thousand Island
• Vinaigrette

Snacks that may worsen syndromes include the following:

• Applesauce
• Chocolate
• Gelatin (eg, Jell-O)
• Any spicy snacks

Vegetables that may worsen syndromes include the following:

• Beets
• Cabbage
• Canned or jarred artichokes
• Peppers (green, red)
• Hot peppers (eg, jalapeño)

Miscellaneous foods that may worsen syndromes include the following:

• Olive oil
• Chili
• Pizza sauce
• Marinara sauce
• Tomato sauce
• Tomato soup

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.

Increased fluid intake is advisable. 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.

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. 

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.

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.