Urethral Syndrome Workup

Updated: Jun 23, 2017
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Laboratory Studies

A urine sample should be collected for urinalysis and urine culture. Urinalysis may show up to three red blood cells (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 computed tomography (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, colony counts of 100,000/mL in a voided urine specimen (10,000/mL 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 low 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

Intravenous pyelography (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. [2] Magnetic resonance imaging (MRI) is emerging as possibly superior to cystography in the identification of urethral diverticula. Ackerman et al reported that MRI may be useful in the identification of pelvic floor hypertonicity (manifested as shortened levator, increased posterior puborectalis angles, and decreased puborectal distances), which may be suggestive of interstitial cystitis/bladder pain syndrome. [3]

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. [2]



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. It is also therapeutic in patients with interstitial cystitis. 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 interstitial cystitis.

The pelvic examination is also often easier to perform with the patient under anesthesia. It 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.