Urethral syndrome is a condition in which pain in the urethra (the tube through which urine exits the body) has no identifiable cause. While urethral syndrome has many hallmarks of a urinary tract infection (UTI), which is caused by bacteria, a urine sample will not show signs of bacteria.
Urethral syndrome mainly affects females, causing recurrent bouts of painful urination and spasms. Urethral syndrome has various causes, from prior infections and injuries to decreased estrogen levels during menopause.
The diagnosis involves excluding all other possible causes of urethral pain. Treatment mainly focuses on symptom relief, although surgery may be used in certain circumstances.
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Urethral Syndrome Is Also Known As
- Abacterial cystitis
- Frequent dysuria syndrome
- Genitourinary pain syndrome
- Symptomatic urinary bacteria
- Urethral pain syndrome
What Causes Urethral Syndrome?
Urethral syndrome is characterized by recurrent episodes of urethral pain and dysuria (painful urination) lasting for more than six months in the absence of a proven cause. The condition is not well understood and remains subject to controversy.
Underlying these symptoms is urethral hypersensitivity, which can trigger painful spasms and frequent urination. The decreased production of mucus in the urethra has also been cited as a factor. It can occur due to prior infection, injury, or changes in hormones.
There is no single cause of urethral syndrome, and, in some cases, no clear cause may be found. Some possible explanations include:
- Chronic pelvic pain syndrome (often associated with stress and pelvic floor dysfunction)
- Eating spicy foods or drinking alcohol or caffeine
- Exposure to irritants such as tampons, diaphragms, spermicidal lubricants, and scented bath or hygiene products
- Low estrogen levels in females
- Low-grade infection of the Skene's glands (small glands on the front wall of the vaginathat help lubricate the urethra)
- Medical procedures such as cystoscopy
- Overactive bladder (a functional disorder characterized by bladder spasms and leakage)
- Painful bladder syndrome (early interstitial cystitis)
- Prior or recent urinary tract infection
- Prior pelvic or urethral surgery
- Undiagnosed viral sexually transmitted infections (STIs), such as herpes or human papillomavirus (HPV)
- Urethral injury, including those caused during sex
- Urethral squamous metaplasia (noncancerous changes to the lining of the urethra)
- Urethral stenosis (the narrowing of the urethra primarily due to infection or injury)
A Note on Gender and Sex Terminology
Verywell Health acknowledges thatsex and genderare related concepts, but they are not the same. To accurately reflect our sources, this article uses terms like “female,” “male,” “woman,” and “man” as the sources use them.
Risk Factors
Urethral syndrome mainly affects females but can affect males and children as well.
Some studies have reported that 4 out of every 10 women seeking treatment for dysuria meet the diagnostic criteria for urethral syndrome. Others suggest that 15% to 30% of women with lower urinary tract symptoms (LUTS)have urethral syndrome.
Urethral syndrome can affect people of almost any age. Among women, the highest incidence is between the ages of 20 and 30 and later in life between the ages of 50 and 60.
White Americans appear to be affected more by urethral syndrome than any other racial or ethnic population, although this may be due to higher rates of healthcare access.
Symptoms of Urethral Syndrome
Urethral syndrome involves a complex of symptoms that can vary from person to person, both in their frequency and severity. Classically, the condition is characterized by:
- Intermittent urethral and/or pelvic pain
- Need to urinate frequently (urinary frequency)
- Need to urinate urgently (urinary urgency)
- Pain with urination
- Waking at night to urinate (nocturia)
In addition to physical symptoms, urethral syndrome is associated with high rates of depression, anxiety, and stress, which can heighten pain awareness and sensitivity. Sexual dysfunction is also common.
Symptoms in Males vs. Females
The symptoms of urethral syndrome in males and females are often indistinguishable. With that said, females are more likely to experience dyspareunia (pain with intercourse). This is particularly true with menopausal women who commonly experience vaginal dryness and atrophy (thinning).
Urethral Syndrome vs. Urinary Tract Infection (UTI)
The symptoms of urethral syndrome are largely indistinguishable from those of an uncomplicated urinary tract infection. The main difference between the two is that UTIs are caused by bacteria, while urethral syndrome is abacterial (occurring without bacteria).
With that said, severe UTIs can manifest symptoms uncommonly seen with urethral syndrome, affecting both the upper and lower urinary tract and the body as a whole.
Examples include:
- Blood in the urine
- Cloudy urine
- Fever with chills
- Flank pain
- Nausea or vomiting
- Swollen lymph nodes in the groin
Urethral syndrome also differs from UTIs in that symptoms are chronic (meaning persistent or frequently recurring for more than six months). While some UTIs are chronic, most cases are acute (rapidly appearing and resolving).
How Urethral Syndrome Is Diagnosed
Urethral syndrome is diagnosed by exclusion, meaning that all other possible causes of urethral pain and dysuria need to be explored and ruled out.
This may involve a battery of tests and procedures, including:
- Urinalysis: Used to check for infections in a urine sample
- Urine culture: Used to check for bacteria by growing them from a urine sample
- Estradiol test: A blood test used to measure the main type of estrogen
- Computed tomography (CT) scan: A series of X-ray images used to detect changes or growths in the urinary tract
- Magnetic resonance imaging (MRI): An imaging study able to detect subtle changes in tissues of the urinary tract, including signs of stenosis
- Abdominal ultrasound: An imaging tool using sound waves that is able to detect tumors and growths in the urinary tract
- Transvaginal ultrasound: A type of ultrasound with a probe inserted into the vagina to visualize pelvic organs
- Cystoscopy: A procedure in which either a flexible or rigid scope is inserted through the urethra and into the bladder to inspect it
- Urethroscopy: A procedure similar to cystoscopy that is used to inspect the urethra
- Uroflowmetry: Used to evaluate the flow of urine to detect problems with urinary sphincters (rings of muscle that act as valves in the body)
- Pap smear: A procedure that collects cells from the cervix to check for signs of cervical cancer and high-risk strains of HPV
- STI screening: Involving a panel of blood tests, urine tests, or swabs
Limitations of Urine Testing
Basic urine tests are limited in their ability to detect bacterial infections. For instance, low-grade infections of the Skene's gland can be missed with urinalysis yet still trigger urethral pain and inflammation. The same can occur with embedded infections in which bacteria evade detection by penetrating the bladder wall and lying dormant.
For this reason, some experts recommend a special type of urinalysis, such as the MicroGenDX test, that can detect the DNA signature of bacteria even in minute quantities.
Treatment and Management
The treatment of urethral syndrome is focused on managing symptoms and preventing recurrence. No specific treatment guidelines exist, but many different approaches are used on a trial-and-error basis.
This includes the use of antibiotics, which may be effective for bacterial UTIs that do not show up on a urinalysis or urine culture.
Other treatments commonly used for urethral syndrome are:
- Alpha-blockers (a class of oral drugs commonly used in people with urination problems)
- Antidepressants (such as amitriptyline and nortriptyline often prescribed for chronic pain)
- Bladder training (a form of behavior therapy used to manage urinary frequency and urgency)
- Hormone replacement therapy (used to treat women with low estrogen)
- Mind-body therapies (such as meditation and guided imagery to help manage stress)
- Physical therapy (most commonly biofeedback and pelvic floor massage)
- Topical anesthetics (such as low-dose lidocaine ointments or creams)
- Topical corticosteroids (steroid ointment or creams)
- Topical vaginal estrogen (commonly used during menopause to ease vaginal pain and dryness)
Oftentimes, more than one treatment is used.
Certain lifestyle changes can also help, including avoiding caffeine, alcohol, and spicy foods, at least until symptoms resolve. You may also consider avoiding spermicidal lubricants, scented bath oils and soaps, and feminine hygiene products.
Surgery is not often used for urethral syndrome. However, if a structural abnormality is found that may contribute to the urethral pain (such as urethral stenosis), certain procedures may be considered, such as:
- Urethral dilation (used to stretch the urethra with the temporary placement of a urinary catheter)
- Urethrotomy (a minimally invasive surgery used to remove scar tissue with lasers or cryotherapy)
- Urethroplasty (an open surgery used to repair and reconstruct the urethra)
When to See a Healthcare Provider
Urethral pain may be a sign of a serious, underlying medical condition. Anyone with persistent or worsening pain should see a healthcare provider, ideally a gynecologist or a urinary tract specialist known as a urologist or a urogynecologist (only sees female patients).
Seek immediate medical care if urethral pain is severe and/or accompanied by:
- High fever with chills
- Nausea and vomiting
- Profuse blood in urine
- Profuse, smelly discharge from the urethra
- Severe back, abdominal, pelvic, or back pain
- Urethral bleeding
Summary
Urethral syndrome is a condition characterized by urethral pain and painful urination that occurs in the absence of an infection or any known cause. The condition is more common in women and, unlike urinary tract infections, is long-lasting and persistent.
Urethral syndrome may be the result of many factors, ranging from prior infections and injuries to changes in hormones and irritants. The diagnosis is based on the elimination of all other possible causes. Treatment of urethral syndrome may involve antibiotics, antidepressants, topical estrogen or steroids, physical therapy, and, in rare cases, surgery.
