What Is Urethral Pain Syndrome

Overview

Urethral pain syndrome (UPS), formerly called urethral syndrome, can be defined as pain localised to the urethra, which is the tube that transmits urine from the bladder to the outside of the body during urination. It is characterised by an unpleasant sensation in the urethra, dysuria (painful urination), urinary frequency, and urgency for a period of more than 6 months, with no identifiable cause. People of any gender, race, or age can have urethral syndrome. However, it is more common in Caucasian people assigned female at birth of childbearing age. Due to the similarity in the symptoms associated with UPS and those of other pelvic conditions, diagnosis of UPS may be difficult at times. Therefore, it is hard to give an accurate estimate of the incidence and prevalence of UPS. Nevertheless, it has been suggested that the prevalence in the UK might be up to 20-30% of all adult women.^1,2,3

Symptoms of UPS

UPS is a complex condition and can present with a variety of symptoms that are common in other urological disorders. However, one characteristic feature of UPS is the absence of proven infection.

• Dysuria
• Urinary urgency
• Urinary frequency
• Nocturia (waking up at night to urinate)
• Persistent/ intermittent urethral and/ or pelvic pain
• Urinary retention (difficulty urinating)
• Dyspareunia (painful intercourse)
• Hematuria (blood in urine)^4,5

Causes of UPS

The exact cause of UPS is unknown; however, multiple mechanisms have been proposed, including:

• Sensory dysfunction

After an Urinary Tract Infection (UTI), patients can develop increased sensitivity of the nerves in the urethra, resulting in UPS. This neurologic dysfunction in UPS results in abnormal processing of sensory information, causing pain in the urinary tract.¹

• Pelvic floor dysfunction

An impairment in the muscles, ligaments, and connective tissue of the pelvic region prevents you from being able to correctly coordinate and relax your pelvic floor muscles and have a bowel movement. This results in increased pelvic floor tension and pain becoming chronic and indefinite.¹

• Psychogenic factors

Some of the studies involving people with UPS showed that several patients had a psychological component to their symptoms. Patients with UPS often demonstrate high levels of anxiety and depression. Several patients also scored high on the hypochondriasis, hysteria, and schizophrenia scales. Nevertheless, it is not very clear if the psychogenic factor is a cause or a by-product of the failure to adequately manage this painful condition.^1,2

• Diet

Some studies suggest that certain foods (such as citrus fruits, cocoa, nuts, pepper, condiments, tomatoes, hot and spicy foods, caffeine, and alcohol) act as triggers, irritating the urinary tract, which in turn exacerbates the inflammation and the pain episodes associated with UPS.¹

• Urethral spasm

Increased spasticity (muscle tone and stiffness) of the external urethral sphincter has been reported in patients with UPS.²

• Bladder outlet obstruction

An anomalous congenital fibrous band encircling the female urethra just near the external meatus causes urethral stenosis in girls.¹

• Infectious

Patients with UPS have low bacteria counts and no polymorphonuclear leukocytes (a type of white blood cell with immune activity) in the urine. Therefore, it is doubtful for bacterial infections to be the primary cause of UPS, but they might be secondarily involved in the exacerbation of the condition.²

• Female prostatitis

In females, UPS may initially develop from an infection in the paraurethral glands, which are similar to the male prostate. If this infection becomes prolonged, chronic inflammation develops and leads to neurologic changes that produce pain. Therefore, UPS can be considered as female prostatitis.^1,2

• Hypoestrogenism

Due to the urethra’s sensitivity to the hormone oestrogen, having low levels of oestrogen causes hypersensitivity within the vagina and urethra and hence aggravates the symptoms of UPS. ^1,2

Diagnosis of UPS

Because of the nonspecific symptoms the UPS presents with, it often gets misdiagnosed and confused with other diseases such as interstitial cystitis, bladder pain syndrome, or overactive bladder.⁵ UPS diagnosis is mainly based on symptoms as well as the exclusion of other obvious causes of lower urinary tract pathology. These include urinary tract infections, vaginal infections, sexually transmitted infections (STIs), atrophic vaginitis, bladder cancer, Bartholin’s gland cysts or infections.¹

A urologist will ask you for your symptoms as well as for your medical history, including surgical, gynaecological, and sexual histories.¹ Usually, the minimum duration of symptoms required for the diagnosis of UPS is 6 months.⁵ The urologist will also perform an internal (pelvic) and external physical exam as well as request some lab and/or other diagnostic tests such as:

• Urinalysis and urine culture with a post-void residual (to rule out urinary tract infections and urinary retention)
• Renal/bladder/ pelvic ultrasound (to look for any stones and rule out cysts, tumours and other conditions)
• Pelvis MRI (to look for urethral diverticulum, assess bladder capacity and function, and rule out interstitial cystitis)¹
• Bacterial vaginosis test 
• Pap smear (to rule out cervical cancer)
• Urine cytology (to rule out bladder cancer)
• Vaginal swabs (to rule out fungal infections and STIs)

In the case of having blood in urine, the urologist may suggest doing a CT scan and possibly a cystoscopy with or without a bladder biopsy as appropriate. The CT scan checks the upper urinary tract, while the cystoscopy views the inside of the urethra or bladder and checks for abnormalities.¹

Treatment of UPS

According to the European Association of Urology (EAU), treatment for urethral pain syndrome should be multidisciplinary and take a ‘trial and error’ approach. This is due to UPS being difficult to manage and exhibiting a high failure rate. Before deciding on the treatment plan, the urologist should discuss with you the available options and identify which aspects are more important to you.¹

Conservative therapy 

Conservative therapy includes behavioural management such as:

• Stress reduction

It is one of the behavioural strategies to decrease triggers. Examples of stress reduction activities are yoga and meditation. Daily sitz baths are also recommended so as to relieve the perineal region.^1,2

• Diet

Removal of irritants reduces the inflammation in the urinary tract. Irritants include citrus fruits, alcohol, caffeine, and hot and spicy foods. Supplementation with sodium or potassium bicarbonate, as well as increasing water intake, renders the urine more basic, causing less urethral irritation. ^1,2

• Pelvic floor treatments

Include pelvic floor muscle therapy and/or biofeedback, an alternative approach that improves your physical and mental health by changing the way your body functions.¹

Local treatments

• Oestrogen replacement makes the vaginal environment more acidic and hence reduces the incidence of UTIs.
• Urethral Instillations, where anti-inflammatory medications are applied directly to the urethra. This method is more beneficial for women.^1,2

Systematic treatments

• Antibiotics

Antibiotics should only be used in cases of infection proven by bacterial culture and not used as the first line of therapy in UPS. Many UPS patients have a past history of UTIs and have low undetected bacterial counts that may become pathogenic upon chronic infection.^1,2

• Analgesics

Analgesics such as NSAIDs and other anti-inflammatories are commonly used to control pain, whereas opioids are generally not recommended for the treatment of UPS.¹

• Alpha-blockers and Muscle relaxants

Alpha-blockers act by relieving increased muscle tone at the bladder, neck, and proximal urethra. Muscle relaxants help with pelvic floor/sphincter spasms.

Commonly used alpha-blockers include doxazosin, terazosin, and tamsulosin.^1,2

• Anticholinergics and Beta-3 agonist

Anticholinergics are used to relieve bladder-related symptoms like urinary frequency and urgency. Beta-3 receptors contribute to urethral smooth muscle relaxation. Mirabegron is the first Beta-3 agonist used to treat overactive bladder syndrome.¹

• Anxiolytics and Antidepressants

Both anxiolytics and antidepressants have been shown to play a crucial role in therapy. Selective serotonin receptor inhibitors are used for their antidepressant properties, while tricyclic antidepressants are beneficial for not only improving mood but also for decreasing chronic pain. However, more long-term efficacy studies are required.^1,2

Psychological support

UPS patients should be regularly followed up on by their urologist or healthcare provider and provided with education, encouragement, and reassurance. Supportive psychotherapy is an integral component of management that can decrease the need for antidepressants and anxiolytics. ¹

Invasive interventions 

One example of urethral intervention is urethral dilation, which is a procedure that stretches the sides of the urethra and makes the duct wider. Urethral dilation is not generally recommended because:

• The risks outweigh the benefits.
• This can result in serious complications, including infection, urethral perforation, bleeding, and pain.
• The symptoms can reoccur with time.¹

Summary

Urethral pain syndrome, formerly called urethral syndrome, is a complex condition whose cause is not well established. It has symptoms correlating with many other pelvic conditions and, hence, can easily be misdiagnosed. It is more commonly seen in women of child-bearing age than in men. Symptoms may get better as you get older, but it can also last a lifetime. Therefore, it is very important to consult a urologist who can advise on the proper treatment plan and self-care to be followed.

FAQs

When should I see my doctor?

When you notice any of the urethral syndrome symptoms that last for long periods of time (with either no improvement or getting worse). Especially if conservative therapy such as stress reduction, diet change, and lifestyle change has failed.

What to expect if I am diagnosed with urethral syndrome?

Urethral syndrome may last throughout your lifetime; however, symptoms can decrease over time, especially with proper treatment and lifestyle changes.

Can I treat urethral syndrome alone?

Since urethral syndrome is a very complex condition whose diagnosis and underlying cause are not well established, It is better to refer to a urologist, who can go through your case thoroughly, assess your situation and recommend the best treatment plan.