AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

In 1949, Powell and Powell coined the term urethral syndrome. Presenting symptoms were frequency and dysuria without demonstrable infection. Urethral syndrome is present in one quarter of patients presenting with lower urinary tract symptoms.

Urethral syndrome, or frequency-dysuria syndrome, is characterized by frequency, dysuria and suprapubic discomfort without any objective finding of urological abnormalities. It is characterized by sterile urine culture results and urinary frequency during the day more than during the night. Dysuria or constant suprapubic discomfort is partially relieved by voiding. Patients also may report of difficulty in starting urination, slow stream, and a feeling of incomplete emptying of the bladder. Most patients are women aged 30-50 years. Vaginal discharge and vaginal lesions must be excluded. History is important, and diagnosis is by exclusion.

Pathophysiology

In urethral syndrome, the etiology is unknown. Historically, urethral stenosis was thought to be the cause of urethral syndrome. Currently theorized etiologies include hormonal imbalances, inflammation of the "female prostate" (Skene glands and the paraurethral glands), a reaction to certain foods, environmental chemicals (eg, douches, bubble bath, soaps, contraceptive gels, condoms), hypersensitivity following urinary tract infection, and traumatic sexual intercourse. Regardless of the initial pain-causing event, the patient has 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. Often, the original cause of the pain has healed, but the pelvic floor dysfunction persists and is worsened by patient anxiety and frustration with the condition.

Frequency

United States

Exact incidence of the disease is unknown because of a lack of consensus in diagnosis.

Mortality/Morbidity

Urethral syndrome is not a fatal condition; however, patients are often miserable because of urinary hesitancy, frequency, and dysuria.

• As a result of the unrelenting symptoms, many patients have concomitant depression, anxiety, or other secondary psychologic morbidities from the condition. The coexistence of neurosis has prompted many physicians to categorize urethral syndrome as a psychosomatic illness.
• Many patients seek out multiple physicians in order to secure relief from their symptoms and are at risk for polypharmacy and narcotic abuse.

Race

Urethral syndrome is more common in white women in westernized civilizations than in women of other races or groups.

Sex

Urethral syndrome occurs more often in females than in males.

Age

Patients are typically aged 13-70 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Usually, a female aged 13-70 years reports suprapubic discomfort, dysuria, and frequency. History is important, and the diagnosis is one of exclusion. A history of smoking or gross hematuria should hasten further evaluation to rule out bladder tumor or carcinoma in situ.

• Urinary complaints: These are the usual focus of the patient, but other aspects of patient history and symptoms must also be evaluated.
• • Frequency: Patients report urinary frequency, ie, every 30-60 minutes during the daytime, with minimal nocturia.
  • Suprapubic pain: Patients report suprapubic discomfort, but this is neither constant nor as severe as in interstitial cystitis (IC). Pain may be relieved by voiding. At night, the pain is not severe enough to disturb sleep.
  • Dysuria: The patient often describes a sensation of constant urethral irritation rather than the searing discomfort with urination that is reported by patients with an active lower urinary tract infection.
  • The Bristol Female Lower Urinary Tract Symptoms (BFLUTS), Urogenital Distress Inventory (UDI-6), and the International Prostate Symptom Score (I-PSS) questionnaires may be useful tools.
• Other pelvic complaints: Associated bowel symptoms, menstrual complaints, and dyspareunia may suggest pelvic floor muscle dysfunction. Irregular or excessive menstruation may indicate a gynecologic abnormality and may warrant referral for gynecologic assessment, especially in postmenopausal women. Timing of the last menstrual cycle may also suggest pregnancy as an etiology for urinary frequency.
• Sexual history: Contraceptive methods (many contraceptive gels and condoms are irritative) and sexual activity (rough intercourse, prolonged oral sex, and intercourse in a heavily chlorinated hot tub or in a shower using bath soap as a lubricant may be the etiology of urethral irritation) may elicit an etiology. A history of sexual abuse has been correlated with pelvic floor muscle dysfunction.
• Habits: Prolonged driving in vehicles with limited shock-absorbing mechanisms (eg, buses, trucks), horseback riding, and long-distance biking can result in urethral irritation. These are more commonly the etiology in men with urethral syndrome than women with urethral syndrome. Women may acquire symptoms from wearing tight thong underwear or blue jeans (especially when worn without underwear).
• Medications and past medical history: Diuretics can cause urinary frequency, as can lithium if secondary diabetes insipidus develops. Cholinergic cold and sinus preparations increase the tone of the bladder neck and proximal urethra and can cause symptoms in some individuals. Prior medical conditions are also important, especially pelvic surgery or radiation therapy.
• Neurological symptoms: Frequent falls, limping, or other neurological symptoms may suggest a CNS problem. Multiple sclerosis has a propensity to strike women at the same age as urethral syndrome, and vague bladder symptoms are often the initial presenting symptom of this disease.

Physical

Diagnosis is made by excluding infection and local vaginal conditions such as genital herpes and other vaginitis. Physical examination findings are usually unremarkable; however, upon genital examination, a cystocele or atrophic urethritis may be found.

• Pelvic examination
• • Initially, the inner thighs and outer labia should be inspected for sensation (sharp vs dull end of a broken cotton-tipped swab works well). Localized hypersensitivity can be an indication of shingles (herpes zoster), even in the absence of skin manifestations. Global hypersensitivity or hyposensitivity may suggest a neurological condition.
  • An initial inspection should be performed to evaluate for ulcers or inflammation caused by herpes, yeast, or other infectious agents. Standard culture swabs and specialized swabs for viral, gonococcal, and chlamydia cultures should be available so that specimens can be obtained at the time of the examination, if indicated.
  • The labia and other external genitalia should be carefully inspected for erythematous patches or white, heaped-up epithelium, which may indicate condyloma or squamous cell carcinoma. Careful examination of the urethra for any lesions is important to exclude urethral prolapse, urethral caruncle, or transitional cell carcinoma. The health of the mucosal tissues should be noted; dry, thin, pale mucosa suggests atrophy, which is usually hormonal in origin.
  • The wall shared by the anterior vaginal wall and the posterior urethral wall should be carefully palpated to exclude masses or stones. Expressed purulent material or a compressible mass detected during this maneuver suggests a urethral diverticulum.
  • The patient should be asked to perform a Valsalva maneuver or cough to assess for urethrocele, cystocele, or rectocele.
  • A speculum examination should be performed to rule out foreign bodies (eg, retained tampons), cervicitis, or other lesions. A Papanicolaou test (Pap smear) should be performed if the patient has not had one in the past year. Many patients have generalized pelvic floor dysfunction and tight pelvic musculature, causing them to experience difficulty with a speculum examination. A pediatric speculum should be available for such situations.
  • The presence of an intact anal wink should be confirmed as part of the pelvic/neurological examination, and a rectal examination should be performed to assess rectal tone and the presence of any masses, rectal/perianal fissures, ulcers, hemorrhoids, or other lesions that may contribute to the patient's symptoms.
• Abdominal examination
• • The presence of any masses or tenderness should be noted. Mild-to-moderate suprapubic discomfort may be present in patients with urethral syndrome, but the pain is not as dramatic as that observed in patients with IC. Uterine enlargement may indicate pregnancy, fibroids, or malignancy and should prompt a pregnancy test, if appropriate, and referral to a gynecologist.
  • Tenderness localized to the pubic symphysis may indicate osteitis pubis, particularly in patients receiving systemic steroid therapy or those with a history of radiation therapy.
• Neurological examination
• • Reflexes, symmetry of strength and sensation, and balance should all be assessed to evaluate for intracranial or spinal cord lesions, lumbar stenosis or disk herniation, or neurodegenerative diseases.
  • For example, multiple sclerosis has a propensity to strike women at the same age as urethral syndrome, and vague bladder symptoms are often the initial presenting symptom of this disease.

Causes

The etiology of urethral syndrome is unknown.

• Historically, urethral stenosis was thought to be the cause of urethral syndrome. The urethral stenosis diagnosis, along with the serial urethral dilations used historically to treat the condition, is appropriate in a very small minority of patients. Also, serial urethral dilatations have fallen out of favor as a ubiquitous treatment for all urethral syndrome patients.
• Unfortunately, a unified alternative etiology for urethral syndrome has not been identified.
• Hormonal imbalances, reaction to certain foods, environmental chemicals (eg, douches, bubble bath, soaps, contraceptive gels, condoms), inflammation of the "female prostate" (Skene glands and the paraurethral glands), localized trauma, hypersensitivity following urinary tract infection, and dysfunction of the pelvic floor musculature have been postulated as causes, without much statistical evidence.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

The distinction between urethral syndrome and mild IC can be particularly challenging. These lower urinary tract pain syndromes may actually simply represent different points along the spectrum of the same general disease process.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• A urine sample should be collected for urinalysis and urine culture.
• • Urinalysis results may show up to 3 RBCs per high-power field. More pronounced microhematuria or any history of gross hematuria should prompt a cystoscopy to evaluate the bladder and an intravenous pyelogram (IVP) or CT scan 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 per milliliter may be significant, especially when accompanied by symptoms, urine cultures of 100,000 colonies of bacteria per milliliter of urine in a voided specimen (10,000 colonies of bacteria per milliliter in men) confirms a urinary tract infection and should be treated 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 small 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 in order 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 a 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

• 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.
• A cystogram 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, a urethral diverticulum.
• MRI is emerging as possibly superior to cytography in the identification of urethral diverticula.
• In men, a prostate ultrasound examination to evaluate for a prostatic abscess may prove useful.
• Pelvic ultrasound is used to visualize the bladder and bladder neck-trigone and to evaluate the female reproductive organs for masses.

Procedures

• 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 IC. It is also therapeutic for IC patients. Cystoscopy under anesthesia also allows an assessment for bladder masses or stones or squamous cell metaplasia at the bladder neck-trigone, and the performance of bladder biopsies to rule out the possibility of carcinoma in situ. Eosinophilia and mast cells in bladder biopsy samples support the diagnosis of IC. The pelvic examination is also often easier to perform with the patient under anesthesia, and one 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.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The goal of treatment is to relieve the discomfort and frequency. This often involves a trial-and-error approach involving behavioral, dietary, and medical therapy. The urologist must gain the confidence of these patients and should provide assurance and encouragement throughout therapy.

• Medical therapy is discussed in detail in Medication. Medications include hormone replacement, anesthetics, antispasmodics, tricyclic antidepressants (TCAs), muscle relaxants, and alpha-blockers.
• Behavioral therapy, including biofeedback, meditation, and hypnosis, has been used with some success. Biofeedback has the most promise for 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.

Surgical Care

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 performed infrequently 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 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 be dramatically successful in reducing or eliminating symptoms.

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.

Consultations

• The majority of 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 can provide support and relief to some patients.

Diet

Intake of foods and liquids that are excreted as irritants in the urine may worsen symptoms.

• Avoid highly acidic foods. These typically include spicy foods, but a more complete, although not comprehensive, list is provided. Food reactions can be extremely individualized. Some 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 with the introduction of a particular food, that food should be eliminated from the diet on a long-term basis. Suspect foods may include the following:
• • Alcohol
  • • Beer
    • Champagne
    • Liquor
    • Wine
  • Beverages
  • • Coffee (decaffeinated, regular)
    • Soda (eg, cola)
    • Tea (decaffeinated, regular, iced)
  • Condiments
  • • 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
  • • Apples
    • Bananas
    • Cantaloupe
    • Grapefruit
    • Grapes
    • Kiwi
    • Lemon
    • Lime
    • Mango
    • Nectarines
    • Oranges
    • Peaches
    • Pears
    • Pineapple
    • Plums
    • Star fruit
    • Strawberries
    • Tomatoes (all varieties)
  • Juices
  • • 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
  • • Bleu cheese
    • Caesar
    • French
    • Honey mustard
    • Italian
    • Poppy seed
    • Ranch
    • Thousand Island
    • Vinaigrette
  • Snacks
  • • Applesauce
    • Chocolate
    • Gelatin (eg, Jell-O)
    • Spicy crackers
    • Spicy nachos
    • Spicy potato chips
  • Vegetables
  • • Beets
    • Cabbage
    • Canned or jarred artichokes
    • Peppers (green, red)
    • Hot peppers (eg, jalapeño)
  • Miscellaneous foods
  • • Olive oil
    • Chili
    • Pizza sauce
    • Marinara sauce
    • Tomato sauce
    • Tomato soup
• Further decrease acidity in foods. A diet high in vegetables, fruits, and dairy products reduces the acidity of urine. The IC Network has developed low-acid recipes especially 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.
• Increase fluid intake. 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.

Activity

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.
• • In fact, 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 it is a potent antidepressant. Walking regularly for 3 months has been shown to have similar improvements in depression as antidepressant medications.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The choice of medical therapy is determined by the patient's predominant symptoms and probable etiology. Determination of the optimum regimen often involves a combination of medications chosen through a process of trial and error. Evaluation for and treatment of all possible infectious etiologies should be undertaken prior to initiating additional medications.

Drug Category: Hormones

Hormone replacement therapy improves mucosal quality in postmenopausal women and may improve resistance to external irritants.

Drug Category: Tricyclic antidepressants

In low doses, effective at relieving chronic pain by interfering with nerve activity. Commonly prescribed for several chronic pain conditions, including IBS and fibromyalgia. Imipramine (Tofranil) and a host of others may be options to consider when prescribing TCAs for chronic pain. However, amitriptyline (Elavil) is the most extensively tested medication of this type for chronic pain.

Drug Category: Anesthetics

Phenazopyridine hydrochloride (Pyridium) is a prescription pain reliever that works by soothing the bladder lining when excreted into urine. Often prescribed for temporary pain relief after surgery, cystoscopy, or catheterization. Not prescribed for long-term use to control IC symptoms because can build up in the body and cause harmful effects. Pyridium colors the urine a very noticeable orange, and care must be taken to prevent staining of undergarments. Patients who wear contact lenses should be aware lenses also occasionally become stained. Uristat is a nonprescription version of phenazopyridine hydrochloride (Pyridium).

Urised, a blend of atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate, and benzoic acid, acts as an anesthetic and antispasmodic and inhibits bacterial growth. Tolterodine tartrate (Detrol) also acts as both an antispasmodic and anesthetic.

Topical 1-2% lidocaine jelly has been used by some patients for external urethral irritation.

Drug Category: Antispasmodics

Decrease contractility of bladder muscle. Multiple formulations are marketed, including flavoxate (Urispas), hyoscyamine sulfate (Anaspaz), trospium chloride (Sanctura), solifenacin succinate (Vesicare), oxybutynin chloride (Ditropan), oxybutynin chloride ER (Ditropan XL), Urised (blend of atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate, and benzoic acid that acts as an antispasmodic and anesthetic and inhibits bacterial growth), and tolterodine tartrate (Detrol), which is also both an antispasmodic and anesthetic.

Drug Category: Alpha-blocking agents

Alpha blockade can help relieve increased muscle tone at the bladder neck and proximal urethra in men and women and provide relief of symptoms in some. Include prazosin (Minipress) and the more specific alpha-1 blockers doxazosin (Cardura), tamsulosin (Flomax), alfuzosin hydrochloride (Uroxatral), and terazosin (Hytrin).

Drug Category: Sedatives

Increased tone of pelvic floor may respond to pharmacological therapy with sedative effects.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Emotional support and encouragement of the patient are essential. Reevaluation for possible urinary tract infection and malignancy is also imperative whenever symptoms worsen.
• Acupuncture and electroacupuncture have been used in China with some short-term benefits; however, the lack of adequate scientific data and expertise by Western physicians in the practice of acupuncture significantly hinder its widespread practice.
• Botulinum toxin (BOTOX®) injections have some promise in treating urethral symptoms that occur with other conditions, but studies have yet to be performed for its use in urethral syndrome.

In/Out Patient Meds

• Even when an optimum medical therapy is determined, symptoms may wax and wane, requiring further adjustment of the medical regimen.

Complications

• The secondary psychological impact of chronic pain syndromes can be substantial. Consultation with a psychiatrist or pain management specialist may be helpful.

Prognosis

• Symptoms usually improve slowly as the patient ages, but the problem may be lifelong.

Patient Education

• Diet, exercise, and stress reduction are all important to any chronic illness. Biofeedback for pelvic relaxation may also be helpful in these patients.
• For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Cancer and Bladder Control Problems.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider other possible causes of urinary frequency and dysuria: Missed malignancy is the most common reason for litigation in such cases.
• Failure to seek consultation with a psychologist in patients who become suicidal

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Allen TD. Commentary on dysfunctional abnormalities of the urinary tract. Urol Clin North Am. Jun 1980;7(2):357-9. [Medline].
• Barrett DM, Wein AJ. Barrett DM, Wein AJ: Voiding dysfunction: Diagnosis, classification, and management. In: Gillenwater JY, Grayhack JT, Howards SS, eds. Adult and Pediatric Urology. Vol 1. 2nd ed. St. Louis, Mo: Mosby-Year Book:. 1073-5.
• Chen YL, Ha LF, Cen J, et al. [Comparative observation on therapeutic effects of electroacupuncture and manual acupuncture on female urethral syndrome]. Zhongguo Zhen Jiu. Jun 2005;25(6):425-6. [Medline].
• Costantini E, Zucchi A, Del Zingaro M, Mearini L. Treatment of urethral syndrome: a prospective randomized study with Nd:YAG laser. Urol Int. 2006;76(2):134-8.
• Cruz F, Silva C. Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update. Curr Opin Urol. Nov 2004;14(6):329-34.
• Gerstenberg TC, Lykkegaard Nielsen M, Lindenberg J. Spastic striated external sphincter syndrome imitating recurrent urinary tract infection in females. Effect of long-term alpha- adrenergic blockade with phenoxybenzamine. Eur Urol. 1983;9(2):87-92. [Medline].
• Lemack GE, Foster B, Zimmern PE. Urethral dilation in women: a questionnaire-based analysis of practice patterns. Urology. Jul 1999;54(1):37-43. [Medline].
• Schmidt RA. The urethral syndrome. Urol Clin North Am. May 1985;12(2):349-54. [Medline].
• Sugaya K, Nishijima S, Oda M, et al. Transabdominal vesical sonography of urethral syndrome and stress incontinence. Int J Urol. Jan 2003;10(1):36-42. [Medline].
• Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. Dec 2001;166(6):2226-31. [Medline].
• Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain. Dec 1997;73(3):269-94. [Medline].
• Zhang D, Xu Z. [Female prostatitis]. Zhonghua Nan Ke Xue. Jul 2004;10(7):547-8, 550. [Medline].

Article Last Updated: May 22, 2006