Urethral pain

Authors: Jane Meijlink, BA Hons, MCIJ and Sharon Eustice, RN, Bphil, MSc, ALNP

Last Updated: April 2018

Current definition

The symptom of ‘Urethral pain - is perceived to be in the urethra, usually when voiding, with increased day- and night-time frequency. It may be combined with a feeling of dull pressure, and sometimes radiates toward the groin, sacrum and perineum. The terms ‘‘chronic urethritis’’ and ‘‘urethral syndrome’’ are no longer recommended’ (1).

Factors:

Persistent or recurrent pain.
No history of current infection or other obvious pathology.
May be subsequent to a previous urinary tract infection.”

History

Previous ICS definitions include: Urethral pain - is felt in the urethra and the individual indicates the urethra as the site. Urethral pain syndrome - is the occurrence of recurrent episodic urethral pain usually on voiding, with daytime frequency and nocturia, in the absence of proven infection or other obvious pathology (2). ** Other definitions **

International association for the study of pain (IASP) Urethral pain syndrome - is the occurrence of chronic or recurrent episodic pain perceived in the urethra, in the absence of proven infection or other obvious local pathology. Urethral pain syndrome is often associated with negative cognitive, behavioral, sexual or emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction. Urethral pain syndrome may occur in men and women (3).

European association of urology (EAU)

Urethral Pain Syndrome – ‘commonly given to patients who present with pain or discomfort in association with micturition (with or without frequency, nocturia, urgency, and urge incontinence) in the absence of evidence of urinary infection’ Some mechanisms for the development of urethral pain syndrome have been proposed. The intimate relation of the urethra with the bladder (both covered with urothelium) suggests that urethral pain syndrome may be a form of bladder pain syndrome (BPS). Mechanisms thought to be basic for BPS may also apply to the urethra. This means that the specific testing with potassium is used to support the theory of epithelial leakage. Another possible mechanism is neuropathic hypersensitivity following urinary tract infection. The relationship with gynaecological and obstetric aspects is unclear. In a small group of patients with urethral pain, it has been found that grand multiparity and delivery without episiotomy were more often seen in patients with urethral syndrome, using univariate analysis (4).

**Controversy **

Urethral pain can be challenging to distinguish from other pain syndromes (5). Therefore, obtaining a thorough clinical history is fundamental for targeted therapies. However, unravelling the constellation of symptoms can be subjective and nebulous. For those patients undergoing urodynamic investigations, pinpointing pain can be demonstrated (6 ). Is urethral pain part of a syndrome? The urethra doesn’t uniquely present with only one symptom, so because there can be various symptoms; and driven in part by the woman’s perception and interpretation, it could be argued that it is. However, a syndrome is ‘a group of symptoms which consistently occur together, or a condition characterized by a set of associated symptoms’ (https://en.oxforddictionaries.com/definition/syndrome). Therefore, given that urethral symptoms aren’t always consistent, diagnosis can be perplexing (7).

**References **

  1. Doggweiler R, Whitmore KE, Meijlink JM, Drake MJ, Frawley H, Nordling J, Hanno P, Fraser MO, Homma Y, Garrido G, Gomes MJ, Elneil S, van de Merwe JP, Lin AT, Tomoe H. A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. 2017 Apr;36(4):984-1008. doi: 10.1002/nau.23072. Epub 2016 Aug 26.

  2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Victor A, Wein A. Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167-78. (see Abrams et al. 2002).

  3. IASP Classification of Chronic Pain, Second Edition (Revised). Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Available at: https://www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677

  4. Engeler D, Baranowski AP, Borovicka J, et al. European Association of Urology Guidelines on Chronic Pelvic Pain. 2016. Page 22. Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Chronic-Pelvic-Pain-2016-1.pdf

  5. Cho ST. Is Urethral Pain Syndrome Really Part of Bladder Pain Syndrome?. Urogenit Tract Infect. 2017 Apr;12(1):22-27. https://doi.org/10.14777/uti.2017.12.1.22

  6. Veit-Rubin, N., Cartwright, R., Esmail, A., Digesu, G. A., Fernando, R. and Khullar, V. (2017), The location of pain and urgency sensations during cystometry. Neurourol. Urodynam., 36: 620–625.

  7. Fall, Magnus et al. (2010) EAU Guidelines on Chronic Pelvic Pain. European Urology, Volume 57 , Issue 1 , 35 - 48

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