A clean catch or catheterized urine specimen for routine urinalysis and culture should be obtained to rule out urinary tract infection. As indicated, urethral and cervical studies for chlamydia should be obtained, and a wet prep for vaginitis should be performed. Urethral syndrome should be considered if infection is ruled out, the evaluation does not disclose vulvovaginitis, and no allergic phenomenon causing contact dermatitis of the urethra can be detected. The possibility of ureoplasma, chlamydia, candida, trichomonas, gonorrhea, and herpes should be eliminated. Cystoscopic evaluation should be performed to rule out urethral diverticulum, stones, and cancer. Pelvic ﬂoor muscles should be evaluated, as spasm of these muscles can lead to urethral pain and tenderness. The urethral pain can also be a manifestation of bladder pain syndrome.
Various forms of therapy are suggested for urethral syndrome. Those patients in whom no infectious agent is present but who have sterile pyuria may respond to a 2-to 3-week course of doxycycline or erythromycin. Long-term, low-dose antimicrobial prophylaxis often is used in women with urgency and frequency symptoms who had careful documentation of recurrent urinary tract infections. Some of these women may continue to have symptoms when their urine is not infected, and bacterial infection redevelops over time. Posttreatment test of cure cultures are useful. It is recommended that all postmenopausal women with this condition be given a trial of local estrogen therapy for at least 2 months. If there is no improvement after antibiotic or estrogen therapy, physical therapy, and cognitive-behavioral therapy, then urethral dilation can be considered but recent studies are lacking. Positive results were noted with biofeedback techniques. Other treatments including acupuncture and laser therapy proved successful (108). Psychological support is very important in this group of women. Management requires a multidisciplinary approach, as is true of chronic pelvic pain in general.
Interstitial cystitis (IC)/bladder pain syndrome occurs more often in women than men. Most patients are between 40 and 60 years of age. In 2002, painful bladder disorders were defined by the International Continence Society (ICS) in a set of new recommendations (109). The most widely used definition, painful bladder syndrome (PBS) is described as a clinical syndrome (i.e., a complex of symptoms) consisting of “suprapubic pain related to bladder filling, accompanied by other symptoms, such as increased daytime and nighttime frequency in the absence of proven infection or other obvious pathology.” By comparison, the term “interstitial cystitis” refers to patients who have PBS symptoms, but who also have “typical cystoscopic and histological features” during bladder hydrodistension (109).
The etiology of IC/PBS is unknown, but several hypotheses exist. A defective glycosaminoglycan (GAG) epithelial layer, which allows irritating substances in the urine to penetrate the urothelium to the subepithelial nerve endings, may be responsible for the syndrome (110). This theoretical mechanism is based on the fact that many IC sufferers have a positive potassium diffusion test and are sensitive to certain foods and beverages. Immunological mechanisms were proposed because abnormal mast cell activity, increased substance P expressing nerve fibers and increased nerve growth factor, were all found in bladder biopsies of IC affected individuals (110). Autoimmune mechanisms may be responsible in some individuals given that there is a higher incidence of systemic lupus erythematosus, allergies, inﬂammatory bowel and irritable bowel disease, and fibromyalgia in patients with bladder symptoms. Another possible mechanism is central sensitization with altered sympathetic and hypothalamic adrenal axis, substantiated by the existence of “phantom” bladder pain even after surgical removal of the bladder (110).