Urethral pain syndrome (UPS) is defined in the 2014 EAU Guidelines as the occurrence of chronic or recurrent episodic pain perceived in the urethra, in the absence of proven infection or other obvious local pathology. UPS is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. In the June 2014 issue of The International Journal of Urology authors try to explain various aetiologies and the therapeutic approaches for this complex syndrome. Low-grade fastidious bacterial infection with bacterial counts as low as 102/mL in the urine is described as one of the causes. The indiscriminate use of antibiotics in these patients is not recommended. There is some suggestion about the beneficial role of selective usage of suppressive antibiotics along with reassurance and careful follow-up in treating some of these patients with recurrent symptoms. Careful serial sections of wax model reconstructions of the para-urethral Skene’s glands resulted in the finding of inflammatory reactions in and around the ducts and glands in postmortem tissues. These glands branch out from the urethral lumen into the adjacent soft tissue alongside the distal two-thirds of the urethra. Some believe that there is an association between UPS and vulvodynia. Spasticity of the external urethral sphincter has been shown on urethral pressure profilometry. Surgical approaches, such as urethral dilatation, periurethral surgical excision and internal cutting procedures, have all been followed in an attempt to reduce this spasticity. The authors suggest that currently there is no good reason for these invasive surgical procedures, as similar or better results are obtained through the use of ααblockers or muscle relaxants. In another study, it was shown that grand multiparity, delivery without episiotomy, two or more abortions, hospital delivery and pelvic organ prolapse were all associated with UPS. Fluctuation in oestrogen levels can arguably lead to symptoms that mirror UPS. Topical oestrogen in the vagina renders the vagina more acidic, increases the maturation index of the epithelium and reduces the incidence of urinary tract infections. Antibiotics are essentially bacteriostatic with the activity of the microbes being simply suppressed temporarily. Once the antibiotic is discontinued, the bacteria will resume their activity and the symptoms will reappear. Some have advised afflicted patients increase their intake of water aiming to increase the production of dilute urine, thus minimising the concentration of potassium being presented to the leaky mucosal barrier and increasing the physiological washing of this mucosal barrier. Authors believe that the pathophysiology of UPS is identical to that of interstitial cystitis and Elmiron can also be a useful adjunct in the management of the UPS. Many of these patients develop a conversion V-type personality disorder. With appropriate counselling and good supportive care, the incidence of this disorder should decline and hence lead to a diminished need for antidepressants and / or anxiolytics.

Enigma of urethral pain syndrome: why are there so many ascribed etiologies and therapeutic approaches?
Phillip H, Okewole I, Chilaka V.
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Ananda Kumar Dhanasekaran

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