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Urethral syndrome

The diagnosis of this condition will have been made on the basis of repeated attacks of frequency and dysuria with repeatedly sterile MSUs.

The diagnosis of this condition will have been made on the basis of repeated attacks of frequency and dysuria with repeatedly sterile MSUs.

Examine to exclude:

•vaginal infection, especially candida, chlamydia, trichomonas, gardnerella or gonorrhoea

•urethral herpes or warts

•significant anterior prolapse

•atrophic vaginitis.

Arrange for three-monthly MSUs to exclude intermittent infection.

Ask for counts as low as 102 to be reported.Ask the patient to keep a diary of input, output and symptoms for one week, and consider managing as for detrusor instability (see urge incontinence below).

Self-help

Patients should:

•alkalinise the urine, for example, with potassium citrate mixture

•avoid coloured toilet paper, scented soaps, bubble baths, douches, antiseptics, talcum powder, vaginal deodorants and deodorised tampons

•ensure that sexual intercourse is not traumatic because of, for instance, lack of lubrication.

Do not treat with antibiotics, as overgrowth with lactobaccilli and candida may be encouragedIf symptoms are disabling, refer to a urologist.

Urge incontinence

Advise patient to reduce excessive fluid intake and try avoiding caffeine.

Suggest bladder retraining as this can cure or improve the condition. Instruct the patient to:

•keep a frequency/volume chart for a week;

•return for discussion of the pattern the diary reveals. In addition, check that the total volume of urine passed does not suggest that the patient is drinking too much

•practise holding the urine when the urge to pass it is there

•slowly increase the interval between voiding up to three hours.

Anticholinergic drugs are helpful in up to 83 per cent of patients, but are limited by side-effects. Undertake a trial for six weeks and, if it is working, review again after six months.

Use oxybutynin, tolterodine, trospium or propiverine; the last three are more expensive than oxybutynin but may have fewer adverse effects.

Sixty per cent show marked improvement or cure in the presence of detrusor instability. Flavoxate and imipramine are no longer used because of lack of efficacy and adverse effects.

Desmopressin nasal spray in a single evening dose may help night-time symptoms in those aged five to 65 years old, including those with multiple sclerosis.

Oestrogen given orally does not help incontinence in contrast to the conclusions of a Cochrane review based on smaller earlier studies.

The case for local oestrogen is unclear. Refer to a urologist for consideration of augmentation cystoplasty those still sufficiently troubled by symptoms despite treatment and who might need surgery.

This is an extract from Practical General Practice, fifth edition, ISBN 07506 8867X, Elsevier, April 2006, price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000. Practical General Practice is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

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