Urethral syndrome: symptoms, tests and treatment when urine tests are clear

The urethra is the short tube that carries urine from the bladder to the outside. Urethral syndrome is the name that has been given to a pattern of symptoms, mostly in women, that looks like a urinary tract infection but where the urine culture is negative. Patient.info describes lower urinary tract symptoms of frequency, urgency, dysuria (pain or burning on passing urine) and suprapubic discomfort with no recognised urinary pathogen grown from the urine.

It is a descriptive label rather than a single disease. Patient.info explains that use of the term is now controversial because there are no agreed diagnostic criteria and there is overlap with other diagnoses such as interstitial cystitis. In 2002 the International Continence Society changed the terminology to urethral pain syndrome as part of the group of genito-urinary pain syndromes. You may therefore see several names used for what may be the same set of symptoms.

Presenting features usually include discomfort above the pubic bone, pain or burning on passing urine and needing to pass urine often, according to Patient.info. These symptoms can be intermittent or constant, and can be mild or disabling. They overlap strongly with a bladder infection. The NHS lists pain or a burning sensation when peeing, needing to pee more often than usual, needing to pee suddenly or urgently, cloudy pee, blood in the pee and lower tummy pain among symptoms of a UTI.

The NHS description of bladder pain syndrome is also relevant, because the conditions overlap. It lists bladder pain or pain in the lower tummy or back, feeling like you need to pee even when the bladder is empty, peeing often in small amounts, waking at night to pee and pain during sex. It says symptoms come and go, with flare-ups and better periods.

Do not assume that every burning or frequent urine is urethral syndrome. The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you think you have a urinary tract infection and you have a very high or low temperature, feel hot or cold, or are shivering, if you are a man, if you have diabetes, if your symptoms get worse quickly or do not improve within 48 hours, if you keep getting UTIs, if you are pregnant, if you have pain in the lower tummy or in the back just under the ribs, or if you have blood in your pee.

The NHS says to call 999 or go to A&E if you or someone you care for is confused, drowsy or has difficulty speaking alongside possible UTI symptoms. For bladder pain, the NHS says to see a GP if pain does not go away or keeps coming back, or if you are peeing much more than usual, and to seek urgent help if you have blood in your pee or bladder pain with a very high temperature.

Patient.info says the cause of urethral syndrome is unknown. One theory is that it may be an extension of bladder pain syndrome, and another is that it may be caused by neuropathic hypersensitivity following a urinary tract infection. The reference lists a wide differential that needs to be considered before the label is used.

• Stress incontinence and urinary tract infection.

• Atrophic urethritis and vaginal atrophy in perimenopausal or postmenopausal women.

• Urethritis due to infections such as chlamydia or gonorrhoea.

• Urethral stenosis, including scarring after surgery, and spasm.

• Structural abnormalities such as diverticula.

• Allergy or irritation, for example from nylon underwear, and trauma during sex.

• Vaginal infection and generalised anxiety.

There is no single test for urethral syndrome. Patient.info describes a sequence that starts with a urine dipstick and a midstream urine sample for microscopy, culture and sensitivities, along with a swab for chlamydia or a first-pass urine sample. If chlamydia is negative and symptoms persist, a sample may be taken by other routes and cultured for slow-growing organisms. If no infection is found, a cystoscopy may be considered to exclude non-infective causes. Further investigations may include a pelvic ultrasound, MRI scan, pelvic floor muscle testing, intravenous urography and urodynamic studies.

In the NHS description of bladder pain syndrome, which overlaps with this condition, there is no single test that can diagnose it and you may need several tests to check for other conditions, such as a UTI. The NHS lists a blood test, a urine test, a physical examination of the pelvis, an ultrasound scan, a cystoscopy and measuring the pressure inside the bladder. A GP will usually do an abdominal and pelvic examination as part of the assessment.

Treatment is led by what is found. Patient.info says that infections such as urinary tract infection and chlamydial urethritis are treated as indicated, and that vaginal oestrogen cream may be curative in patients with atrophic urethritis. Behavioural therapy, including biofeedback, meditation and hypnosis, has been used with some success, and exercise and massage programmes can be very helpful. Highly acidic foods, including spicy foods, should be avoided. The reference also says urethral dilatation is now only performed if true urethral stenosis is found because there is little evidence it works and it may cause scarring.

The NHS advice for bladder pain syndrome gives a practical set of measures that many people with similar symptoms find useful. It suggests keeping a food diary to identify foods and drinks that make symptoms worse, taking regular low-impact exercise such as walking, swimming or yoga, trying relaxation techniques, and not having too much spicy or acidic food, alcohol or caffeinated drinks. It also lists physiotherapy to strengthen the pelvic floor, bladder retraining, help with managing long-term pain and mental health support as treatment and support that can help.

Patient.info says symptoms usually improve with age but may be lifelong, and that chronic pain may have a severe psychological impact. Persistent urinary symptoms can interfere with sleep, work and intimacy, and it is reasonable to ask for help with each of these. A pain management or specialist urology service can be an option if symptoms remain troublesome.

Keeping a bladder diary of what you drink, how often you pass urine and when pain is worse gives a clinician something concrete to work with and can reveal patterns. If treatment for infection has not helped and tests are clear, it is reasonable to ask about the next steps, for example whether bladder pain syndrome or atrophic changes are being considered.

On the NHS, the GP carries out the first tests and may refer to urology, gynaecology or a bladder pain service if symptoms persist. Some people choose a private urologist or urogynaecologist for a quicker cystoscopy or a second opinion. The key questions are the same on either route: what has been excluded, what is the working diagnosis and what is the plan if the first treatment does not help.