Causes of Urethral Pain and Treatment Options

Urethra pain may be caused by many underlying conditions, including sexually transmitted infections (STIs), prostatitis, local irritation from soaps or spermicides, and urinary tract infections (UTIs). In addition, menopause can sometimes lead to vaginal dryness, which may also contribute to urethra pain.

People often describe urethra pain as a burning sensation. And since the urethra is the tube through which urine passes from the bladder to the outside of the body, it can make peeing very uncomfortable—sometimes even excruciating.

This article explains the causes, diagnosis, complications, and treatment of urethral pain.

Urethra pain in women and men.

Causes

The urethra is the tube running from the bladder to the outside of the body. Depending on a person's anatomy, there are differences in the structure and function of the urethra. These differences can play a role in the different conditions that lead to urethral pain.

• People with a vagina: The urethra carries urine from the bladder to the external urethral sphincter, located between the vagina and the clitoris. The urethra is very short. This, along with the proximity to the anus, makes it much easier for bacteria to make their way from the skin into the bladder. For this reason, there is a much higher incidence of bladder infections (cystitis) in those with a vagina.
• People with a penis: The urethra not only carries urine out of the body but also semen. It is much longer, with much of the length lying outside of the pelvis in the penis.

Conditions that irritate the urethra can cause urethral pain. The major causes are discussed below.

Urethritis

Urethritis is a medical term that means "inflammation of the urethra." This inflammation may be caused by:

• Contact dermatitis from spermicides, soaps, semen, and lotions
• Infections, especially sexually transmitted infections. You may have heard these commonly referred to as "sexually transmitted diseases," or STDs, but referring to infections is a more general term that covers asymptomatic cases that also need attention.

Possible STIs that can cause urethritis include:

• Gonorrhea: Gonorrhea is caused by the bacteria Neisseria gonorrheae. It was once the most common cause of urethritis. It can cause pain in the urethra, penile discharge, vaginal discharge (often greenish-yellow), and pelvic pain, among other symptoms.
• Chlamydia: Chlamydia, and a few of the other conditions listed below, are often referred to as "nongonococcal urethritis," which is any urethritis not caused by gonorrhea. In addition to urethral pain, it can cause penile and vaginal discharge, pain with ejaculation, and vaginal pain with intercourse. The infection may be asymptomatic, but can still cause damage even when no symptoms are present.
• Mycoplasma genitalium: This infection can cause urethral pain but is often asymptomatic. In people with a vagina, it is often associated with bacterial vaginosis, a change in the balance of bacteria in the vagina.
• Trichomoniasis: Trichomoniasis is an STI caused by a parasite. It can cause a frothy vaginal discharge with a strong odor and generalized discomfort in the penis.
• Ureaplasma: Ureaplasma differs from other STIs in that many people are asymptomatic and experience few complications. It is, however, often connected with different STIs and can cause urethral pain.
• Adenovirus: Adenovirus is a relatively uncommon cause of urethritis. It may cause urethral pain, especially in people with a penis.
• Herpes simplex virus: Infections with herpes, especially the initial infection, can cause severe urethral pain. Visible sores and ulcers often form on the external genitalia. Lesions may also be present on the urethral lining.
• Syphilis: An open sore called a chancre characterizes the primary stage of syphilis. Unlike with herpes, these ulcers are less likely to be painful.

Reactive Arthritis

Reactive arthritis (Reiter's syndrome) is another potential cause of urethral pain. Infections of the eyes, urinary tract, and genitals often accompany this type of joint pain and inflammation. These co-infections can include:

• Postinfectious arthritis (inflammation of joints)
• Nongonococcal urethritis
• Conjunctivitis (pink eye) or uveitis (inflammation of the wall of the eyeball)

Reactive arthritis can be associated with:

• Chlamydia infections
• Some gastrointestinal infections (such as salmonella and Shigella)
• Connective tissue diseases such as psoriatic arthritis and ankylosing spondylitis

Urinary Tract Infections (UTIs)

UTIs often cause urethral pain, but they are much more common in people with a vagina (due to the short length of the urethra). Up to 60% of those with a vagina will have a UTI during their lifetimes. In addition to urethral pain, people may experience:

• Frequent need to urinate
• Sudden need to urinate
• Blood in the urine

Interstitial cystitis is a somewhat poorly understood condition. The severe urethral pain mimics a bad UTI, but urine cultures don't show an infection. It's thought by some to be a systemic (body-wide) condition rather than a localized infection. It is often associated with other conditions such as fibromyalgia.

Urinary Tract Obstruction

Anything that blocks the urethra can lead to the buildup of urine. This buildup stretches the tissues, causing significant urethral pain. There are many potential causes of obstruction, including:

• Urethral strictures: This narrowing of the urethra may be caused by chronic urinary tract infections, having a catheter for a significant period, or surgery or radiation that involves the urethra.
• Enlarged prostate gland: This can press on the urethra.
• Tumors: Growths from ovarian cancer, uterine cancer, bladder cancer, or prostate cancer may also compress the urethra. This pressure can obstruct the urethra and, in severe cases, possibly lead to damage to both kidneys caused by urine backing up (hydronephrosis).
• Trauma: A pelvic fracture, for instance, may result in urethral obstruction and pain.
• Kidney stones: These may become lodged in the urethra, though this is much less common than in the ureter, the tube from each kidney to the bladder. However, when they occur in the ureter, the pain feels like it's coming from the urethra or testis.

Medications/Foods

Some medications, such as Procardia (nifedipine), can irritate the urethra and cause pain. Radiation therapy may also result in chronic pain (radiation cystitis).

There are some bladder-irritating foods, as well, that may irritate the urethra and cause pain. Common culprits include:

• Coffee and tea
• Acidic fruits and juices such as orange juice
• Tomato products
• Chocolate
• Carbonated beverages
• Spicy foods
• Alcohol

Trauma

Damage to the urethra can lead to pain. Examples of trauma include:

• An injury
• A procedure such as a cystoscopy
• Insertion of a foreign body into the urethra

Skin Conditions

Some noninfectious skin conditions, when present near the opening of the urethra, may cause pain. A few of these include psoriasis and lichen sclerosis.

Prostate, Epididymis, and Testicle-Related Causes

As noted, benign prostate hyperplasia can occur in people with a prostate. It can lead to narrowing of the urethra and cause pain.

Other conditions that may result in urethral pain in people with a penis include:

• Prostatitis: Inflammation of the prostate, which may be bacterial or nonbacterial
• Epididymitis: Inflammation of the tubes in the testicle that carry sperm
• Orchitis: Swelling of the testicles

Vaginal Causes

Urethral irritation that leads to pain is common in people with a vagina. This irritation may be due to:

• Spermicides
• Douches
• Soaps and lotions
• Friction from intercourse

Yeast infections are another common cause. These fungal infections can cause significant discomfort and itching.

Bacterial vaginosis is yet another cause related to the vagina. This infection can be very frustrating due to its often chronic nature. Symptoms include vaginal discharge and a fishy odor.

In those who are menopausal, vaginal atrophy can lead to urethral pain and vaginal pain, and dryness. When severe, the urethra can push out of the urethral opening (urethral prolapse). Vaginal atrophy can also increase the risk of UTIs.

Diagnosis

Diagnosis of urethritis starts with a careful medical history. Your healthcare provider will ask you about any possible risk factors for STIs, such as a new sexual partner or condomless sex. They will also ask about any urological problems you have had in the past.

Your doctor will then perform a physical exam. They will pay special attention to the presence of urethral discharge, ulcers, and enlarged inguinal lymph nodes (lymph nodes in the groin). Additionally, they may gently "milk" the penis by pulling down the shaft to check for discharge.

Your doctor may also examine other areas, such as the scrotum, cervix, anus, and throat, for signs of inflammation. Depending on the results, they may order further tests or recommend a referral to a urologist.

Labs and Tests

Lab tests to evaluate urethral pain include a urinalysis. This test looks for:

• White blood cells as signs of infection
• Red blood cells and crystals as a clue to kidney stones or other urologic issues

Screening guidelines for STIs include tests for the major STIs such as gonorrhea and chlamydia. If your doctor suspects a yeast infection, they will also do a KOH prep test. Tests for STIs may involve:

• A vaginal or cervical swab
• A urethral swab
• A urine test for STIs along with—or as an alternative to—the swabs above

Your doctor may do a urine culture to determine if an infection is present. This test can determine the type of bacteria present and its sensitivity to antibiotics. This knowledge helps determine the specific antibiotic that will be most effective in fighting the infection.

Other lab tests may include:

• Complete blood count if you have a fever or other systemic (body-wide) signs of infection
• Kidney function tests including a BUN, creatinine, and electrolytes if there is concern your kidneys may be affected
• Sed rate (ESR), a test for inflammation
• C-reactive protein, another inflammation marker
• HLA B27 if reactive arthritis is suspected

Imaging

Imaging tests are typically not used to evaluate urethritis. However, it may be necessary if your doctor suspects a kidney infection (pyelonephritis) or kidney stones, or if there is a significant amount of blood in the urine.

More often, imaging tests look for complications of STIs, such as an abscess in an ovary or a fallopian tube.

Procedures

A cystoscopy is a test that involves inserting a narrow lighted tube into the urethra and bladder. It may be done to:

• Look for the presence of strictures (swelling or blockage) in the urethra
• Determine cause of red blood cells in the urine
• Evaluate people with interstitial cystitis

Sometimes, if there is scarring and strictures, your doctor may need to dilate (open) the urethra to relieve symptoms.

If your doctor suspects that a mass is causing a urethral obstruction, they may order a pelvic computed tomography (CT) scan to get a better look.

Differential Diagnosis

In addition to the conditions noted above, several medical conditions may lead to urethral pain. These include:

• Lumbar disc disease
• Spinal stenosis
• Cysts on the spinal cord that compress the nerves that travel to the urethra
• Crohn's disease (especially with fistulas)
• Endometriosis

Complications

Some complications may occur with the common causes of urethral pain. These complications make a proper diagnosis essential. Complications include:

• Pelvic inflammatory disease (PID): Untreated STIs such as chlamydia can lead to pelvic inflammatory disease, one of the leading causes of infertility.
• Pregnancy complications: When pregnancy does occur, there is an increased risk of ectopic pregnancy that can sometimes be life-threatening. In addition, some of these infections can cause problems during pregnancy, such as premature birth and more.
• Chronic pelvic pain: This may occur due to the inflammation and damage from these infections. This inflammation may also increase the risk of contracting HIV if exposure occurs.
• Septic arthritis and blindness: Gonorrhea may result in nonreproductive and pelvic-related complications of STIs.
• Kidney damage or disease: Urethral obstruction may back up urine into the kidney, resulting in kidney damage (hydroureteronephrosis). Chronic urinary tract infections, especially pyelonephritis, may also lead to kidney disease.

In addition, even atrophic vaginitis (vaginal dryness related to menopause) can lead to complications, increasing the risk of urinary tract infections and contracting STIs.

Treatment

The treatment of urethral pain depends on the underlying cause. Common treatments include:

• Lidocaine, Pyridium: For symptom management, topical lidocaine gel or Pyridium (phenazopyridine) medication may reduce pain (note that Pyridium can turn urine red).
• Antibiotics: For STIs due to bacteria, treatment depends on the particular bacteria causing the condition. Unfortunately, antibiotic resistance is increasing. So you must see a healthcare provider familiar with the latest recommendations. In addition, antibiotics are the standard form of treatment for UTIs.
• Antiparasitics: Doctors treat protozoal infections such as trichomoniasis with drugs for the parasite.
• Antivirals: Doctors treat herpes with antiviral medications. Partners must be treated as well.
• Lubricants and hormones: There are several treatment options for atrophic vaginitis, including lubricants and topical estrogen and androgen therapy.
• Dilation: Treatment of urethral obstruction will depend on the cause and may include dilation if scar tissue or strictures are present.
• Surgery: If a tumor is pressing on the urethra, your doctor may need to remove it.
  

Prevention

Fortunately, there are simple measures you can take to prevent the more common causes of urethral pain. Safer sex practices can help reduce your risk of STIs. You can make sex safer by:

• Always using an external condom and other barriers
• Limiting the number of sexual partners you have
• Getting tested for STIs regularly

Tips for reducing the risk of urinary tract infections include:

• Stay hydrated.
• Wash before and after sex.
• Urinate before and after sex.
• Don't hold your urine.
• Wipe from the front to the back.
• Choose showers over baths (if UTIs become a problem).
• Wear loose cotton underwear.
• Avoid harsh lotions.
• Clean under the foreskin of an uncircumcised penis regularly.

When to See a Healthcare Provider

It is never normal to have pain in the urethra. So a healthcare provider should always evaluate this symptom unless it has a clear, reversible cause, such as stinging immediately after using a new personal care product. That said, some conditions are more urgent than others.

Untreated infections with chlamydia and gonorrhea can permanently damage reproductive organs. Even in the absence of symptoms, this can lead to long-term complications.

Summary

Urethral pain may be caused by many things, including STIs, trauma, bacterial or fungal infections, and obstruction. To accurately diagnose what is causing pain in your urethra, your doctor will do a physical exam. They may also order labs and imaging tests.

Treatment depends on the cause and may include antibiotics, antiparasitics, antivirals, or symptom management. Urethra pain is never normal. If you have pain in your urethra, be sure to see your doctor.