Causes of Urethral Pain and Treatment Options

Everything you need to know about pain in the urethra

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Pain in the urethra (the tube that passes from the bladder to the outside of the body) can be very uncomfortable. While the pain is often burning in quality (depending on the cause), it can sometimes be severe to the point where the thought of urinating is excruciating. In both men and women, common causes of urethral pain include sexually transmitted diseases (STDs) such as chlamydia, local irritation from soaps or spermicides, and urinary tract infections (UTIs).

In men, prostatitis isn't an uncommon cause, whereas in women, vaginal dryness due to menopause can be an issue. Diagnostic tests may include tests for common STDs, a urinalysis, and further blood tests and imaging studies for the less common causes. The treatment will depend on the specific cause, with treatment of partners of importance in the case STDs.

Causes

The urethra is the tube the passes from the bladder to the outside of the body via the urethral sphincter. There are differences in the structure and function of the urethra in men and women, and these differences can play a role in the different conditions that lead to urethral pain. In female urologic-related anatomy, the urethra serves to carry urine from the bladder to the external sphincter of the urethra and is very short, residing completely within the pelvis. In men, the urethra acts as a conduit not only for urine, but semen, and is much longer, with much of the length lying outside of the pelvis in the penis.

The relatively short urethra in women makes it much easier for bacteria to make their way from the skin to the bladder, leading to a much higher incidence of bladder infections (cystitis) in women.

Many of the causes of urethral pain are the same between the sexes, yet there are also some causes unique to men or women. Possible causes include:

Urethritis

Urethritis is a medical term that means "inflammation of the urethra." This inflammation may be caused by minor issues, such as inflammation and/or contact dermatitis due to spermicides, soaps, semen, and lotions, but is also commonly related to infections, especially sexually transmitted infections.

Possible causes of urethritis in men, as well as women, include:

  • Gonorrhea: Gonorrhea is caused by the bacteria Neisseria gonorrheae, and was, at one time, the most common cause of urethritis. It can cause pain in the urethra, penile discharge in men and vaginal discharge in women (often greenish-yellow), and pelvic pain, among other symptoms.
  • Chlamydia: Chlamydia, and a few of the other diseases listed below, are often referred to as "nongonococcal urethritis." Combined with gonorrhea, they are the most common causes of urethritis. In addition to urethral pain, it can cause penile discharge in men and vaginal discharge in women, pain with ejaculation in men and pain with intercourse in women, though the infection may be asymptomatic as well (but can still cause damage when no symptoms are present).
  • Mycoplasma genitalium: Now the third most common STD in the United States, this infection can cause urethral pain but is often asymptomatic. In women, it is often associated with bacterial vaginosis.
  • Trichomoniasis: Trichomoniasis is an STD caused by a parasite that can cause urethral pain in both men and women. In women, it tends to cause a frothy discharge with a strong odor. Men often note generalized discomfort of their penis as well.
  • Ureaplasma: Ureaplasma differs from other STDs in that many people are asymptomatic and experience few complications. It is, however, often connected with other STDs, and can cause urethral pain.
  • Adenovirus: Adenovirus is a relatively uncommon cause of urethritis, but may cause urethral pain, especially in men.
  • Herpes simplex virus: Infections with herpes, especially the initial infection, can cause severe urethral pain, often combined with visible sores and ulcers externally.
  • Syphilis: The primary stage of syphilis is often characterized by an open sore called a chancre. Unlike herpes, the ulcers are less likely to be painful.

Reactive arthritis (Reiter's syndrome) is another potential cause of urethral pain, with the classic triad being that of postinfectious arthritis (inflammation of joints), nongonococcal urethritis, and conjunctivitis (pink eye) or uveitis (inflammation of the uvea of the eye). It can be associated with chlamydia infections, some gastrointestinal infections (such as Salmonella and Shigella), and connective tissue diseases such as psoriatic arthritis and ankylosing spondylitis.

Urinary Tract Infections (UTIs)

Urinary tract infections often cause urethral pain but they are much more common in women (due to the short length of the urethra), and up to 60 percent of women experience a UTI during their lifetime. In addition to urethral pain, people may experience frequency, urgency, and may notice blood tinged urine.

Interstitial cystitis is a somewhat poorly understood condition characterized by severe urethral pain that mimics a bad UTI, but urine cultures are negative. It's thought by some to be a systemic (body-wide) condition rather than a local condition, and is often associated with other conditions such as fibromyalgia.

Urinary Tract Obstruction/Anatomic Causes

Anything that causes obstruction in the urethra can lead to the buildup of urine that stretches the tissues, causing significant urethral pain. There are many potential causes that may occur within the urethra or externally.

Urethral strictures (narrowing) may develop in people who have had chronic urinary tract infections, have had a catheter for a significant period of time, or have had surgery or radiation that involves the urethra. An enlarged prostate gland can cause narrowing of the urethra from the outside. Tumors such as ovarian cancer, uterine cancer, bladder cancer, or prostate cancer may also press on the urethra, causing an obstruction.

Finally, trauma, such as a pelvic fracture, may result in urethral obstruction and pain. Kidney stones may become lodged in the urethra, though this is much less common than in the ureter. When they occur in the ureter, however, pain may radiate so that it feels as if it's coming from the urethra.

Medications/Foods

Some medications such as Procardia (nifedipine) can be irritating to the urethra and cause pain. Radiation therapy may also result in chronic pain in this region (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, and carbonated beverages.

Trauma

Damage to the urethra either related to a traumatic injury, a procedure such as cystoscopy, or the insertion of a foreign body into the urethra may lead to pain.

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.

Causes Unique to Men

As noted, benign prostate hyperplasia in men can lead to narrowing of the urethra and pain. Other conditions that may result in urethral pain in men include prostatitis (bacterial and nonbacterial), epididymitis, and orchitis, although these conditions often have other symptoms as well.

Causes Unique to Women

Urethral irritation leading to pain is common in women and may be due to spermicides, douches, soaps and lotions, or friction from intercourse. Yeast infections are another common cause and can cause significant discomfort along with itching. Bacterial vaginosis is yet another cause unique to women, and can be very frustrating due to its often chronic nature and associated symptoms including vaginal discharge and a fish-like odor.

In women who are menopausal, vaginal atrophy can lead to urethral pain along with vaginal pain and dryness. When severe, urethral prolapse may occur. Atrophy of the urethra and vagina can also increase the risk of urinary tract infections.

When to See a Doctor

It is never normal to have pain in the urethra, and this symptom should always be evaluated by a physician unless it is transient with a clear cause, such as having an onset immediately after using a new personal care product that stings. That said, some conditions call for more urgent evaluation than others.

You should see your doctor urgently if you have a fever or chills, severe pain, blood in your urine, or are unable to urinate. If your symptoms are mild or intermittent, it's still important to make an appointment.

Untreated infections with chlamydia and gonorrhea can do damage to reproductive organs even in the absence of symptoms and lead to long-term complications.

Diagnosis

The diagnosis of urethritis begins with taking a careful medical history. Your doctor will ask you about any risk factors for STDs, such as a new sexual partner or unprotected sex. She will also ask about any urological problems you have had in the past.

A physical exam is then done with special attention given to the presence of urethral discharge, ulcers, enlarged inguinal lymph nodes, and with men, a physician may gently "milk" the penis by pulling down on the shaft to check for discharge.

The physical may also include an examination of other pelvic regions (such as the scrotum in men and the cervix in women) and an examination of the anus and throat for signs of inflammation. Depending on the results, the physician may order further tests or recommend a referral to a urologist.

Labs and Tests

Lab tests to evaluate urethral pain often include a urinalysis to look for white blood cells or leukocyte esterase as signs as infection, or red blood cells and crystals as a clue to kidney stones. In women, a vaginal and/or cervical swab for STDs is usually done and a urethral swab for men. There are also urine tests for STDs that may be recommended along with—or as an alternative to—the swabs noted. Screening guidelines for STDs include tests for the major STDs such as gonorrhea and chlamydia. If a yeast infection is suspected, a KOH test will be done.

If an infection is present, a urine culture is done to determine the type of bacteria causing the infection, as well as to determine the antibiotics to which the infection is most sensitive (sensitivities).

Other lab tests may include a 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, and a sed rate (ESR), C-reactive protein, and possibly HLA B27 if reactive arthritis suspected.

Imaging

Imaging tests are not often needed to evaluate urethritis, but may be needed in some cases, such as if a kidney infection is present (pyelonephritis), or if kidney stones are suspected. More often, imaging tests are needed to look for complications of sexually transmitted diseases, such as a tubo-ovarian abscess in women.

Procedures

A cystoscopy, a test that involves inserting a narrow lighted tube into the urethra and bladder, may be used to look for the presence of strictures in the urethra or to evaluate people with interstitial cystitis. Sometimes, such as with scarring and strictures, the urethra will need to be dilated to relieve symptoms.

If it's thought that a mass such as a tumor is causing a urethral obstruction, a pelvic CT scan may be needed.

Differential Diagnosis

In addition to the conditions noted above, there are a number of medical conditions that may lead to urethral pain. Lumbar disc disease, spinal stenosis, or cysts on the spinal cord may cause nerve compression. When this involves the nerves that travel to the urethra, pain may feel like it is coming from the urethra. Other conditions that may cause pain include Crohn's disease (especially with fistulas), and endometriosis.

Complications

There are a number of complications that may occur with the common causes of urethral pain, making a proper diagnosis essential.

Untreated STDs such as chlamydia can lead to pelvic inflammatory disease, one of the leading causes of infertility. When pregnancy does occur, there is an increased risk of tubal pregnancy (ectopic pregnancy) that can sometimes be life-threatening. In addition, some of these infections can cause problems during pregnancy, such as preterm births and more. For both men and women, chronic pelvic pain may occur due to the inflammation and damage from these infections, and this inflammation may also result in the enhanced transmission of HIV if exposure occurs.

Non-reproductive and pelvic-related complications of STDs may include things such as septic arthritis and blindness due to gonorrhea.

Urethral obstruction may result in the backup of urine into the kidney, resulting in kidney damage. Chronic urinary tract infections, especially pyelonephritis, may also lead to kidney disease.

Even atrophic vaginitis (vaginal dryness related to menopause) can lead to complications, as it increases the risk of both urinary tract infections and contracting STDs.

Treatment

The treatment of urethral pain depends on the underlying cause. For symptom management, topical lidocaine gel or the medication Pyridium (phenazopyride) may reduce pain (note that Pyridium can turn urine red).

For sexually transmitted diseases due to bacteria, treatment will depend on the particular bacteria causing the disease. Unfortunately, antibiotic resistance is increasing, and it's important that you see a doctor familiar with the latest recommendations. Protozoal infections such as trichomoniasis are treated with drugs for the parasite, and herpes may be treated with antiviral medications. It's important that partners be treated as well.

For urinary tract infections, antibiotics are used as well and cultures are done to ensure the antibiotic prescribed is effective.

There are a number of treatment options for atrophic vaginitis, including lubricants and vaginal estrogen and androgen therapy.

Treatment of urethral obstruction will depend on the cause and may include dilatation if scar tissue or strictures are present, or treatment of a tumor that is pressing on the urethral externally.

Prevention

Fortunately, there are simple measures that can be taken to prevent the more common causes of urethral pain. Safe sex practices, such as always using a condom, limiting the number of sexual partners you have, and getting regular STD testing are important.

Tips for reducing the risk of urinary tract infections include staying hydrated, washing before and after sex, urinating right after sex, and not holding urine. For women, wiping from the front the back, and choosing showers over baths (if UTIs become a problem) may help. Wearing loose cotton underwear and avoiding harsh lotions is also beneficial. For men who are uncircumcised, cleaning under the foreskin regularly may reduce risk.

A Word From Verywell

Because some of the causes of urethral pain are sexually transmitted diseases, people are sometimes hesitant to talk to their doctor. There are many potential causes of urethral pain, and even if you have an STD, these are common and nothing to be embarrassed about. Pain, in general, is our body's way of letting us know that something is wrong, and with urethral pain, listening to your body may not only help you obtain relief from the pain but may prevent or reduce the risk of complications related to many of the causes.

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