The Female and and in the Male

STEPHEN N . ROUS, M.D.

Professor and Chairman, Department of , M edica/ University ofSouth Carolina, Charleston, South Carolina

Two common urological problems frequently duct. It is about 3 to 5 cm in length and is surrounded encountered by the primary care physician are the by suburethral and paraurethral glands, the ducts of female urethral syndrome and urethritis in the male. which empty for the most part into the distal portion Although I will touch on chronic prostatitis in this of the near the urethral meatus. Normally, discussion, I question whether it is anything but a the urethra is colonized by a certain number of in­ relatively uncommon entity. troital , usually limited to the distal portion of the urethra, and when the bacteria are limited to FEMALE URETHRAL SYNDROME this area, there are usually no symptoms. However, While the female urethral syndrome is neither when bacterial colonization extends to the proximal life-threatening nor even serious, it causes great dis­ suburethral and paraurethral glands, the symptoms comfort to the patient and is probably the most com­ of the female urethral syndrome occur. mon genitourinary (GU) complaint bringing women to the primary care physician. Combined with cystitis Diagnosis it may account for as many as two thirds of the When a patient comes to the physician with outpatient visits to the urologist, at least in my expe­ symptoms of the female urethral syndrome, diagnos­ rience. tic evaluation should be based on the following pro­ The symptoms of the syndrome are: cedures: I. Frequency of voiding with or without burn- I. Urinalysis and urine cultures. The findings in a ing, patient with one or more symptoms will usually show 2. Discomfort in the region of the urethra, a modest of 15 to 20 white cells per high power 3. Pressure low in the pelvis, field . Culturing the urine-aerobic, anaerobic and, in 4. Urgency and/or nocturia, and selected cases, acid fast-is imperative because, un­ 5. Terminal . less negative cultures, which are a feature of the syn­ By far the most common symptom is the frequency of drome, are established, the patient's symptoms may urination with or without burning, and it may occur be confused with bacterial cystitis. with any or all of the other symptoms. 2. Urograms and cystograms. When symptoms Anatomically, the female urethra is homologous persist, an excretory urogram should be done. Usu­ to the prostatic urethra, proximal to the ejaculatory ally the results will be normal, b.ut occasionally there will be a patient with a stone in the distal that This is an edited transcript of the lecture delivered by Dr. can produce the symptoms of urgency and frequency. Rous at the 49th Annual McGuire Lecture Series, December 3, While the patient's bladder is full of the contrast 1977, at the Medical College of Virginia, Richmond, Virginia. Correspondence and reprint requests to Dr. Stephen N. Rous, medium that has come down from the kidneys, she Department of Urology, Medical University of South Carolina, should also be asked to void under x-ray control. Charleston, SC 29403. This will often demonstrate whether or not a urethral

MCV QUARTERLY 14(2): 65-68, 1978 65 66 ROUS: FEMALE URETHRAL SYNDROME/MALE URETHRITIS AND PROSTATITIS diverticulum exists, and the presence of one can for treating this condition such as unroofing the sub­ sometimes mimic the symptoms of the syndrome. If a urethral and paraurethral ducts and fulgurating urethral diverticulum is suspected, the patient should them. additionally undergo a retrograde urethrogram. 3. Vaginal examination. Not only is a vaginal ex­ amination important to check for gynecological pa­ URETHRITIS AND PROSTATITIS IN THE MALE Urethritis is probably the single most common thology but it is useful specifically to detect the pres­ urological problem bringing men to the primary care ence of a urethral diverticulum. This is a readily physician or the urologist. It is defined as inflamma­ detectable mass which varies in size from a pea to a tion, with or without , of any portion of the golf ball and is found in the midline on the anterior urethra and is broken down into specific and non­ vaginal wall. It may or may not have stones in it. specific varieties. 4. and urethroscopy. These proce­ Urethritis is very much more common than dures establish conclusively the diagnosis of the fe­ chronic prostatitis or prostatostasis with which it is male urethral syndrome. In appearance the urethra often confused. This confusion between urethritis will look very similar to a red cobblestone road and and prostatitis is not surprising in view of the ana­ this is called a granular urethritis; the pathology tomical relationship between the urethra and the sometimes extends up into the trigone and is then . The numerous ducts connecting the poste­ called a granular urethro-. rior urethra with the underlying prostate gland allow for a great similarity of symptoms of infection or Treatment between the two. There are several ways in which to treat the female urethral syndrome. Systemic antimicrobial therapy is usually unsuccessful because the anti­ Causes microbials are not able to penetrate the suburethral The etiology of urethritis is almost invariably and paraurethral glands in sufficient quantities. How­ that of sexual contact. It can be by conventional or ever, with some of these patients I have used Fura­ anal intercourse, or, often, fellatio . Since it is well cin* Urethral Inserts® which put the antimicrobial known that bacteria in the mouth can be more viru­ agent in direct proximity to the suburethral and para­ lent than bacteria in the vagina or the anus, fellatio as urethral ducts. It is well worth the time spent to show a source of urethritis should always be kept in mind these patients how to use the inserts. There are two and the patient should be asked about the nature of methods I have found helpful. One method is to put a his sexual contact. mirror on a stool, have the woman put one leg up on There are a number of bacterial causes of ure­ it, and looking into the mirror, guide the suppository thritis. Specific urethritis is caused by the gonococcus into her urethra. She should then lie down and put organism. It affects the anterior portion of the ure­ her legs tightly together for 20 to 30 minutes. The thra initially but will usually involve the posterior other method is best for supple individuals who can portion if left untreated. Mycoplasma, Trichomonas sit upright, put a mirror between their legs, and then vaginalis, and Candida are causes of nonspecific ure­ guide the suppository into the urethra. thritis, as are viruses, gram-positive organisms, and Another means of treating the syndrome is by some others. Bacterial usually affect the urethral dilatation in selected patients. The rationale posterior portion of the urethra. behind this is that the procedure opens the para­ The most common non bacterial cause of inflam­ urethral and suburethral ducts and promotes drain­ mation is urethral "stripping." The affected patient age from the underlying glands as well as stretches does this every time he urinates and as many times in the urethral meatus to promote a more rapid flow of between voidings as privacy will allow. He takes out urine. This procedure is best used in combination his penis, milks it out proximal to distal, and turns it with the urethral inserts. up to look at the meatus to see if there is still some Finally, there are a number of surgical methods discharge. The urethral mucosa is almost as sensitive as the conjunctiva of the eye and if a urethra is • Unfortunately, Furacin inserts have just been removed from traumatized by this vigorous stripping, a minimal the market. An acceptabl e substitute is Protargol Urethral suppos­ discharge will often be produced, particularly in a itories ( 17 %) which can be made-to-order in pharmacies. urethra that has had recent infection in it. It is there- ROUS: FEMALE URETHRAL SYNDROME/ MALE URETHRITIS AND PROSTATITIS 67 fore very important to discourage patients from this post-prostatic massage fourth-glass specimen, the in­ practice. fection is in the urethra. If the opposite is true, the Another much less common cause of urethritis is infection is in the prostate. Bacterial colony counts persistently alkaline urine. A certain number of pa­ from the urethra and prostate range from several tients seem to have urine that has a ph of 6.8 or hundred per cc up to a few thousand per cc. When higher. It may be that such patients consume large these studies are carried out, it will be seen that true quantities of citrus juice which is metabolized to bi­ bacterial infection of the prostate gland is uncom­ carbonate and produces an alkaline urine, or it may mon. There is, however, a condition called pro­ be for other reasons. In any case, during the act of statostasis which occurs more frequently, but not, in voiding, the calcium phosphate crystals, which are my opinion, nearly as frequently as posterior urethri­ precipitated out of solution because of the high ph, tis. Prostatostasis can develop when a man goes from act as irritants to the urethra and continue to irritate feast to famine sexually. The prostatic fluid is made it until the next voiding. continuously in abundant supply and when there is no ejaculation, the prostate gland enlarges and pro­ duces the symptoms already noted in conjunction Symptoms with nonspecific posterior urethritis. The patient The symptoms of anterior gonococcal urethritis should be encouraged to masturbate frequently, and/ include a copious urethral discharge that ranges from or to have intercourse to relieve this condition. Both green to yellow in color; it may at times be whitish. It work equally well as does prostatic massage, al­ is usually accompanied by burning on voiding and a though the latter is the least favored therapy. feeling of discomfort in the penile or anterior urethra. For specific, or gonococcal, urethritis, a culture Rarely, there may be minimal or no urethral dis­ can be obtained from the discharge and, in the rare charge. The symptoms of posterior or nonspecific patient without discharge, from swabbing the distal urethritis are virtually the same as chronic prostatitis urethra. The culture has to be made under increased or prostatostasis. They consist of an itching or burn­ C02 tension on a Thayer-Martin medium. It is best to ing "inside" or at the base of the penis; discomfort or do a smear and see gram-negative intracellular diplo­ itching in the urethra on voiding; and most common, cocci for the provisional diagnosis, but the culture a minimal, clear mucoid urethral discharge on arising should confirm it finally. The treatment of choice for in the morning, or a 2 to 3 cm brownish or yellowish gonococcal urethritis is aqueous procaine penicillin stain inside the patient's shorts that is seen at night. G with probenecid; alternative treatment is ampicillin with probenecid. For patients who are allergic to the Diagnosis and Treatment penicillin group of drugs, spectinomycin and tetracy­ The technique of three-glass urine collection in cline are acceptable alternatives. conjunction with prosta tic massage and/ or the post­ The mycoplasma organisms found with some prostatic massage fourth-glass specimen is used for cases of nonspecific urethritis can be confusing be­ determining the anatomical source of urethral infec­ cause these organisms have been reported in asymp­ tion and more specifically for separating chronic tomatic as well as symptomatic individuals. The or­ prostatitis from nonspecific urethritis. A three-glass ganisms are cultured with a urethral swab or using urine specimen is first obtained, then the patient is the urine sediment, and the mycoplasma organisms asked to hold his urethra tightly shut while the physi­ are identified morphologically and by specific bio­ cian massages the prostate vigorously. After the pros­ chemical and bacteriologic tests. Patients with this tatic massage, the patient is asked to release his ure­ infection are treated with one of the tetracycline thra and a few drops of prostatic secretions will group of drugs, although probably no more than 60% usually come out into the culture tube or onto a slide. to 70% are cured by the medication. If no secretions are obtained, the patient should void is not, in my experience, a few cc of urine into a fourth glass and this will a common cause of urethritis in the male. However, it contain the prostatic secretions. The specimens in the should be considered a possibility particularly if the first, second, and third glasses are then cultured as consort has a trichomonas infection. The organism is are the prostatic secretions or the fourth-glass speci­ seen either on a wet mount of the urine specimen or men. If the first and/or third-glass urine has more in urethral discharge. This infection is best treated bacteria colonies than the prostatic secretions or the with (Flagyl®). 68 ROUS: FEMALE URETHRAL SYNDROME/MALE URETHRITIS AND PROSTATITIS

For those patients. with inflammatory and non­ Inflammation due to urethral stripping can be cured organism causes of urethritis, treatment is relatively by counseling the patient to refrain from this activity. simple. The rare individuals with persistently alkaline The most important point in treating patients urine can be successfully treated with ascorbic acid with nonspecific urethritis is to reassure them that for two to three days until the symptoms disappear. these infections are self-limited, not serious, and will However, care should be taken not to use this means not lead to impotency, sterility, prostatic hyperplasia,. on patients with known uric acid or cystine lithiasis. or prostatic cancer.