I. Definition
Female urethral syndrome (femal urethral syndrome), also known as symptomatic aseptic urine and aseptic urinary frequency-void discomfort syndrome. It is a group of syndromes characterized by symptoms of lower urinary tract irritation, while routine urine examination and urine bacterial culture are not abnormal.
Normal adults generally urinate on average 4-6 times during the day for men and 3-5 times for women, and 0-2 times at night after going to bed. If the frequency of urination is significantly increased beyond this range, it is considered frequent urination. Frequent urination can be divided into physiological and pathological. Physiological urinary frequency is caused by excessive drinking, nervousness or cold weather; pathological urinary frequency is caused by diseases of the genitourinary system or other systems.
Etiology
The etiology is complex and there are many debates. However, it is divided into two types: non-infectious urethral syndrome and infectious urethral syndrome. Among them, infectious urethral syndrome accounts for about 75% and non-infectious urethral syndrome accounts for about 25%.
(A) Non-infectious urethral syndrome
The pathogenic factors are.
1, there are abnormalities in the external urethral opening: such as the fusion of labia minora adhesions, the fusion of the urethral hymen, and the hymenal umbrella. Its abnormality makes the distance between the urethral opening and the vaginal opening smaller, so that vaginal secretions can easily contaminate the urethral opening and the urethral opening is easily irritated.
(1) Fused labia minora: due to congenital malformation or low estrogen, the labia minora are not separated or the labia minora are adhered due to juvenile vulvovaginitis, covering part of the vaginal opening and urethral opening, resulting in easy access of vaginal contents to the urethra and bladder.
(2) Urethral hymen fusion: when first intercourse, the hymen formation hymen scar such as close to the urethral orifice causes pain and perihymenitis during each intercourse, or pushes the urethra into the vaginal orifice, and the urethral orifice is irritated and often contaminated by vaginal secretion impregnation.
(3) Hymen umbrella: If the hymen is thicker, it can form a large lamellar membrane, covering the vagina and urethra, which affects the discharge of secretions. During urination, it can form urine reflux from the urethral orifice.
(4) The shape of the external urethral orifice: Lin Jinghe and Mei Hua reported that the external urethral orifice of women is divided into fusion type, flap type and dike type (Figure 25 a 1). Among them, 37,6% of the external urethral orifices were of the hole type, 3,8% of the longitudinal cleft type, 42,4% of the posterior edge of the flap type, and 2,4% of the dike type had a thick hymenal base and formed a dike-like bulge behind the external urethral orifice.
(5) The distance from the urethral orifice to the vaginal orifice: Recently, He Chuxu et al. reported that among 372 women, 82 cases (22%) had urethral syndrome, and observed that the distance from the urethral orifice to the vaginal orifice was closely related to urethral syndrome.
The closer the urethral orifice is to the vaginal orifice, the higher the prevalence, and the spacing is below 3mm is significantly higher.
2. Local irritation of the urethra: it can be mechanical or chemical, such as irritation from intra-urethral instrumentation, sexual intercourse; chemical irritation or allergy to contraceptive drugs, bathing fluids, vaginal douches, soaps or disinfectants; allergy to special clothing (such as frequent wearing of chemical fiber underwear) or pigmented underwear. Insufficient water consumption and irritation of the urethra by concentrated urine; irritation of the urethra by increased leucorrhea.
3. Imbalance of sex hormones: Low level of female hormones in menopausal women leads to atrophic vaginitis. Postmenopausal women have less estrogen secretion, making the urethral mucosa atrophy, thinning, and easy to be damaged.
(4) Urethral obstruction: (1) distal: fibrosis of the tissues around the urethra, resulting in narrowing of the distal urethra and narrowing of the external urethral orifice; bulging of the anterior vaginal wall, which can block the external urethral orifice, and due to the bulging of the anterior vaginal wall, the urethra arches upward when lying down, forming a kind of arch bridge, which makes the urethra bend and leads to poor urination. (2) Proximal: urinary tract obstruction such as bladder neck obstruction. Urodynamic examination can be performed in such cases. (3) External urethral sphincter spasm: It is thought that female urethral syndrome is due to spasm of the external urethral sphincter. Urodynamic tests show increased tone of the external urethral sphincter, which is a neurological factor; however, others believe that it is a psychiatric factor and that some of the symptoms of urethral syndrome disappear after the resolution of psychiatric problems. This can explain the rapid onset of the disease and the quick relief of symptoms.
5, psychoneurological factors: only seen in the daytime and before going to sleep, which is an important point of differentiation. It is common in patients with mental stress or hysteria, resulting in spasm of the external urethral sphincter, unstable bladder and abnormal contraction of the bladder forcing muscle. This type is highlighted by symptoms of urinary tract irritation, no bacteriuria, no inflammation of the urinary tract, and ineffective long-term application of antibiotics.
6. Smaller bladder capacity: (1) When the bladder is occupied by tumors, stones, foreign bodies, and ectopic endometrium, it can lead to smaller bladder capacity. (2) Compression of the bladder by organs around the bladder can lead to smaller bladder capacity, such as pregnant uterus, ectopic fibroids. (3) Tuberculous contracture of the bladder.
7. Drugs.
(B) Infectious urethral syndrome
Caused by microbial infections, such as chlamydia and mycoplasma infections, causing urethritis, cystitis triangularis, and vaginitis, cervicitis, and vestibulitis. Because many patients have pus urine, it is difficult to establish the diagnosis only because certain bacteria require special methods of culture, and the general culture is often negative and the bacterial multiplication number is often below 105. However, 3 negative cultures of clean middle urine are required to exclude the possibility of urinary tract tuberculosis, fungal, anaerobic, chlamydial, and gonococcal infections. It is often associated with a history of impure intercourse, and antibiotics for couples together are effective.
III. Diagnosis
Most often seen in middle-aged married women. The pathological basis of this disorder is female vesicourethral dysfunction.
(A) Symptoms
(1) Prominent symptoms of urinary tract irritation: there are obvious characteristic symptoms such as frequent urination, painful urination, urgent urination, discomfort in urination, and still a sense of incomplete urination at the end of urination. Accompanied by a decrease in urine volume.
(2) With reflex lower abdominal or renal area pain. Lower abdominal cramping.
(3) Rarely accompanied by chills and fever.
(4) The onset of symptoms is characteristic and can occur suddenly or disappear suddenly, or recur periodically, both of which are variable in duration or persistent.
(2) Physical signs
Palpation of the anterior vaginal wall shows tenderness at the urethra and bladder neck.
(C) Laboratory tests
(1) Routine urinalysis
No abnormal findings in non-infectious urethral syndrome; in infectious urethral syndrome, only a few leukocytes and pus cells, less than 5 / high magnification field.
(2) Midstream urine culture: no fungal bacteriuria, 3 times of midstream urine bacterial culture were negative. Also exclude the possibility of false negatives of tuberculosis, anaerobic bacteria, fungi, etc. causing urinary tract infection.
(3) Chlamydia and mycoplasma examination
In infectious urethral syndrome, sometimes foci of infection in the bladder, urethra or adjacent organs can be found, and positive chlamydia and mycoplasma tests can be performed.
IV. Differential diagnosis
1. Non-specific urethral infection
In the case of non-specific urethral infection, especially lower urinary tract infection, there are also obvious symptoms of urinary tract irritation, which need to be distinguished from it. Urethral non-specific infection is different from female urethral syndrome: in laboratory tests, routine urinalysis shows a large number of white blood cells, pus cells (>5/high magnification field) and red blood cells; middle urine culture has pathogenic bacteria growth, quantitative culture bacterial count is >105/ml urine.
2.Urinary tuberculosis infection
In case of urinary tract tuberculosis infection, the prominent manifestations are urinary frequency, urinary urgency and urinary pain. The general bacterial culture of urine has no bacterial growth and should be distinguished from it. However, the frequency of urination is obvious at night and is progressive in character; it is accompanied by rice-like pus urine and terminal hematuria; there is often a history of tuberculosis; there is a manifestation of urethral obstruction; the urethra is thick and hard on palpation; there are tuberculosis nodules and ulcers on cystoscopy and urethroscopy.
3.Urinary tract fungal infection
It can show symptoms of urinary tract irritation, and the general bacterial culture of urine has no pathogenic bacteria growth. But it is different from female urethral syndrome. It has the following different characteristics: it is more common in people with diabetes, tumors, immune deficiency and long-term application of antibiotics, hormones, immunosuppressants and indwelling catheters. It is caused by an upstream infection. It is characterized by the discharge of “fungal balls” in the urine, and fungal spores and hyphae can be seen microscopically.
4.Unstable bladder
It can be differentiated by the symptoms of urinary frequency and urgency. But it occurs in the following diseases: diabetes, poliomyelitis, encephalitis, stroke, cerebrospinal bulge, nerve center or peripheral nerve injury. It also occurs when the application of anticholinergic drugs such as atropine and probenecid causes hyperreflexia of the detrusor muscle. It also shows symptoms of urinary dysfunction such as dyspareunia, urinary retention, and urinary incontinence. During the anal examination, perineal sensation is decreased and the anal sphincter is relaxed. During cystometry, the patient is instructed to cough, move around or inject fluid rapidly, which can induce uninhibited bladder contraction. With spina bifida, spondylolisthesis deformity.
V. Treatment
1.Acute attack period: eliminate symptoms as soon as possible, eliminate infection and causative factors.
(1) drink more water and urinate more often; (2) wash the vulva and vagina; (3) apply heat to the lower abdomen and perineum; (4) alkalinize urine: can reduce irritation symptoms, baking Soda 1,0 tid (0,5/tablet). (5) Symptomatic treatment: anti-inflammatory and antispasmodic, analgesic, diuretic, etc. are used. (6) Give antibiotics according to urine culture results. (7) Some cases related to neurological or psychiatric factors can be relieved by giving oral tranquilizer and psychiatric treatment. In elderly postmenopausal female patients, appropriate treatment with small doses of estrogen is also effective. (8) Chinese herbal medicine is mainly used to clear heat and remove dampness. (9) Bladder training therapy to enhance the nervous system’s ability to control urination, reduce the sensitivity of the bladder, and reverse abnormal urination habits. (10) Local medication, using 2% silver nitrate to coat the urethra and bladder neck. (11) Closure therapy, making closure therapy in the proximal urethra or bladder triangle.
2.Surgical treatment: After the infection is controlled, surgical treatment is chosen according to the local situation. (That is, surgery is performed only if there is a local problem). In fact, the surgery in this case must consist of three parts: cystoscopy + vestibuloplasty + urethral dilatation.
(1) Vestibuloplasty: separation of the labia minora if the labia minora are fused; dike or flap excision for flap and dike types; for the fused type, lengthening of the urethro-vaginal orifice spacing so that the distance between the external urethral orifice and the vaginal orifice is extended arch to > 1 cm. in cases of distal urethral stricture, excision of the fibrous tissue of the anterior urethral wall or multiple longitudinal incisions are possible (Richardson procedure). (2) Perform cystoscopy (prepare for electroscopy): for the presence of trabeculae in the bladder and for urethral obstruction, mainly bladder neck obstruction, (3) Perform urethral dilatation at the same time as the above procedure to facilitate the flow of urine.