What causes urethral pain during urination?

Urethral Pain During Urination: Causes and Management

Urethral pain during urination is most commonly caused by urethritis—inflammation of the urethra typically due to sexually transmitted infections (Neisseria gonorrhoeae and Chlamydia trachomatis) in sexually active individuals, or by urinary tract infections, urethral strictures, and less commonly by trauma, dermatologic conditions, or interstitial causes. 1, 2, 3

Primary Infectious Causes

Sexually Transmitted Urethritis

• In sexually active men under 35 years, the two bacterial pathogens of proven clinical importance are N. gonorrhoeae and C. trachomatis, which account for the majority of cases. 1, 2
• Asymptomatic infections are extremely common—many patients have no symptoms despite active, transmissible infection. 1, 2
• Additional pathogens include Mycoplasma genitalium (increasingly recognized), Ureaplasma urealyticum (20-40% of non-gonococcal cases), and Trichomonas vaginalis (2-5% of cases). 1, 4, 3
• Herpes simplex virus occasionally causes urethritis. 1

Urinary Tract Infection

• Lower urinary tract infections (cystitis) are the most common cause of acute dysuria overall, particularly in women. 5, 6
• In men over 35 years, urinary symptoms are more likely due to Gram-negative enteric organisms (E. coli, Klebsiella, Enterococcus), especially with history of urinary instrumentation or anatomical abnormalities. 2, 7

Structural and Obstructive Causes

Urethral Stricture Disease

• Urethral stricture should be included in the differential when patients present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infections, and rising post-void residual. 1
• Common risk factors include history of hypospadias surgery, urethral catheterization or instrumentation, traumatic injury, transurethral surgery, and prostate cancer treatment. 1
• In women, strictures are most commonly iatrogenic from painful or traumatic catheterization, multiple urethral dilations leading to fibrosis, or from blunt pelvic trauma, obstetric complications, malignancy, radiation, or skin diseases like lichen sclerosus. 1

Urethral Trauma

• Urethral injuries are uncommon but mostly affect males following blunt trauma, divided into anterior (bulbar and penile) and posterior injuries (prostatic or membranous urethra). 1
• Penetrating injuries require immediate surgical evaluation when clinical conditions allow. 1

Non-Infectious Inflammatory Causes

• Foreign body in the urinary tract can cause localized inflammation and pain. 6
• Dermatologic conditions including lichen sclerosus and lichen planus affect the urethra and cause painful urination. 1
• Urethral pain syndrome involves persistent or recurrent episodic urethral pain on voiding with daytime frequency and nocturia, in the absence of proven infection—a condition of uncertain etiology requiring multidisciplinary management. 8

Non-Inflammatory Causes

• Medication-related dysuria can occur with certain drugs. 6
• Urethral anatomic abnormalities and local trauma contribute to painful urination. 6
• Interstitial cystitis/bladder pain syndrome presents with chronic urethral and bladder pain. 6
• Human papillomavirus (HPV) has been identified in the urethra of women with recurrent UTIs and urethral syndrome, even without high-risk sexual behaviors, associated with higher rates of bacterial infections. 7

Diagnostic Approach

Initial Evaluation

• History should identify: presence of urethral discharge, sexual activity and risk factors, recent instrumentation, trauma history, and associated symptoms (fever, flank pain, vaginal symptoms). 1, 2, 6
• Physical examination should assess for urethral discharge, meatal erythema, genital lesions, and in women, vulvovaginal irritation. 1, 6

Laboratory Testing

• Urinalysis is essential in all cases to detect pyuria, bacteriuria, and hematuria. 1, 6
• For suspected urethritis: Gram stain of urethral discharge or intraurethral swab showing ≥5 polymorphonuclear leukocytes per oil immersion field, or first-void urine showing ≥10 white blood cells per high-power field. 1, 9, 4, 3
• Nucleic acid amplification testing (NAAT) on first-void urine or urethral swab for C. trachomatis and N. gonorrhoeae is the gold standard. 4, 3
• Urine culture is indicated when UTI is suspected or in cases with complicating features. 6

Advanced Evaluation

• For suspected stricture: uroflowmetry, post-void residual ultrasound, and if indicated, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or cystoscopy to determine stricture location and length. 1

Treatment Based on Etiology

Empiric Treatment for Urethritis (When Diagnostic Tools Unavailable)

• Ceftriaxone 250-500 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 7 days provides coverage for both gonorrhea and chlamydia. 2, 9, 3
• Alternative: Azithromycin 1 g orally single dose can replace doxycycline for improved compliance. 9, 4

Targeted Treatment

• For confirmed gonococcal urethritis: Ceftriaxone 1 g IM/IV single dose PLUS Azithromycin 1 g PO single dose. 4
• For non-gonococcal urethritis: Doxycycline 100 mg PO twice daily for 7 days. 1, 4
• For M. genitalium: Azithromycin 500 mg PO day 1, then 250 mg daily for 4 days; moxifloxacin 400 mg daily for 7-14 days for macrolide-resistant cases. 4
• For T. vaginalis: Metronidazole or tinidazole 2 g PO single dose. 4

Critical Management Requirements

• Patients must abstain from sexual intercourse for 7 days after therapy initiation AND until symptoms resolve AND until all partners are adequately treated. 2, 9
• All sexual partners within the preceding 60 days must be evaluated and treated, as partners are often asymptomatic carriers. 2, 9
• Re-evaluate if no improvement within 3 days—failure to improve requires reassessment of diagnosis and consideration of alternative pathogens. 2

Common Pitfalls to Avoid

• Do not assume all urethral pain is infectious—consider stricture disease, especially with history of instrumentation or weak stream. 1
• Do not treat asymptomatic bacteriuria except in pregnancy, before urologic procedures, or in specific high-risk populations. 4
• Do not perform repeat testing less than 3 weeks after treatment due to risk of false-positive results. 3
• Do not overlook partner treatment—this is mandatory for STI-related urethritis to prevent reinfection. 2, 9, 4
• In women with vulvovaginal symptoms, evaluate for vaginitis rather than assuming urethritis or UTI. 6