There seems little doubt that the “urethral syndrome” has several possible causes, and should be reclassified by the various aetiologies. Since 55% of patients with acute dysuria and frequency do not have “significant bacteriuria”, how should they be treated? Many women with acute symptoms are told by the receptionist that there is “nothing wrong” when they telephone for their mid-stream sample of urine result. This leaves the patient confused and angry.
As previously discussed, some women do have counts of 102, which should be considered as “significant”. However, this level of bacteria would be reported as “no growth” by a laboratory using the Kass criteria. Stamm is a strong advocate that many of these women actually have a bacterial infection, despite a “negative” culture. He argues that women with less than 105 c.f.u./ml should not be ignored if they have symptoms. Often they have low counts because they are early in the infection, and can be shown to achieve counts of 105 over the following few days. Other reasons for a low bacterial count are a rapid urine flow because the women is drinking so much, a low urine pH <5 decreases the ability of E. coli to multiply, and possible bacteriostatic agents in the urine from over-the-counter preparations, or cranberry juice. Stamm claims that 95% of dysuric women with proven pyuria have treatable infections.
Chlamydia trachomatis is certainly an underdiagnosed cause of urethritis in sexually active women with pyuria. The prevalence of Chlamydia infection varies between 2 and 12% in general practice populations. Women under the age of 25 with a recent change of sexual partner, who do not use barrier contraception, are the major “at-risk” group. They may also present with a mucopurulent vaginal discharge. On examination the cervix is friable and there is sterile pyuria. The difficulty of detecting Chlamydia in general practice is one that needs to be addressed, as many of these women go undiagnosed and untreated, and their contacts untraced. If cervical abnormalities are detected, such patients should be investigated for Chlamydia according to locally agreed protocols. The long-term sequelae of possible pelvic inflammatory disease and ectopic pregnancy must be avoided. The actual risk to an individual from one episode of Chlamydia has not yet been quantified.
There is still a group of women who have dysuria and pyuria who do not have Chlamydia or more than 102 uropathogenic E. coli. Rosamund Maskell advocates that these women have fastidious micro-organisms that need to be grown in carbon-dioxide-dependent cultures. There is still controversy about these “fastidious” bacteria, and her work has not been supported by other researchers in the field.
O’Dowd, feels that the syndrome has much more in common with the irritable bowel syndrome than it does with urinary tract infection. They may coexist within the same patient and he feels that these women may receive unnecessary courses of antibiotics without giving support and understanding to the psychological aspects that may be causing somatization in women who have no clear infective aetiology for their urethral symptoms.
As there has really been no satisfactory explanation for this group of women with symptoms but no isolated causative agent, this group have naturally given up on conventional medicine and turned to self-help. Women have tried changing their diet to a ketogenic one on the understanding that this might change the local environment and pH of the urethra. Women also try excluding caffeine (tea, coffee, and cola drinks), which excites the detrusor muscle of the bladder. They may try making their urine alkaline, or acid, since the optimal pH for E. coli is pH 6 – 7. If the pH is changed, some women find symptomatic relief.
However, there remains an unhappy, untreated, symptomatic group of women who have the diagnosis of urethral syndrome with (at present) no underlying aetiological factor. This group needs to be studied further.