The irritable urethral syndrome: discussion.
Year: 1985
Type: article
Abstract: T HE symptoms of lower urinary tract disorder are so widespread that the lay term 'cystitis' is deemed to be self-explanatory by both patient and doctor. The urethral syndrome is a symptom complex of frequency, dysuria and a feeling of incomplete bladder emptying in women in the absence of demonstrable infection. The syndrome has become so controversial that not only is there dispute about the causes but also about what it should be called. To understand some of the difficulties clinicians and researchers have found, it is necessary to trace the origins of the urethral syndrome. The year 1956 was a landmark in the diagnosis of urinary tract infections. Edward Kass developed a reproducible quantitative method for separating contaminants from true bacteriuria: workir'g on asymptomatic females in a hospital outpatients department, he arbitrarily designated a count of 105 bacteria or more per millilitre of urine as the dividing line between true bacilluria and contamination.' Large populations were screened for asymptomatic bacteriuria using Kass' criterion to distinguish between true bacteriuria and contamination in the process of collection. The same criterion has gradually become applied to symptomatic patients those with 105 or more conventional organisms per ml being interpreted as significant infection and those with less than 105 organisms per ml being regarded as having insignificant infection. When Kass' criterion was applied to women presenting to their general practitioner with lower urinary tract symptoms, significant bacteriuria was found in only half the patients.2 The remaining 50 per cent have either sterile urines or insignificant bacteriuria, and it is to these women that the label 'urethral syndrome' has been applied. In a prevalence study in the Rhondda Valley Waters found that one woman in five had experienced urinary symptoms in the previous year, yet only 10 per cent of these women consulted their doctor about the symptoms.3 Thus it would seem that most of the women were not sufficiently troubled by the symptoms to seek medical attention. The prevailing philosophy on research into the urethral syndrome over the last decade seems to be that if a conventional organism is not found, then a closer microbiological search for other organisms is needed. Indeed, research into the urethral syndrome has moved from the community to the specialist and the laboratory. Such investigations have employed microbiological skills and techniques not normally available in the community. The population base for these studies has been either the referred patient, the symptomatic student, or genitourinary clinic patients many of whom have really been suffering from urethritis or lower urinary tract infections (UTI) and not the urethral syndrome. There is great risk of scientific and therapeutic error in extrapolating from such selected populations onto a more general population. Of all the unconventional organisms currently associated with the urethral syndrome, Chlamydia trachomatis is the one most often mentioned. Until recently most of our knowledge about the incidence of genital Chlamydia came from genitourinary and campus clinics. It would seem that the more sexually active and promiscuous a population is, the more likely it is to have Chlamydia. There is a higher isolation rate in symptomatic women who already have gonorrhoea, Trichomonas vaginale or who have been in contact with a male who has non-specific urethritis. A low incidence of genital Chlamydia was reported in asymptomatic patients attending routine family planning clinics, and in hospital staff volunteers.4 Two recent studies of patients presenting to general practitioners have not yielded any Chlamydia in association with urinary symptoms.5'6 However, one study in which the women attending an inner city practice were screened revealed an incidence of Chlamydia of 8 per cent but most of these women had co-existing vaginal discharge and genitourinary symptoms.7 While promiscuity is often a value judgement, it would seem appropriate to look for Chlamydia in promiscuous women with persistent genitourinary or vaginal symptoms in general practice. However, women suspecting a venereal cause for their symptoms are likely to refer themselves to the more anonymous genitourinary clinic. In another search for a bacteriological explanation for the urethral syndrome, Maskell has implicated organisms which require carbon dioxide for their survival.8 These fastidious microaerophilic organisms, notably lactobacilli, are commensals in the vagina. Maskell's hypothesis has
Source: PubMed Central
Author: T C O'Dowd
Language: English
Subfield: Urology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W184115329