Urethral Dilatations for Recurrent UTIs
Frederick R. Jelovsek MD
"My doctor is suggesting that I have urethral dilatations for recurring bladder infections. I am getting conflicting information regarding this procedure. Are they helpful or not?"
" I am perimenopausal at the age of 46. I use the Vivelle patch (.05)." RLN
Dilatation of the urethra using size graduated dilators has been used for many years by urologists as one method of enlarging the tube (urethra) from the bladder to the outside to make urine flow out easier. It is more commonly used as a treatment in males than females because their longer urethra is more subject to stricture due to scarring from trauma or infection. It is still sometimes used in women although less frequently than it used to be.
Why is urethral dilatation used in women?
There are two main reasons that the urethra is dilated. One is to relieve painful urination caused when the urethra is constricted and the bladder detrusor muscle is contracting during the act of voiding. This causes painful voiding since the internal bladder pressure remains high for a longer time than normal because of obstruction to outflow. The second reason for urethral dilatation is to avoid chronic bladder infections and reflux of urine into the ureters and kidneys. This would happen if the pressure inside the bladder exceeds 40 cm of water and can lead to permanent kidney damage.
Urologists who have been trained in recent years tend to use urethral dilatation less than those trained earlier. Those that still use it confine its use mainly to urethral syndrome, urethral stricture and sometimes detrusor sphincter dysynergia although its success in that muscle spastic condition of the urethra is not very good.
If your doctor is thinking of using it for you, then it is probably thought that you have a urethral stricture that is leading to chronic bacterial infections of the bladder. It could also be possible that your doctor thinks you have urethral syndrome especially if your urine cultures are negative most of the time.
What is urethral syndrome?
Urethral syndrome is defined as 'symptoms suggestive of a lower tract urinary infection but in the absence of significant bacteruria with a conventional pathogen'. There are other non-infective causes that should be considered such as trauma, allergies, and anatomical features like diverticula and post surgical scarring. Most women will give a history of chronic recurrent UTIs but the cultures seem to not show any conventional bacterial growth. There may also be a history of these episodes often being related to sexual intercourse.
It is not fair to say that urethral syndrome is not due to infection because many physicians believe that it is due to a low grade infection of the Skene's glands on the sides and bottom of the urethra. At least symptoms often respond to antibiotics. The Skene's glands are embryologically related to the prostate gland in the male, thus urethral syndrome may almost be a type of chronic prostatitis in a woman. Treatment of acute urethral syndrome is antibiotics just the same as treatment for a UTI. For chronic urethral syndrome a long term, low dose antibiotic treatment is given on a continuous basis or after intercourse each time if that seems to be prominent in relationship to symptoms occurring.
How does outflow obstruction cause chronic urinary tract infections?
There are always some bacteria in the bladder but the counts are usually quite low. When a bladder detrusor muscle contraction is not able to force urine out of the urethra fast enough, some of the urine can go back up the ureters all the way to the kidneys. In fact this may be the cause of some of the components of low back pain with voiding when there is outflow obstruction. The bacteria can then get into the kidneys and cause pyleonephritis or kidney infection.
Diagnosis of bladder-ureter reflux is made by voiding cystourethrogram. This is a study in which xray opaque dye is placed in the bladder and then an xray is taken as a woman voids to see if urine from the bladder has any "back flow".
What are alternative treatments for urethral dilatation?
If the urethra is narrowed, it could be due to:
- involuntary contraction of the external urethral sphincter muscle
- involuntary contraction of the internal urethral sphincter muscle
- external compression or irritation of the urethra by Skene's gland infection, urethral diverticula, or surgical continence procedures
- scarring of the intrinsic muscle or epithelium of the urethra due to past trauma, surgery, or infection
Alternative treatments would include
- smooth muscle relaxants that decrease contraction of the external urethral sphincter such as diazepam (Valium®) or Xanex® or any other benzodiazepine.
- alpha receptor blocking meds such as prazosin (Minipress®), terazosin (Hytrin®), doxazosin (Cardura®), alpha-methyldopa (Aldomet®) and reserpine (Diupres®,Hydropres®) will cause relaxation of the internal urethral sphincter muscle.
- antibiotic treatment of Skene's gland infections, removal of urethral diverticula, or take down of previous continence procedures such as slings or needle urethropexies.
If all of these have been tried or taken into account then intrinsic urethral stricture may be the cause and dilatations may be the needed therapy.
Should I go ahead with the dilatations?
The answer to this depends upon whether all of the above causes have been considered or ruled out. Do we definitely know that your chronic urinary tract infections grow out bacteria and have you been tried on chronic low dose antibiotics to make sure there is not a low grade infectious process such as urethral syndrome? Is there evidence of urethral narrowing on exam by the urologist such that only narrow diameter dilators can be passed into the urethra? If so, you need to have a trial of urethral muscle relaxers.
I assume your doctor has not found any external causes for urethral compression such as diverticula or past surgery. Women who use condoms or diaphragms for contraception also have a higher incidence of urinary tract infections probably due to external irritation of the urethra during sexual intercourse.
Using the low dose estrogens via the patch is a good idea. At least it is helpful in making sure that the skin (epithelium) lining the urethra has good lubrication and protection. In your case I assume it has not helped lessen the infections.
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