Vol. 116, November

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright © 1976 by The Williams & Wilkins Co.

TREATMENT OF URETHRAL SYNDROME WITH TRIAMCINOLONE ACETONIDE BARRY L. ALTMAN

ABSTRACT

A new method for the treatment of the urethral syndrome is presented. Therapy involves the submucosal injection of triamcinolone acetonide around Skene's glands to decrease inflammation and scarring. It is a simple office procedure, while all other therapeutic modalities are surgical. The urethral syndrome has proved to be enigmatic in office practice. There have been reports indicating that distal irritable urinary symptoms can exist without pyuria or bacteriuria. Gallagher and associates showed the presence of the urethral syndrome in female subjects as a residual of urethritis and cystourethritis. 1 The syndrome consists of dysuria, frequency and persistent perineal discomfort, especially after coitus. It is associated with sterile urine. Fair and associates have shown the presence of Lactobacillus and Corynebacillus in the urethras of the patients but there is an absence of the usual pathogenic flora causing the irritable symptoms of lower urinary tract infection. 2 Immergut and Gilbert postulated that increased intraurethral resistance contributes to the symptomatology owing to ineffective emptying of the bladder.' They stated that urethral dilatations are valueless because of the return of the urethral caliber to its pre-dilatation level since the urethra is surrounded by elastic tissue. Several investigators are proponents of internal urethrotomy for treatment of the urethral syndrome. 3- 5 The rate of success in the relief of symptoms varies but averages approximately 60 per cent. We too have subscribed to this methodology and have performed more than 200 urethrotomies. However, we were not satisfied with our results, having seen recurrent symptoms in approximately 40 per cent of the .Patients up to 4 years after urethrotomy. Richardson devised the external urethroplasty to decrease distal urethral resistance to urination. 6 His series included 179 of 300 women with an apparent urethral syndrome. However, this approach seemed to be rather radical. Eberhart thought that unroofing the obstructed ducts of Skene's glands (apparently owing to cicatrix formation) would alleviate symptoms, and even cure cystourethritis and pyleonephritis. 7 The treatment described herein for the urethral syndrome relies on the concept that there is definite scarring of the ducts of Skene's glands. If this is so then collagenous material must be formed within the normai elastic connective tissue of the urethra through which the ducts travel. Five years ago Orentreich stimulated our interest in triamcinolone, using it to decrease the inflammatory process of cystic skin lesions and to alleviate scarring. 8 With the information presented thus far it seemed reasonable to use this method to treat the urethral syndrome by direct injection of the submucosa of the urethra especially into the cystic and duct structures of Skene's glands. Although the pathology of the urethral syndrome is not definitely proved it is safe to say that there is an inflammatory process involving Skene's glands. The continuous process of inflammation eventually causes obstruction of the paraurethral ducts by scarring and eventuates in cystic formation. MATERIALS AND METHOD

Recent literature has revealed distinct benefits with triamcinolone injected locally in areas of cicatrix formation. Damico Accepted for publication April 15, 1976.

and associates used it as adjuvant therapy for vesical neck contractures. 9 Triamcinolone acts as a catalyst, enhancing the activity of the endogenous collagenase. It interferes with the mechanism of collagen formation and so decreases cicatricial formation. Hebert has used this successfully in the treatment of urethral strictures.'"· 11 A tuberculin syringe with a 25 gauge needle on the Luer tip is used with 1 cc triamcinolone acetonide suspension (10 mg.). A Mosher speculum is inserted after the introitus is bathed with betadine solution. The entire floor of the urethra is visualized with adequate lighting. Multiple injections into the submucosa and connective tissue are performed through the entire length of the urethra from the 3 to 9 o'clock positions. The urethra is then massaged via the vaginal introitus. A tampon is inserted Symptoms in 7 patients Pt. GA JM NT CM* DS EM* CJ

Perinea! Pain

Post-Coital Pain

Dysuria

Frequency

Moderate

Unchanged Slightly less lnchanged

Unchanged

Unchanged

Less

Unchanged

Unchanged Unchanged

Less Less Less

Rarely Moderate

* Re-injected 6 months ago and recent telephone communication revealed patients free of all symptoms.

in the introitus for compression hemostasis since there may be some minor bleeding. The patient is instructed to remove the tampon and take warm baths 3 times a day for 3 days. RESULTS

There were 66 women treated in this fashion, several of whom had emotional problems stemming from the chronicity of the symptoms. Many patients with similar symptoms were denied treatment owing to various inconsistencies in their history, indicating that they may have been unreliable for followup evaluation. Followup ranges from 6 months to 5 years. Twelve patients were lost to followup. Letters have been sent annually to each patient requesting information as to symptomatology. Of the 54 patients responding to our inquiry 47 (87 per cent) indicated that they were free of symptoms. The remaining 7 patients have had improvement but complained of some symptomatology (see table). In all cases the urine culture was negative. In 5 patients the urethral culture revealed Escherichia coli. These patients were treated according to sensitivities. If symptoms persisted despite repeat negative cultures we considered the patients candidates and they were incorporated in the statistics. The same was true for 1 patient with Staphylococcus albus and another with non-hemolytic beta streptococcus.

584

ALTMAN CONCLUSION

Although this series is rather limited it is still significant owing to the statistic of resolution of symptomatology in 87 per cent of the patients. The method is simple and can be performed as an office procedure. It is possible that statistics can be improved by using combination therapy of internal urethrotomy and urethral injection of triamcinolone acetonide.

1777 Hamburg Turnpike, Wayne, New Jersey 07470 REFERENCES

1. Gallagher, D. J., Montgomerie, J. Z. and North, J. D.: Acute infections of the urinary tract and the urethral syndrome in general practice. Brit. Med. J., 1: 622, 1965. 2. Fair, W. R., Timothy, M. M., Millar, M. A. and Stamey, T. A.: Bacteriologic and hormonal observations of the urethra and vaginal vestibule in normal premenopausal women. J. Urol., 104: 426, 1970.

3. Immergut, M. A. and Gilbert, E. C.: The clinical response of women to internal urethrotomy. J. Urol., 109: 90, 1973. 4. McLean, P. and Emmett, J. L.: Internal urethrotomy in women for recurrent infection and chronic urethritis. J. Urol., 101: 724, 1969. 5. Kerr, W. S., Jr.: Results of internal urethrotomy in female patients for urethral stenosis. J. Urol., 102: 449, 1969. 6. Richardson, F. H.: External urethroplasty in women: technique and clinical evaluation. J. Urol., 101: 719, 1969. 7. Eberhart, C.: The etiology and treatment of urethritis in female patients. J. Urol., 79: 293, 1958. 8. Orentreich, N.: Personal communication. 9. Damico, C. F., Mebust, W. K., Valk, W. L. and Foret, J. D.: Triamcinolone: adjuvant therapy for vesical neck contractures. J. Urol., 110: 203, 1973. 10. Hebert, P. W.: The treatment of urethral stricture: transurethral injection of triamcinolone: a preliminary report. J. Urol., 105: 403, 1971. 11. Hebert, P. W.: The treatment of urethral stricture: transurethral injection of triamcinolone. J. Urol., 108: 745, 1972.

Treatment of urethral syndrome with triamcinolone acetonide.

Vol. 116, November THE JOURNAL OF UROLOGY Printed in U.S.A. Copyright © 1976 by The Williams & Wilkins Co. TREATMENT OF URETHRAL SYNDROME WITH TRI...
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