Urethral Syndrome in Indian Female Patients

URETHRAL SYNDROME IN INDIAN FEMALE PATIENTS

OP Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

Irritable bowel syndrome is a well known entity where the patient suffers immensely, but the doctor often cannot help. In our country urethral syndrome is another entity which can be compared to irritable bowel syndrome where the doctor can do nothing to help the patient. In many patients of urethral syndrome there is associated irritable bowel syndrome, irritable stomach syndrome in the form of symptoms of peptic ulcer syndrome, irritable oesophagus syndrome in the form of symptoms of reflux oesophagitis and hyperacidity and symptoms of irritable heart syndrome in the form of palpitations, dyspnoea and chest pains etc. Thus it is certain type of personalities of the patients who suffer from such syndromes.

I shall first discuss this syndrome in females and then in males. This is because the aetiology and the presentation of this syndrome is different in both sexes.

Urethral Syndrome in Females

In India cysto-urethritis syndrome is extremely common and this syndrome later on remains as urethral syndrome which continues for a very long time and as a prolonged illness. The following are the known causes of urethritis in Indian females.

1. Since the infection is of E. Coli type, it comes from the anus (stools). Thus the wrong habit of washing the perineum. (after passing stools) forwards introduces E Coli into the urethra.

2. Indian women are known to deliver every one to two years. In the past putting a catheter in the bladder was a common procedure during the delivery. This very often introduces infection. Even otherwise every delivery during which the foetus comes out produces a trauma to the urethra. Which can easily get infected.

3. In our country the females have been taught by their parents to lie down immobile at the end of the sexual intercourse so that the semen deposited in the vagina remains there; thus increasing the chances of conception. Unfortunately during the sexual intercourse due to the rubbing of the urethra, a lot of E. Coli from the perinuem get deposited into the urethra. Ideally a woman must pass urine after the sexual intercourse and before going to bed, thus flushing away the E. Coli from the urethra. Indian women do just the opposite.

4. Because of poverty, very few Indian women use sanitary towels during the menstruation. Unfortunately blood is a very good medium for E. Coli or any organisms to travel. Thus the old dirty linen used during the menstrual periods is a sure aetiological cause to spread the infection into the urethra.

5. Most Indian women drink less water and pass urine less frequently. This is exactly the opposite of what they should be doing. Drinking more water is the single best method of preventing and treating urethral syndrome in our tropical climate.

Following are the symptoms due to cysto-urethritis:

1. Increased frequency of urine

2. Urgency of urine

3. Burning of urine

4. Poor stream of urine

5. Straining while passing urine

6. Post micturition dribbling.

All these symptoms would respond to any antibiotic;. However, those women who develop a stricture of the urethra will respond to a cystoscopy examination during which the urethra can be dilated. Many of these patients feel greatly relieved by this procedure, which costs about Rs. 1,000 to 2,000/- because it involves at least one day's hospitalisation and possibly services of an anaesthetist. Though many of these patients are temporarily relieved they often relapse. Thus the long term results after the use of repeated or long term antibiotics or cystoscopy remain same. So poor are the long term results that a good urologist surgeon avoids doing cystoscopy on such patients so as not to get a bad name. Though many patients are relieved of some of the symptoms mentioned above by antibiotics, the symptoms of burning of the urine in the form of urethral syndrome continue. In these patients no clear guide lines are available as to how often the antibiotics should be used. Finding a few pus cells in urine of symptom of burning urine is certainly not a definite indication to start antibiotic. The fact is that the patients who complain of poor stream of urine and post micturition dribbling will benefit by urethral dilatation done during cystoscopy examination. But in majority of women nothing can be done for the complaint of burning urine except advising them to drink lot of water or to alkalinise the urine. In fact, many of these women have many other symptoms to be attended to like those of irritable bowel syndrome etc. Many of them have a neurotic personality. They come from lower social status. It is interesting to note that after having examined hundreds of Arab women who have delivered more than 7-8 children, I have not seen this entity in that population. Similarly this syndrome is not seen in certain communities of India like Punjabis, Sindhis, Christians and women of high social status.

Urethral Syndrome in Males

This syndrome which is extremely common in India specially in certain communities and lower social status men, is seen very rarely in foreign countries. In certain communities hailing from UP, Bihar, Maharashtra and Gujarat, this syndrome is extremely common. In fact in Bhaaiyas and Pathans it is -a universal syndrome. The standard complaint of the patients is burning of the urine. In addition majority of them complain of passing white discharge in the urine which is sticky and mucoid. Many of them complain of dysuria and constant burning pain inside the shaft of the penis. Many of them complain of so called spermaturia. Most of the urologists will diagnose these patients as having chronic prostatitis. The fact is that even if these patients are treated by leading urologists the results are very poor. It appears to me that these patients form a large focus of malpractice. Because they are difficult to treat they are often sent for a prostatic massage and culture of the semen. The reports of the pathologists are of stereo-type. Always 2-3 pus cells are reported and some rare organisms are isolated in the culture. Most of these organisms are unheard of and are possibly non-pathogenic. When these patients do not respond to antibiotics combined with repeated prostatic massages, cystoscopy is advised. Ver., Often non-specific detailed findings of cystoscopy are shown to the patient and the family doctor impressing them that the prostatic urethra was found to be inflamed. After spending 1000 to 2000 rupees, the condition of these patients remains same. They continue to complain of burning of urine and burning of urethra. Some of these patients who have a straight forward chronic prostatitis with a complaint of a slight discharge noticed at the tip of glans penis early morning respond to antibiotics. Majority do not. Like Arab patients who have constant perineal fixation for piles, these patients are obsessed with their urethra, and the urine. Often they complain of change in colour of urine to deep yellow (which is a normal phenomenon depending on the amount of intake of fluids etc) and complain of passing semen in the urine while straining for the stool.

Many of these patients visit number of doctors and try their treatments. Some of them reach a urologist and are cystoscoped and yet are not free of their symptoms. Many land up with homeopathic and ayurvedic consultants. Many patients are ultimately referred to psychiatrists because of accompanying multiple symptoms in connection with the colon, heart, stomach, oesophagus and rest of the body. On the whole they have a nervous and hypochondriac personality and complain of tiredness, weakness, giddiness, joint pains, poor sleep, sexual weakness much more than many other patients suffering from other illnesses. In fact many of them land up with impotency and connect it to the urethral syndrome.

Unfortunately there is no known treatment of this syndrome. Till the public in our country becomes busy, develops hobbies like reading, sports etc. and have less spare time, this syndrome is likely to continue. The type of patients who suffer from this syndrome are the ones, who in order to pass time, go on observing the act of micturition, defaecation etc. in so much detail that they will confuse any doctor when they describe the picture of the urine and stools. A number of them experiment and collect urine in the bottle and note white deposits at the bottom. Not many doctors would know that very often if the urine is kept in a bottle, the normal crystals of phosphates will get deposited at the bottom.

In case one wants to wish ill-luck to a particular general practitioner one should wish him to face half a dozen patients of urethral syndrome. This will make any doctor crazy. In fact I have overheard many urologist surgeons say that they would like to send a case of urethral syndrome for cystoscopy to their competitor.

Finally, it is possible that these patients who have more spare time have become conscious of passage of urine through the tunnel of urethra lined by mucous membrane. Most of normal people do not feel the urine passing through the tunnel. The situation is exactly similar to patients with normal heart who become conscious of the heart beats and develop the complaints of palpitations which does not respond to any treatment.