Q: After going on a long bicycling vacation, I developed all the symptoms of a urinary tract infection. But my tests came up negative. What else could it be? I’m a 58-year-old woman.
A: It could be a condition known by a variety of names: female urethral syndrome, nonrelaxing or hypertonic pelvic floor dysfunction, and pelvic floor spasm. You may have heard of weak pelvic floormuscles, which can result in urine leakage from activities such as sneezing or jumping. Pelvic floor spasm is essentially the opposite problem, with the pelvic floor muscles overcontracting rather than failing to contract. (A related condition occurs in men and is known as prostadynia.) Symptoms vary but can include burning during urination, a slowed urine stream, difficulty urinating, lower abdominal discomfort or pain, and frequent urination—which helps explain why the condition is often initially misidentified as a urinary tract infection. Then the tests come back negative for bacteria and the symptoms persist, becoming chronic. (In addition to the UTI-like symptoms listed above, a woman may also experience constipation or pain during sexual intercourse.) The physician may then order all manner of additional tests.
But what he or she often fails to do is examine the pelvic floor, a dome-shaped complex of muscles that helps with proper urination and the passing of feces, among other functions. A variety of factors may cause these muscles to contract inappropriately or impair their ability to relax, including cycling, falling on your tailbone (coccyx), having given birth vaginally or received an episiotomy during childbirth, intense high-impact physical activity, or skeletal asymmetry of the pelvis. But often a cause isn’t found.
Conclusive data on the prevalence of the condition are lacking, but according to one estimate we found, from a Denver urology clinic—which uses the term “female urethral syndrome”—as many as 25 percent of women with bladder or urinary symptoms may have it. Because the syndrome isn’t widely recognizedby doctors, and because it can cause such problematic symptoms, a woman may go from doctor to doctor, including urologists and gynecologists, seeking an answer, only to be given antibiotics (which won’t help) or various tests to rule out other problems, such as urine-flow tests or ultrasounds of the bladder.
Even a typical pelvic exam at the gynecologist isn’t likely to catch the problem, as noted in a 2012 review paper, since it doesn’t address the pelvic floor musculature. Getting the right diagnosis generally requires a digital exam (using a gloved finger) of the vagina and anus to palpate the tense muscles, along with a visual exam of the vaginawhile the woman contracts and relaxes the pelvic floor muscles (for example, by doing Kegel exercises).
If pelvic floor spasms are diagnosed, treatment is often provided by a physical therapist and may include avoiding activities that aggravate the symptoms (such as cycling with a seat that’s too hard or doesn’t fit ergonomically), behavioral changes (such as not holding in urine if you have to go), and education about the pelvic floor—possibly accompanied by biofeedback—to increase awareness of what it feels like when the muscles are tensed vs. relaxed. The therapist may also use manual techniques such as massage or myofascial or “trigger point” release. Self-help measures such as warm baths or a warm heating pad placed over the perineal or lower abdominal area might also be recommended. To find a physical therapist who specializes in pelvic floor dysfunction, ask your primary care provider or gynecologist for a referral, or use the directory in the Women’s Health section of the American Physical Therapy Associationwebsite.