Persistent Sore Below Urethra: A Complex Case Explored

Dear Aunt Vadge,

I haven’t been sexually active for four years and I quit taking birth control pills a year ago. My current problem is an irritated, slightly itchy, non-healing red area about 4 mm wide on the skin right below my urethral opening. I’ve had this problem for six months following my first-ever UTI in April 2015 (which escalated to tiny kidney stones and an emergency room visit). I took some basic antibiotic, then Cipro, and then three months later Clindamyacin and then a sulfa-based antibiotic (Sulfamethoxazoe 400 mg and Trimethoprim 80 mg).

I’ve been to the urology, gynecology, and dermatology departments at my local hospital numerous times (probably about a dozen appointments total) and no one can definitively figure out why it’s hurting. When I’ve done urine cultures, the quick test revealed an elevated white blood cell count, but then the 3-day test revealed “mixed culture” which the doctors couldn’t seem to explain what that meant other than cross-contamination. I’ve submitted two urine samples by catheter and in both those cases the urine bacteria count was less than 1,000 colonies, so no bacterial infection.

I’ve done a bladder volume test (normal) and both external and vaginal ultrasounds of the bladder and kidneys (normal). In the gynecology department they did a cervical swab which revealed Gardnerella vaginalis and Staphylococcus lugdunensis, so they gave me a week’s worth of metronidazole suppositories and iodine for sitz baths.

At no point during my treatment has any doctor suspected or seen signs of yeast or other fungi. At different points they also gave me the following topical ointments: Nystatin/Neomycin sulfate, sertaconazole nitrate 2%, and Betamethasone valerate 0.06%. They are soothing for a few minutes but then the pain comes back. They gave me Celebrex and Keto pain relievers, which seemed like they fixed the problem for the week I was taking them, but then it came back after I stopped.

Finally they sent me to the dermatology department, who said it might be an allergy or eczema (I have had eczema on my legs before for years, but not in the last ten years). They gave me an allergy pill called Levocetirizine (no difference) and a topical ointment (Betamethasone and neomycin) which is helping a little. Later they gave me Sulconazole which is also helping a little.

I also recently didn’t wear underwear for four days and switched to a different laundry detergent to see if that would help. It felt a bit better but did not actually go away. I’ve also tried all of the following: raw apple cider vinegar (drinking, sitz baths, and applying directly to the affected area), applying tea tree oil to the area, putting natural yogurt in my vagina, not using soap on my vulva (I use Dove on my face and the rest of my body), not using my silicone menstrual cup and just pinning a cloth rag to my underwear when I have my period, taking probiotics and drinking kefir every day. I don’t wear underwear when I sleep and it does seem to hurt less in the mornings.

Some days it hurts more and some days less. When it hurts a lot it feels like a piece of glass stuck in my urethra, otherwise it is a bearable but constant dull pain. I have suggested to my many doctors that it could be a parasite that I got from a natural sulphur hot spring I soaked in a month before this all started, but they say that’s impossible to get in this country (Taiwan), and that they looked at my urine with a microscope and would have seen any parasites because they are much bigger than bacteria.

My discharge odor seems normal to me (but I only know what mine is like, not other womens) and is whitish/clearish. I’m at my wits’ end. It hurts and no medicine or lifestyle change seems to be permanently helping. I had the chance to have sex recently and couldn’t because of this problem. Also I’m frustrated by the language barrier (doctors here usually do speak English but the nursing and reception staff usually don’t). This ongoing health problem is the biggest stress in my life. Can you please help me?

Yours,
Sore
Age 34, Taiwan
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Dear Sore,

The problem you describe (and thank you for the photos) could have its origins in a couple of places, so we’ll just go through them with you here.

Urethral caruncles

It could be a urethral caruncle. That is, a lesion on the exit point of your urethra (urethral meatus), which is a puckering of flesh that protects your vulvar flesh from your acidic urine on the way out.

Urethral caruncles are most often benign, and occur for a few reasons, including low oestrogen conditions. In fact these urethral caruncles most often occur in elderly women, which makes it somewhat more of a concern in you, age 34.

Without knowing more about your hormonal and general health status, it is impossible to tell if you are suffering low oestrogen. So, that is one option, and one way to find out is to discuss the suggestion with your doctor and suggest you try some topical oestrogen cream. It might just work. If low oestrogen is the problem, the lesion should completely disappear, but then you need to figure out what’s going on with your hormones – you shouldn’t have low oestrogen at your age unless something else is wrong.

So now we get into the other reasons you may have a lesion on your urethra (or near to it).

Cancer

Sorry to leap straight into that, but it cannot be ignored. It seems like the sort of thing your doctors should have already looked out for despite its rarity, but you don’t mention this at all in your email. It seems obvious, so if you know for sure that this has been ruled out, we can move on.

Urethral cancer is hard to diagnose, so if you are in an area that doesn’t commonly see vulvar lesions of any kind, they may not recognise it. Otherwise you need to be examined (again), and possibly have a biopsy done to check the cells. Speak to your doctor about this if you haven’t already. (Read about urethral cancer here.)

Involvement of the Skene’s glands (female prostate)

The Skene’s glands are so close to the urethra and the involvement of one of these glands can’t be ruled out. There is a condition called Skenitis, which is infection and inflammation in a gland or duct, which can mimic urethral troubles, and this can lead to Skene’s gland cysts or abscesses. This could be causing your problem. It would be great to find out if you could separate the position of the actual main lesion, since the Skene’s are just off the urethra on both sides (check Google images), and using your photo, it seems like it is possible on the right side. If the lesion was up the top, it would be far less likely.

If the Skene’s gland was infected or had a growth in it, it is possible that your urine tests would have come back clean, since the infection is actually not in your urine (though it is nearby and could cause contamination, which is why you wouldn’t see the cross-contamination on the tests that were done using a catheter).

Again, it seems obvious, so I’m sure your doctors have checked for this type of cyst or abscess, but it would pay to check.

Contact dermatitis

The itch and slight help by allergy medication can provide some clues, and possibly point to some form of contact dermatitis, though this is not necessarily correct since allergies are broader than just one spot, and would tend to affect your labia rather than the raw flesh, since that is what comes into contact with the outside world. Not high on my list of main suspects, but requires an honourable mention since you are clearly responsive to going low irritant.

Urethral prolapse

This seems unlikely since urethral prolapse actually shows all the way around the urethral meatus, not just in one section, since the whole urethra has popped out the end. The urethra is like two socks stitched together neatly, one inside the other, and one sock – while normally stitched together so they match – slides out of the other, and comes out the hole. You appear to have been examined for this eventuality, so it is probably safe to assume it is not a urethral prolapse. (Read more about urethral prolapse here.)

Urethral diverticula

Urethral diverticula is a condition whereby the urethra pouches into the vagina, which can be caused by enlarged Skene’s glands (female prostate glands, paraurethral glands). The symptoms of this, however, do not match yours. Symptoms of urethral diverticula include dribbling after urinating (post-void dribbling), painful urination, and painful sex (dyspareunia), plus usually a history of urinary tract infections. But, symptoms do vary and this condition can be completely asymptomatic and discovered incidentally.

Going forward

You’ve had quite a lot of medicine, so you’re doing the right thing by chowing down on kefir and probiotics. Go as hypoallergenic as you can with everything that comes into contact with your vagina, including being careful about what you have on your hands when you touch yourself. Also, make sure your toilet paper is also not causing an issue. You can quickly end up with an ongoing problem from toilet paper (non-specific urethritis and other irritations).

It really sounds like you have tried so many things, which must be exhausting and a bit traumatising, especially the pain and then missing out on sex. You really need to discover the true cause of the problem, but doing that is going to be a mixed bag of more testing. Because you’ve tried so many things, it makes this process somewhat easier to narrow down and also gives you more options to discuss with your doctor.

The parasite option is beyond our scope, really, but if you believe this could be true, the internet is at your fingertips, so don’t take their word for it – do your research and see if it’s actually possible, what the symptoms would be, and see if you can find anyone else who may have had a similar experience. You mention that when you changed your laundry detergent, stopped wearing underwear at night, and took Celebrex and Keto painkillers, which are actually anti-inflammatories, your symptoms abated. This gives us a huge clue, and a way to try to figure out how to fix the problem.

In our urethral caruncles article, at the bottom we suggest some naturopathic remedies for really reducing inflammation in the body. Your lesion has responded very well to anti-inflammatories, which while that doesn’t tell us really what it is, it tells us what it will respond to in terms of symptom management in the meantime.

The painkillers didn’t clear up the problem permanently, since it came straight back, which is also significant – if the problem was simply due to the small sore being irritated constantly (by life), anti-inflammatories should have resolved the problem more permanently, by removing the inflammation. This is not 100 per cent always true, but it’s a clue. It could work on a larger scale for longer with a change in diet and adding a few choice supplements to your daily routine.

Many problems cause inflammation, but something specific is causing this particular inflammation. It is so specific. It is one tiny spot on your body that is howling at you. Because we know you respond to anti-inflammatories, I’d suggest you head towards an anti-inflammatory diet in a bigger way at least temporarily, and add the fish oils in high therapeutic doses. This means at least 500 mg EPA (check the back of the container – you will need to take probably more than four capsules at once to get this dose). See if this makes a difference while you investigate the other options.

Alternatively you can use our easy access to non-steroidal anti-inflammatories, but of course the naturopath in me baulks at recommending over-the-counter drugs when food can do a great job! But, don’t forget that you can get rid of the symptoms at least temporarily when times get tough using anti-inflammatories. It could relieve your suffering just long enough to get you laid and give you a break. Chronic pain is bad for the soul.

Please write back and tell us what you think, and how you go.

Warmest regards,
Aunt Vadge