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Dear Aunt Vadge,
I haven’t been sexually active for four years and I stopped the pill a year ago. My 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 it for six months, following my first-ever UTI in April 2015 (which escalated to tiny kidney stones and an emergency room visit). I took a basic antibiotic, then Cipro, then three months later Clindamycin and a sulfa-based antibiotic.
I’ve been to urology, gynaecology and dermatology at my local hospital about a dozen times and no one can definitively work out why it hurts. A quick urine test showed elevated white cells, but the 3-day culture came back ‘mixed’, which the doctors put down to contamination. Two catheter samples both showed fewer than 1,000 colonies, so no bacterial infection. A bladder volume test and external and vaginal ultrasounds of the bladder and kidneys were all normal.
A cervical swab in gynaecology grew Gardnerella vaginalis and Staphylococcus lugdunensis, so they gave me a week of metronidazole suppositories and iodine sitz baths. No doctor has ever suspected yeast. At different points I was also given Nystatin/Neomycin, sertaconazole 2%, and betamethasone 0.06%, all soothing for a few minutes before the pain returns. Celebrex and other anti-inflammatory painkillers seemed to fix it while I was taking them, but it came back when I stopped.
Dermatology thought it might be an allergy or eczema (I had eczema on my legs years ago). An antihistamine did nothing, but a betamethasone/neomycin ointment and later sulconazole each helped a little. I also went without underwear for four days, switched laundry detergent, tried apple cider vinegar (drinking, sitz baths and applied directly), tea tree oil, yoghurt internally, no soap on my vulva, no menstrual cup, plus probiotics and kefir daily. It hurts less in the mornings and when I skip underwear at night.
Some days it hurts more, some less. At its worst it feels like a piece of glass in my urethra; otherwise it’s a dull, constant ache. I wondered about a parasite from a sulphur hot spring I soaked in a month before it started, but the doctors say that’s not possible here (Taiwan) and that they’d have seen it under the microscope. My discharge seems normal and whitish. I’m at my wits’ end, it stopped me having sex recently, and this is the biggest stress in my life. Can you please help?
Yours,
Sore
Age 34, Taiwan
Dear Sore,
Thank you for the thorough history and the photos. A stubborn little spot like this could come from a few different places, so let’s walk through them together.
Urethral caruncle
It could be a urethral caruncle: a small lesion at the exit of your urethra (the urethral meatus), where a little pucker of flesh normally protects your vulval skin from acidic urine.
Caruncles are usually benign and have a few causes, including low-oestrogen conditions. They’re most common in older, post-menopausal women, which makes one a bit more of a question mark at 34. Without knowing more about your hormones it’s impossible to say, but one option worth raising with your doctor is a trial of topical oestrogen cream. If low oestrogen is the driver, the lesion should clear completely, and then the job becomes working out why your oestrogen is low at your age, because it shouldn’t be unless something else is going on.
Cancer
I won’t tiptoe around it, because a non-healing lesion always needs it ruled out. Urethral cancer is rare and can be hard to spot, especially somewhere that doesn’t see many vulval lesions. If it hasn’t already been formally excluded, ask your doctor about being examined again and possibly a biopsy to check the cells. This is the sort of thing to nail down early rather than assume.
The Skene’s glands (female prostate)
The Skene’s glands sit right beside the urethra, and one of them being involved can’t be ruled out. There’s a condition called skenitis (inflammation or infection of a gland or duct) that can mimic urethral trouble and lead to Skene’s duct cysts or abscesses. From your photo, the lesion looks like it could be off to the right side, which would fit; a spot right at the top would make this less likely.
An infected or blocked Skene’s gland would also explain your clean urine tests, because the trouble isn’t in the urine itself. It’s obvious enough that your doctors have probably checked, but it’s worth confirming.
Contact dermatitis
The itch, and the slight relief from antihistamines and going low-irritant, hint at some form of contact dermatitis. It’s not top of my list, because an allergy would usually be broader and affect the labia rather than one raw spot, but it earns an honourable mention given how clearly you respond to reducing irritants.
Urethral prolapse and diverticula
A urethral prolapse tends to show all the way around the meatus rather than in one section, and you seem to have been examined for it, so it’s probably not that. Urethral diverticula (a pouching of the urethra into the vagina, sometimes from enlarged Skene’s glands) usually brings post-void dribbling, painful urination and painful sex (dyspareunia) on a background of UTIs, which doesn’t quite match you, though it can be silent and found by chance.
Going forward
You’ve had a lot of medicine, so you’re doing the right thing loading up on kefir and probiotics. Go as low-irritant as you can with everything that touches your vulva, including whatever is on your hands when you touch yourself, and check that your toilet paper isn’t part of the problem, which can quietly drive non-specific urethritis and similar irritations.
The most useful clue in your whole email is that anti-inflammatories helped: the detergent change, going without underwear, and the Celebrex and other anti-inflammatory painkillers all eased it. That doesn’t tell us exactly what this is, but it tells us loudly what it responds to. That it came straight back when you stopped is also telling; if it were simply a small sore being knocked about by daily life, anti-inflammatories should have settled it for good. Not a hard rule, but a clue.
Since you clearly respond to bringing inflammation down, I’d lean into an anti-inflammatory diet in a bigger way, at least for a while, and add fish oils at a proper therapeutic dose, meaning at least 500 mg EPA (check the label, you’ll likely need more than four capsules to hit that). See whether that shifts things while you chase down the other options with your doctor. Our urethral caruncles article lists some naturopathic anti-inflammatory measures at the bottom.
The naturopath in me would rather food did the work than an over-the-counter drug, but don’t forget you can take the edge off with anti-inflammatories when things get grim, just enough to get a break and, yes, to get laid. Chronic pain is hard on the soul, and this has clearly been exhausting and a bit traumatising. Please write back and let us know how you go.
Warmest regards,
Aunt Vadge
This is general information and not a substitute for personalised medical advice.
