Selective evening urethral pain

Specialty: Nephrology and urology.

• afternoon urethral discomfort
• burning urethra that worsens in the afternoon

Why it occurs

• Chronic abacterial prostatitis or chronic pelvic pain syndrome (accumulated physical fatigue, prolonged maintenance of sitting postures during the workday, and background pelvic venous congestion selectively exacerbate urethral pain towards the end of the afternoon)
• Muscle spasm or hypertonia of the pelvic floor muscles (perineal muscle tension increases after daily standing or sitting activity causing referred urethral pain)
• Interstitial cystitis of mild-moderate onset
• Cystocele or pelvic organ prolapse that pulls on the urethra at the end of the day due to accumulated standing

Initial workup

Detailed prostate and perineal physical examination; voiding diary for 3 days to record the hourly distribution of pain and urinary symptoms; repeated negative urine sediment and urine culture; pre- and post-void vesicoprostatic ultrasound; biomechanical and posture assessment of the pelvic floor.

Standard management

• Tamsulosin — 0.4 mg daily orally administered in the middle of the afternoon to selectively relax the urethra and prostate, mitigating afternoon discomfort
• Pregabalin — 75 mg orally at night to modulate the neuropathic pain component
• Postural ergonomics measures (frequent standing breaks if you work seated) and specialized pelvic floor physiotherapy.