Case Report
 
Urethral Coitus Mimicking Vaginal Intercourse: A Case of Megalourethra
 
Sakshi Chopra, Ruchi Hooda, M Gouri Devi
Department of Reproductive Medicine, Ridge IVF Centre, Delhi-110007, India.


Corresponding Author:
Dr Sakshi Chopra
Email: 385saki@gmail.com

Abstract

Background: Urethral coitus is an extremely rare clinical entity, often associated with congenital vaginal anomalies such as agenesis or hypoplasia. However, it may occasionally occur in women with normally developed external genitalia, presenting with non-specific symptoms like dyspareunia, urinary incontinence, and recurrent urinary tract infections (UTIs). Due to its rarity and sensitive nature, it is frequently misdiagnosed or overlooked. Case Report: A 33-year-old woman presented with dyspareunia, urinary incontinence, and recurrent UTIs during infertility evaluation. Despite normal menstrual cycles and external genitalia, she reported painful intercourse and confusion regarding penetration. Imaging revealed normal uterus and ovaries, with a collapsed lower vaginal segment. Examination under anesthesia identified a dilated, incompetent urethral meatus allowing one-finger passage, with urine leakage, and a small vaginal opening below it. Vaginal dilation was performed, and urethroplasty was advised alongside pelvic floor exercises. She was placed under follow-up for infertility management. Conclusion: Urethral coitus in the presence of a normal-appearing vagina is an underrecognized cause of dyspareunia and urinary symptoms. Early diagnosis through careful history-taking, imaging, and examination is essential to prevent long-term complications such as megalourethra and psychological distress.  

Introduction 

The female urethra is a short, tubular structure extending from the bladder to the external urethral meatus, located anterior to the vaginal opening. Urine flow is typically painless and under voluntary control. Rarely, urethral coitus is a condition where sexual intercourse occurs via the urethra and may cause significant trauma, leading to urethral dilatation, urinary incontinence, and recurrent urinary tract infections (UTIs).
Urethral intercourse is an exceptionally rare condition, with only about thirty documented cases globally [1]. It is most commonly reported in women with congenital anomalies such as vaginal agenesis or hypoplasia. However, it may occasionally occur in women with normal external genitalia, presenting with non-specific symptoms such as painful intercourse, recurrent infections, and unexplained urinary complaints [2,3]. In such cases, a high index of suspicion is essential to avoid delayed or missed diagnosis.

Case Report

A 33-year-old woman presented for infertility evaluation with complaints of dyspareunia, urinary incontinence, and recurrent UTIs. Married for three years, she had been attempting conception for one year. Her menstrual cycles were regular, and there was no history of pelvic surgery, trauma, radiotherapy, or chemotherapy. Initial intercourse was painful, gradually becoming tolerable, though associated with incomplete penetration and repeated urinary infections. The patient was uncertain about the anatomical site of penetration during intercourse, leading to suspicion of urethral coitus.
On examination, secondary sexual characteristics were normal. The vulva, clitoris, labia majora, and labia minora appeared anatomically normal, but the patient could not tolerate a full per vaginal exam due to pain. Urine culture was sterile. Abdominal ultrasonography showed a normal-sized anteverted uterus with adequate endometrial thickness and normal ovaries. MRI of the pelvis revealed a retroverted uterus (6.8×3.8×3.1 cm), normal ovaries, a visible upper third of the vaginal cavity, and a collapsed lower two-thirds. An examination under anaesthesia revealed a dilated urethral meatus, easily admitting one finger with evident urinary leakage [Fig.1]. A small vaginal opening was noted below the urethral orifice. Vaginal dilation was performed via margin incision. Transvaginal ultrasound confirmed a normal uterus and ovaries [Fig.2].
A micturating cystourethrogram (MCU) revealed no structural urinary tract abnormalities [Fig.3]. Urethroplasty was recommended, along with Kegel exercises. The patient was also advised to use serial vaginal dilators and was scheduled for further infertility evaluation and follow-up.




Discussion

Urethral intercourse, though rare, can occur in the absence of classic Müllerian anomalies. When present, it may result in complications such as megalourethra, urinary incontinence, pain, recurrent UTIs, or trauma [4]. In some reports, including those by Zargham et al. stress incontinence has been directly linked to urethral coitus [5]. In this case, improper identification of the vaginal introitus led to unintentional urethral penetration and subsequent complications. Diagnostic delays are common due to the sensitive nature of the complaint and lack of awareness among clinicians. Proper clinical evaluation, including imaging modalities like ultrasound and MRI, plays a key role in establishing the diagnosis.
Megalourethra results in poor urethral sphincter function, contributing to stress urinary incontinence and impaired quality of life. Although most frequently associated with vaginal anomalies such as agenesis or imperforate hymen, urethral coitus may occur even when the external genitalia appear anatomically normal. The incidence of such cases is likely underreported due to social stigma and diagnostic challenges [6]. Surgical correction remains the mainstay of treatment for complications such as incontinence and urethral dilation, with techniques including urethral plication and sling procedures. Adjunct therapies like Kegel exercises and vaginal dilators aid in rehabilitation and prevention of recurrence.

Conclusion

Urethral dilatation due to unrecognized urethral coitus can present with dyspareunia, urinary incontinence, and psychological distress. Early identification and appropriate intervention are crucial to prevent long-term complications. Multidisciplinary management involving urologists and gynaecologists ensures optimal outcomes in these rare and often overlooked cases.

Contributors: SC: manuscript writing, patient management; RH: manuscript editing, patient management; MGD: critical inputs into the manuscript. SC will act as a study guarantor. All authors approved the final version of this manuscript and are responsible for all aspects of this study.
Funding: None; Competing interests: None stated.

References
  1. Ucar MG, Ilhan TT, Kebapcilar AG, Tosun Z, Çelik C. Urethral coitus in a case of vaginal agenesis is only vaginoplasty enough to treat the urinary problems. J Clin Diagn Res. 2016;10:DQ01-DQ03.
  2. Aksakal OS, Cavkaytar S, Guzel AI, Uzan C, Doganay M. Urinary incontinence due to urethral coitus in multiparous woman. Female Pelvic Med Reconstr Surg. 2015;21:e39-e40.
  3. Habek D, Arbanas G, Jukic V. An unusual case of infertility: Urethral coitus due to cribriform hymen. Arch Sex Behav. 2018;47:811-813.
  4. Bacopoulou F, Creatsas G, Chrousos GP, Papanikolaou N, Deligeoroglou E. Primary amenorrhea in adolescent girls: normal coitus or not? Always take a look in the physician's office. BMC Womens Health. 2014;14:23.
  5. Zargham M, Abbasi H, Alizadeh F, Khorami MH, Tadayon F, Gharaati MR, et al. Intraurethral intercourse: a report of two cases. Urol J. 2014;11:1343-1346. 
  6. Tomoe H, Sekiguchi Y, Horiguchi M, Toma H. Questionnaire survey on female urinary frequency and incontinence. Int J Urol. 2005;12(7):621-630.