STRICTURE URETHRA

Issah J. kiswagala

(MD)

SURGICAL ANATOMY

• The urethra is a tube that carries urine from the bladder so it can be expelled from the body. In addition to urine, the male urethra transports semen – a fluid containing spermatozoa and sex gland secretions.
• The male urethra is approximately 15-20cm long. In females, the urethra is relatively short (approximately 4cm).
• According to the latest classification, the male urethra can be divided anatomically into three parts (proximal to distal):
• Prostatic urethra: Begins as a continuation of the bladder neck and passes through the prostate gland. It is the widest and most dilatable portion of the urethra.
• Membranous urethra: Passes through the pelvic floor and the deep perineal pouch. It is the narrowest and least dilatable portion of the urethra.
• Penile (bulbous) urethra: Passes through the bulb and corpus spongiosum of the penis, ending at the external urethral orifice (the meatus).

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• In the glans (head) of the penis, the urethra dilates to form the navicular fossa.
• Urethra is lined by stratified columnar epithelium, which is protected from the corrosive urine by mucus secreting glands.

URETHRAL STRICTURE

• Usually the urethra is wide enough for urine to flow freely through it. When the urethra narrows, it can restrict urinary flow. This is known as a urethral stricture.

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EPIDEMIOLOGY

• Urethral stricture is a medical condition that mainly affects men.
• The real incidence of male urethral stricture disease remains unknown, and worldwide differences have been observed based on geography, population, and mean country income.
• The number of patients with urethral strictures climbs sharply after 55 yr of age in the Western population. 
• Trauma remains the most common aetiology of urethral strictures in developing and Third World countries. About 90% of men with urethral stricture disease present complications.

AETIOLOGY/RISK FACTORS

AETIOLOGICAL CLASSIFICATION.

Classification I:

1. Congenital - very rare
2. Inflammatory:
• a. Post-gonococcal is commonest (70%).
• Gonococcal stricture occurs one year after infection due to periurethral fibrosis
• Retention develops only 10-15 years later.
• Common in the bulb of urethra especially in the roof.
• Here multiple strictures are common, proximal stricture is the narrowest

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• b. Tuberculous.
• c. Other infection (urethritis) and schistosomiasis

3. Traumatic: Bulbous, membranous.
4. Post - instrumentation: Catheterization, dilator, transurethral procedures such as cystoscope.
5. Postoperative: Prostate surgery (4%), urethrostomy or repair of ruptured urethra

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Classification II:

1. Proximal: Common in bulbous urethra (70%).
2. Distal: Congenital (in the external meatus). Often traumatic in children

Classification III:

1. Permeable: Permits urine to pass.
2. Impermeable.

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Classification IV:

1. Passable: Allows catheter to pass.
2. Impassable.

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Classification V:

It can be;-

1. single or
2. multiple

CLINICAL FEATURES

• Common in young age (20--40 years).
• Poor urinary stream
• History of straining while passing urine.
• Frequency, dysuria
• Incomplete emptying
• Retention and often with overflow
• Forking and spraying of the stream
• Pain, burning micturition, suprapubic tenderness
• Thickening and button-like feeling in bulbar urethra.(Bulbous urethra is felt clinically by lifting the scrotum in midline in the perineum.)

DIFFERENTIAL DIAGNOSIS

• BPH
• Bladder calculi
• Bladder carcinoma

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INVESTIGATIONS

• Complete blood count (↓Hb%)
• Blood urea and serum creatinine.
• Urine microscopy and culture.
• Ascending urethrogram is an essential investigation to see the site, type, extent and false passage.
• U/S abdomen.
• IVU to see hydronephrosis and function of kidney
• X-ray of pelvis to see old fracture with history of trauma.

TREATMENT

PRE – REFERRAL MANAGEMENT.

• Catheterization if fails then do suprapubic puncture with a canullae OR
• Do SPC then refer to a district/regional hospital

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TREATMENT

1. Intermittent dilatation:
• Gradual dilatation, initially with thin dilators, later with thicker dilators of increasing size.
• Dilatation should be done in OT under aseptic precaution.
2. Urethroplasty:
• Stricture is excised and urethra is reconstructed using prepuceal skin or scrotal skin.(Johanson’s urethroplasty).

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3. Visual internal cystoscopic urethrotomy or stricturotomy:
• Here using cystoscope, stricture is visualized and is cut at 12 o’clock position, until it bleeds (fibrous tissue is cut completely).
• After that Foley’s catheter is passed and kept in position for 48 hours.
4. External urethrotomy by open method.
• Presently not commonly done as cystoscopic urethrotomy is more popular.

PROGNOSIS

• Prognosis is good if it’s done timely and proper

COMPLICATIONS

• Retention of urine
• Urethral fistula
• Infection-urethritis, cystitis, pyelonephritis
• Urethral diverticula
• Peri-urethral abscess
• Bilateral hydronephrosis
• Stone formation
• Renal failure
• Due to straining—hernia, haemorrhoids, rectal prolapse

FOLLOW UP

• There is no consescus about the optimal intervals and duration of follow up. Since most stricture recurrence occurs in the first 12 months after treatment,
• 3- 4 monthly follow up for 24 months and then yearly seems reasonable.
• After anastomotic urethroplasty patients should be followed for at least 5 years and substitution urethroplasty for 15 years