Urethral stricture

Urethral stricture
Specialty	Urology

A urethral stricture is a narrowing of the urethra caused by injury or disease such as urinary tract infections or other forms of urethritis.

Signs and symptoms

During the early stages of the condition, the subject may experience pain during urination and the inability to fully empty the bladder. It is not uncommon for the bladder's capacity to significantly increase due to this inability to completely void.

Urethral strictures may cause problems with urination, including in certain cases the complete inability to urinate, which is a medical emergency. Additionally, a urinary tract infection is often present at, or prior to initial diagnosis. Antibiotics, quinolone class anti-infective agents, or a combination of trimethoprim/sulfamethoxazole are often employed as the initial stage of treatment. Occasionally, some degree of relief from straining, or improvement of the urinary stream (depending on the severity of the stricture) occurs with antibiotic treatment due to the reduction of urethral inflammation.

• Obstructive voiding symptoms namely:
  • Decreased force of urinary stream
  • Incomplete emptying of the bladder
  • Urinary terminal dribbling
  • Urinary intermittency
  • Deflected urinary stream

• Increased frequency of micturition
• Acute or chronic retention of urine
• Hydronephrotic signs due to back pressure

Complications

• Urinary retention
• Urethral diverticulum
• Periurethral abscess
• Urethral fistula
• Bilateral hydronephrosis
• Urinary infections
• Urinary calculus
• Hernia, haemorrhoids or Rectal prolapse from straining

Causes

Urethral strictures are generally caused by either injury-related trauma to the tract or by a viral or bacterial infection of the tract, often caused by certain sexually transmitted infections (STIs). The body's attempt to repair the damage caused by the injury or infection creates a buildup of scar tissue in the tract resulting in a significant narrowing or even closure of the passage. Instrumentation of the urethra, particularly before the advent of flexible uro-endoscopy, was (and remains) an important causative event.

Short strictures in the bulbar urethra, particularly between the proximal 1/3 and distal 2/3 of the bulb, may be congenital. They probably form as a membrane at the junction between the posterior and anterior urethral segments. It is not usually noticeable until later in life, as it fails to widen as the urethra does with growth, thus it only impedes urinary flow relative to the rest of the urethra after puberty. Moreover, the patient will often not "know any different", and so will not complain about poor flow.

The urethra runs between the legs very close to the skin, leaving it vulnerable to trauma. Simply falling off a bike and hitting between the legs may result in the formation of scar tissue within the urethra tract. This condition is often not found until the patient has problems urinating because these are painless growths of scar tissue.

Passage of kidney stones through the urethra can be painful and subsequently can lead to urethral strictures.

In infants and toddlers, can be as a result of inflammation following a circumcision and not noticeable until toilet training when a deflected stream is observed or when the child must strain to produce a urinary stream.

Diagnosis

Urethrography showing an urethra stricture in a man.

• Cystoscopy
• Urethrography

Treatment

Instrumental treatment

• Urethral dilitation with urethral sounds or filiform catheter and followers (at prescribed intervals depending upon the severity and location of the stricture and the age/health of the patient) (office procedure - topical anesthetic)
• Bougies of increasing size (gum, elastic, continuous dilatation) (this is a seldom used method/treatment modality due to the increased possibility of infection, discomfort, and time involved)
• PRN Urethral Dilitation, usually every three to six months (office procedure - topical anesthetic)

Emergency treatment

• Dilatation with filiform and followers, and drainage of the urinary bladder through the follower catheter/lumen (Emergency Department or office-based procedure)
• Cystoscope guided insertion of filiform and followers, and drainage of the urinary bladder through the follower catheter/lumen (Emergency Department or office-based procedure)
• Visual Internal Urethrotomy with placement of Foley catheter and urinary drainage system for 7 days post-procedure (Operating Room based procedure under local or general anesthesia)
• Insertion of a suprapubic catheter with catheter drainage system (prior to surgical resolution) (Operating Room, Emergency Department or office-based procedure)

Surgery

• Visual internal urethrotomy
• Laser ablation urethrotomy
• Single-Stage urethroplasty (anastomotic, penile flap or buccal mucosal onlay procedures)
• Two-stage "Johansen's urethroplasty" (limited to the most severe cases, usually for traumatic stricture or BXO)
• Temporary urethral stent placement
• Permanent urethral stent placement

Ongoing care

Because of the high rate of recurrence, Urethral Stricture Disease is often a lifetime-long diagnosis, even after successful surgical resolution of the stricture. Patients should be monitored (and treated) for urinary tract infection , including patient instruction/education on detection of the symptoms of UTI and undergo a non-invasive Uroflowmetric Study at annual intervals for at least five years (post surgery). Additionally, after age 40, it is recommended that the prostate be monitored (in males) at intervals as determined by the physician/practitioner overseeing the situation. Although no formal studies are available documenting this, there appears to be a slightly higher incidence of prostatitis in stricture patients versus the general population. Patient education and counseling is an important aspect of the successful resolution, and continued care for the stricture patient.

References

• MacDonald MF, Al-Qudah HS, Santucci RA (2005). "Minimal impact urethroplasty allows same-day surgery in most patients". Urology. 66 (4): 850–3. doi:10.1016/j.urology.2005.04.057. PMID 16230151. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

• Al-Qudah HS, Cavalcanti AG, Santucci RA (2005). "Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty". International Braz J Urol. 31 (5): 459–63, discussion 464. doi:10.1590/S1677-55382005000500007. PMID 16255792.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Santucci RA, McAninch JW, Mario LA; et al. (2004). "Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications". J Urol. 172 (1): 201–3. doi:10.1097/01.ju.0000128810.86535.be. PMID 15201773. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

• Kizer WS, Armenakas NA, Brandes SB, Cavalcanti AG, Santucci RA, Morey AF (2007). "Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting". J Urol. 177 (4): 1378–81, discussion 1381–2. doi:10.1016/j.juro.2006.11.036. PMID 17382736. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

• Al-Qudah HS, Santucci RA (2005). "Extended complications of urethroplasty". Int Braz J Urol. 31 (4): 315–23, discussion 324–5. PMID 16137399.

• Santucci RA, Mario LA, McAninch JW (2002). "Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients". J Urol. 167 (4): 1715–9. doi:10.1016/S0022-5347(05)65184-1. PMID 11912394. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Essentials of Surgery 4th Edition 2007 by Professor Muhammad Shamim

External links

• Reconstructive Urology

• Urethral stricture support group