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STRICTURE URETHRA

Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)

RELEVANT SCENARIO(S)
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A fifty seven years old man had history of urethral surgery one year ago, now presents with slowing of stream and incomplete bladder evacuation. Discuss relevant anatomy, investigations and management

LEARNING OBJECTIVES

POSSIBLE QUESTIONS

To be able to learn; Anatomy Etiology Investigation Treatment

Discuss various parts of urethra. Discuss investigations for urethral stricture. Discuss various options for treatment.

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STRICTURE URETHRA
Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)

ANATOMY
Stricture urethra is the narrowing of urethra. It is a scar resulting from tissue injury or destruction leading to shortening of the circumference. These changes result in reduced area of the urethral lumen and significant urodynamic effects. Its length varies from 1cm to more than 4cm. It is not so uncommon in males and very rare in females. It is more common in young or middle aged men and is equally common in all races. PARTS OF URETHRA PROSTATIC URETHRA It is the part of urethra from bladder neck (urethrovesical junction) to verumontanum. It is surrounded by the prostatic glandular tissue. MEMBRANOUS URETHRA It is the part of the urethra which traverses deep perineal pouch. It starts from (prostatic urethra) verumontanum proximally and ends at bulbous urethra distally. It is surrounded by external urethral sphincter. It is not attached to fixed tissue structures. Both prostatic and membranous urethra form posterior urethra. BULBOUS URETHRA It is the part of urethra covered by the midline fusion of bulbo-spongiosis muscles. Its proximal end is continuous with membranous urethra at the lower end of external urethral sphincter and it ends at penile urethra distally. PENILE URETHRA It is the pendulous part of urethra distal to bulbous urethra. It lies distal to suspensory ligaments of penis. It is also covered by corpus spongiosum. It ends at fossa navicularis. FOSSA NAVICULARIS It is the terminal part of urethra which is embedded in the erectile tissue of the glans penis terminating at the external urethral meatus. The bulbous urethra, penile urethra and fossa navicularis from the anterior urethra.

Anatomy of male urethra

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ETIOLOGY
CONGENITAL The congenital conditions having narrowing of urethra are not true strictures but have similar urodynamic effects. These are ;
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Tuberculosis (rarely) Bilharziasis.

Double barrel urethra or anterior urethral valves. Posterior urethral valves.

POST OPERATIVE ! Post prostatectomy ! Post amputation of penis NEOPLASTIC Carcinoma of prostate or bladder tumor spreading to urethra. CLINICAL FEATURES Reduced urinary flow Dysuria (Painful urination) Spraying of urine (Double stream) Straining to pass urine Frequency of micturition Pooling of urine in bladder Urinary tract infection Peri urethral abscess Pain lower abdomen Urinary retention Dribbling of urine Incontinence (Residual urine)

TRAUMATIC STRICTURES Fracture pelvis is most commonly associated with injury to urethra which follows to stricture urethra. IATROGENIC ! During catheterization ! During cystoscopy ! During transurethral resection
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GUN SHOT WOUNDS Closed anterior urethral injuries. Rupture of membranous urethra. Combined urethral, perineal and rectal injuries.

INFLAMMATORY STRICTURES ! Acute urethritis and its aftermath. (Gonococcal and non specific urethritis.) ! Chronic urethritis.

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Urethral stricture

Urethral stricture

Urethrogram

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INVESTIGATIONS
URINE EXAMINATION Microscopic. Macroscopic. Chemical (Sugar, albumen). Microbiological (culture and sensitivity). BLOOD EXAMINATION Haemoglobin percentage Total leucocyte count Differential leucocyte count Urea and electrolytes Creatinine clearance SONOURETHROGRAPHY It is the sonographic visualization of the urethra. It is an excellent investigation for the anterior urethral strictures. It can show the stricture and periurethral fibrosis as well. Its results are not so good for posterior urethral strictures. it can show the length of blind stricture as well1. Sonourethrography is an accurate predictor of stricture length and periurethral strictures. It is unsatisfactory in visualizing the posterior urethral strictures. MRI URETHROGRAPHY It is not performed commonly because of expenses and less availability. EXCRETORY UROGRAPHY This is extremely helpful to see the effects of stricture on the upper urinary tract and for measurement of the residual urine. RETROGRADE URETHROGRAPHY It is the contrast medium radiological visualization of the interior of urethra. It is the most important and helpful investigation. It shows the site and size of the stricture. It also shows the relationship of stricture with urogenital diaphragm. It has its own limitations. Radiourethrography under estimates the length of strictures in most of the cases2. URETHROSCOPY It is the endoscopic visualization of stricture and it is not only of diagnostic value but also of therapeutic value as dilatation can be performed. Catheter may be passed through it and internal urethrotomy can also be done with the urethrotome. RESIDUAL URINE MEASUREMENTS URODYNAMICS STUDIES Urinary flow rate is reduced.

Urethrogram

Urethrogram

Urethrogram

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TREATMENT
MANAGEMENT There are three aims of treatment in patients with stricture urethra ; ! Treatment to improve urinary flow rate ! Treatment of symptoms as of acute retention. The acute retention is relieved by suprapubic puncture of the bladder with disposable sterilized vesical catheter ! To avoid complications ! Adequate assessment of the site and size of the stricture and its effects on the bladder and upper urinary tract. ! Definitive treatment of the stricture. The site and size of stricture and its effects on urinary tract can be assessed by various direct and indirect investigations. DILATATION Gradual dilatation of urethra is still the most common and most useful method of its treatment. It is traditional treatment. Gentleness is very important while performing the urethral dilatation as rough dilatation or urethral injury leads to worsening of the stricture. Urethral dilatation can achieve upto 30% 3 good results over 5 years in patients with stricture . The urethral dilatation can help to avoid surgery in patients with sphincter strictures which can endanger the urinary continence after resection4. SELF DILATATION The patient is trained to lubricate and insert it regularly to keep the urethra dilated. It has the advantage of avoiding the complications being relatively safe option. STEROIDS The use of local steroid creams after urethral injuries or dilatation has been tried, but results have not been so great as one would have thought. INTERNAL URETHROTOMY OPTICAL & BLIND URETHROTOMY This is the longitudinal slitting of the stricture surgically from inside the urethra by urethrotome either optical or blind one. Otis urethrotome is used blindly and is quite useful. The healing of surgical wound is by first degree. Optical urethrotome is used to do selective urethrotomy of the stricture under vision. Cold knife or hot loop can be used for this propose. The results of this operation are reasonably satisfactory in most of the strictures. Endoscopic resection of the callus (stricture scar) improves the results of urethrotomy alone by 15%5. ND-YAG LASER THERAPY The laser is used for treatment of strictures endoscopically. It can achieve upto 73% successful results over 2 years period. It is better than internal urethrotomy with hot loop or cold knife6. EXTERNAL URETHROTOMY This is the opening of the urethra onto the skin. It is used as first stage procedure for urethroplasty. In this procedure, the stricture is opened up externally into perineum and free flow of urine is established proximal to the stricture.

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STENTING Walls stent is a self expanding resident prosthesis. It is inserted endoscopically into the stenosed part of 7 urethra. It has shown excellent short term results . URETHROPLASTY This is reconstruction of the urethra. Different

techniques have been used to make a urethral tube but satisfactory procedures have not been developed yet. Anastomotic urethroplasty for post traumatic strictures and "Patch" urethroplasty for post infective strictures give satisfactory results. The incidence of impotence is higher after urethroplasty8,9.

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.REFERENCES

Fernandez Fernandez A. Ramirez Estaban A. Gil Fabra J. et al. Diagnostic efficacy of echographic urethrography in the study of urethral stenosis. Actas Urologicas Espanolas.1992 Sep. [JC:2a1] : 16(8): 627-30.

32 cases with a follow up exceeding 5 years. Annals DUrologie. 1989. [JC:6ad] 23(6)-2. 6. Vicente J. Salvador J. Caffartti J. Endoscopic urothrotomy versus urethrotomy plus ND-YAG laser in the treatment of urethral stricture. European Urology. 1990. [JC:enm] 18(3):166-8. Resel L. Blanco E. Platas A. Mohammad Z. Mendez S. Tobio R. New permanent expendable prosthesis for the treatment of urethral stenosis. Actas urologicas Espanolas. 1990 Nov-Dec. [JC:2a1] 14(6): 422-6. Mundy AR. Results and complications of urethroplasty and its future. British Journal of Urology. 1993 Mar. [JC:b3k] 71(3): 322-5. Charles J Devine Jr. Gerald H Jordan. Steven M Schlossberg. Surgery of penis and urethra. CAMPBELL'S urology sixth edition. Walsh.Retik. Stamey. Vaughan. W B Saunders Company London, 1992. P: 29573032.

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Gupta S. Majumder B. Tiwari A. Gupta RK. Kumar B. Gujral RB. Sono-urethrography in the evaluation of anterior urethral strictures: correlation with radiographic urethrography. JCU-Journal of Clinical Ultrasound. 1993 May. [JC:htv] 21(4): 231-9. Hermanowicz M. Manande J. Rossi D. Serment G. Richaud C. Ducasson J. Long term evaluation of the treatment results of male urethral stenosis. Annals D. Urologie. 1990. [JC:6ad] 24(1): 68-72. Mundy AR. The treatment of sphincter strictures. Mundy AR. British journal of urology. 1989 Dec. [JC:b3k] 64(6): 626-8. Guillenin P. L Hermite J. Chopin G. Hubert J. Internal urethrotomy with endoscopic resection of the callus.

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