Urethral strictures

Introduction

A narrowing of the urethra

Caused by injury or disease including UTIs and other forms of urethritis.

Above insult leads to scar tissue formation which contracts hence reducing the caliber of the urethral lumen.

End result is the resistance to antegrade flow of urine and semen.

Causes

• Traumatic

• Iatrogenic :post instrumentation( including catheter ,urethral endoscopy)

• Post operative :open prostatectomy ,amputation of the penis.

• Congenital

• Malignancies

Presentation :

• Obstructive voiding symptoms ,urine retention(decreased force of stream incomplete bladder emptying ,dribbling ,intermittency)

• UTI s

•Complications • Retention of urine • Urethral diverticulum• Peri urethral abcess • Urethral fistulas • Urethral calculi• Hernia ,heamorrhoides and rectal

prolapse.

•Management

Principles of treatment

Proper understanding of the relevant anatomy

Accurate diagnosis

Skilled surgical technique

Making diagnosis

Suggestive history

Findings on physical exam

Radiographic technique

Radiographic imaging:

Contrast studies achieved by retrograde and antegrade cystourethrography.

Ultrasonography : A transducer placed longitudinally along the penis.

Can evaluate Stricture length

Degree and depth of spongiofibrosisEndoscopic evaluation

Done using either rigid or flexible cystourethorgraphy

Treatment

Note : no medical therapy exists for urethral stricture Surgical therapy:Uretharal dilatation Internal urethrotomy Permanent utrethral stents Open reconstruction

Primary repair Tissue transfer ,repair techniques

Urethral dilatation

The objective in patients with isolated strictures Drawbacks

It’s a blind procedure hence false passages can be created

recurrence rate infection

Internal urethrotomy Stricture is incised under direct vision using endoscopic

equipment. Objective is to incise the stricture and ensuring epithelialization before wound contraction reduces the lumen caliber.

Complications

Recurrence of stricture Bleeding

Extravasation of the irrigation fluid into the perispongial tissues.]Permanent urethral stents

Placed endoscopically Designated to be incorporated into the wall to produce a patent lumen.

Most useful in short strictures located in the bulbar urethra and in elderly patients.Draw backs

If placed distal to the bulbous urethra it can cause pain while sitting or during intercourse.

Migration of the stent Contraindicated in patients with dense strictures or prior urethral reconstruction.

Open reconstruction

Primary repair Hold standard against which other procedures are

compared to. Involves complete excision of the strictures with

reanstomosis . Technical points to be observed

Complete excision of the areas of fibrosis Widely patent

Tension free anastomosis Young patients have an additional benefit of having compliant tissues hence wide strictures can be safely excised and primary anastomosis done.

Complications

•

Post operative chordae

Penile shortening

Ejaculatory dysfunction

Decreased glans sensitivity

The repair is usually stented with a silicon catheter and urine delivered using a suprapubic catheter as healing takes place.

Tissue transfer

•TechniqueReserved for patients in whom multiple procedures have failed.

Conducted as two stage procedureSuccess depends on the blood supply of the local tissues at the site of placement.

Graft is harvested from desired non hair bearing location e.g. Buccal

mucosa ,rectal or bladder .

1st stage

Urethra is opened via a ventral midline incision and the scarred urethra is excised completely.

Dartos fascia is mobilized bilaterally and closed over the urethral bed.

Desired skin is harvested and sutured to the dartos covered ventral urethral bed.

Catheter is placed for suturing.

2nd stage

Takes place 6-9 months after the initial operation.

Skin strip is mobilized along the urethra that will be used to fashion a neo urethra.

Dartos fascia is not interfered with.

Must be water tight closure.

Catheter is left in site for stenting purposes.

Complications:

Post voiding dribbling.

Post operative diverticulum.

Skin retraction of the ventral skin of the penis.

Urethra cutaneous fistula.

Above can be minimized by having the appropriate experience and surgical technique.

Oral complications : pain ,persistent numbness ,tightness or coarseness over donor site.

Contra indications to surgery

Active urinary tract infection.

Must rule out malignancy ,endoscopic biopsy done in case of luminal mass.

Prognosis

• Prospective randomized comparison of internal urethrotomy and dilatation showed no significant difference in efficacy when used as the initial treatment.

• Recurrence rate is directly proportional to the stricture length.

• Rate at 12 months • 2cm ------ 40%• 2-4cm -----50% increased to 75% at 48

months.• > 4cm ------80%

Stents

Long term success rate of 84% at 5 years.

And increased patient satisfaction.

Excision with primary anastomosis

•Most successful. • Tissue transfer graft have overall success rate of > 95% over one year however there

is deterioration over time• External location and degree of scarring • Benign or malignant prostate obstruction • Post operative bladder neck contraction.• Complications • Chronic prostatitis• Chronic UTI • Epidydimal • Diverticula • Urethrocutaneous fistula• Peri urethral abscess.• Urethral carcinoma • Vesical stones from stasis • Ascending pyelonephritis.• Renal failure

Circumcision

•Is the surgical removal of some or all of the foreskin.• Indications : young boy • Social • Religion • Therapeutic:• Phimosis • Infection: balanitis ,balanoposthitis ,posthitis • Xeroderma balanitis obliterans • Paraphimosis tight phrenulum• UTI • Adults • Inability to retract foresking• Tight frenulum• Balanitis• Before radiotherapy

•Timing varies • Technique • Plastibel • Open as in adult• Complications • Bleeding • Infection• Meatal ulcer• Meatal stenosis • Pain • Psychological trauma • Lose of glans sensitivity • An ulcerated meatus in the circumcised meatus is a frequent

sumptom .• The ammonical diaper is the cause of this lesion.• Benefits

Foreskin 50% at 1 year retractable

90% at 3 years

99% at 17 years

Whitish ring of indurated skin.

Phimosis

• The foreskin can not be fully retracted over the glans penis .• Normal separation after 3 years• Non-retractability • Pathology :acquired • • .Balanitis xertica obliterans • Scarring• Balanitis• Repeated catheterization• Foreceful retraction• Untreated diabetic • Presentation • Pain during urination.• Obvious ballooning of foresking with urination.

RX/

• Betamethason 4-6 weeks

Betamethason dipropionate 0.05% for 2 weeks

Operation

Circumcision

Paraphimosis

• The foreskin becomes trapped behind the glans penis and can not be reduced .

• Treated as medical emergency if• -persists for several hours• -signs of lack of blood flow.• It can result in gangrene.• Caused by • -during penile exam• -penile cleaning • -urethral catheterization• -Cystoscopy

Treatment:

• Manual

• Dorsal slit

Circumcision

•

Ulceration of the urethral meatus

• Is quite common in circumcised boys.• Delayed up to 2 years from circumcision.• Lack of protective prepuce• Friction • Ammonical dermatitis • Frenular artery ligation• Ulcer form a scab• Process cause fibrosis• Acquired pin hole meatus • follow up hypospedias repair .• phimosis • sparing or dribbling • chronic retention• renal impairment

treatment

• medical

• local measures to soften the scab and alkalinization of urine .

• Meatotomy

STD

Gonorrheal urethritis • Gonorrhea is a STD• Caused by gram Neisseria gonnorhea • Gram negative kidney shaped diploccoi • Infect the anterior urethra of men.• Cervix in women• Presentaion within 2 to 10 days • Urethral discomfort • Dysuria scalding • Urethral discharge • May be slight discharge and white to yellow • Investigations :urethral smear gram staining • .

Complications

• • Posterior urethritis • Prostatitis • Epidydimorchitis• Periurethral abcess • Urethral strictures • Gonoccocal strictures • Iridocyclitis • Septicemia and endocarditis•

Treatment

• Antibiotics

Ciprofloxacin

Pencillin

• Contact For control

Women

• ASymptomatic• Increased vaginal discharge • Painful urination• Vaginal bleeding between periods • Abdominal pain • Pelvic pain• Complications • Infertility• Women pelvic inflammatory diesease• Increase risk of HIV

Non specific urethritis Non gonoccocal urethritis

• Diagnosed by exclusion• Chlamydia trachomatis• Ureaplasma urealytica • 50% unknown cause• Clinical features • • Dysuria : • a few days to 3 months discharge • Epididymitis • Rx • Doxycycline

Reiter's disease

• Sexually acquired reactive urethritis • Subacute urethritis 4-6 weeks clean

discharge.• Cnojuctivitis 50%• 10 days to 2 weeks arthritis • Keratoderma blennorhagic • Nodulr • Vesicular • Pusturlar• In the Sole of foot• Prognosis

• Arthiritis • Anterior uveitis • Treatment • Topical steroids and mydiatrics for the

eye• Antibiotics and systemic steroids

• •