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STRICTURE URETHRASTRICTURE URETHRAMuhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)

STRICTURE URETHRASTRICTURE URETHRASTRICTURE URETHRA

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POSSIBLE QUESTIONSLEARNING OBJECTIVES

To be able to learn;

Anatomy Etiology InvestigationTreatment

Discuss various parts of urethra.

Discuss investigations for urethral stricture.

Discuss various options fortreatment.

RELEVANT SCENARIO(S)

l 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

Anatomy of male urethra

Stricture urethra is the narrowing of urethra. It is a Both prostatic and membranous urethra form scar resulting from tissue injury or destruction posterior urethra.leading to shortening of the circumference. These changes result in reduced area of the urethral lumen

It is the part of urethra covered by the midline fusion and significant urodynamic effects. Its length varies of bulbo-spongiosis muscles. Its proximal end is from 1cm to more than 4cm. It is not so uncommon in continuous with membranous urethra at the lower males and very rare in females. It is more common in end of external urethral sphincter and it ends at young or middle aged men and is equally common in penile urethra distally.all races.

It is the pendulous part of urethra distal to bulbous It is the part of urethra from bladder neck (urethro- urethra. It lies distal to suspensory ligaments of vesical junction) to verumontanum. It is surrounded penis. It is also covered by corpus spongiosum. It by the prostatic glandular tissue. ends at fossa navicularis.

It is the terminal part of urethra which is embedded in It is the part of the urethra which traverses deep the erectile tissue of the glans penis terminating at perineal pouch. It starts from (prostatic urethra) the external urethral meatus. The bulbous urethra, verumontanum proximally and ends at bulbous penile urethra and fossa navicularis from the anterior urethra distally. It is surrounded by external urethral urethra.sphincter. It is not attached to fixed tissue structures.

BULBOUS URETHRA

PENILE URETHRAPARTS OF URETHRAPROSTATIC URETHRA

FOSSA NAVICULARISMEMBRANOUS URETHRA

ANATOMY

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

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Urethral stricture Urethral stricture

ETIOLOGY CONGENITAL

POST OPERATIVE

NEOPLASTICTRAUMATIC STRICTURES

CLINICAL FEATURESIATROGENIC

GUN SHOT WOUNDS

INFLAMMATORY STRICTURES

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

! Post prostatectomy! Double barrel urethra or anterior urethral valves.

! Post amputation of penis! Posterior urethral valves.

Carcinoma of prostate or bladder tumor spreading to Fracture pelvis is most commonly associated with

urethra.injury to urethra which follows to stricture urethra.

! Reduced urinary flowDuring catheterization! Dysuria (Painful urination)During cystoscopy! Spraying of urine (Double stream)During transurethral resection! Straining to pass urine

! Frequency of micturition! Closed anterior urethral injuries. ! Pooling of urine in bladder! Rupture of membranous urethra.

! Urinary tract infection! Combined urethral, perineal and rectal injuries.

! Peri urethral abscess

! Pain lower abdomen

! Urinary retention! Acute urethritis and its aftermath.

! Dribbling of urine (Gonococcal and non specific urethritis.)! Incontinence (Residual urine)! Chronic urethritis.

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Urethrogram

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URINE EXAMINATION EXCRETORY UROGRAPHY

RETROGRADE URETHROGRAPHYBLOOD EXAMINATION

SONOURETHROGRAPHY

URETHROSCOPY

RESIDUAL URINE MEASUREMENTSURODYNAMICS STUDIES

MRI URETHROGRAPHY

Microscopic. This is extremely helpful to see the effects of stricture

Macroscopic. on the upper urinary tract and for measurement of

Chemical (Sugar, albumen). the residual urine.

Microbiological (culture and sensitivity).

It is the contrast medium radiological visualization of Haemoglobin percentage

the interior of urethra. It is the most important and Total leucocyte count

helpful investigation. It shows the site and size of the Differential leucocyte count

stricture. It also shows the relationship of stricture Urea and electrolytes

with urogenital diaphragm. It has its own limitations. Creatinine clearance

Radiourethrography under estimates the length of 2strictures in most of the cases .

It is the sonographic visualization of the urethra. It is

an excellent investigation for the anterior urethral It is the endoscopic visualization of stricture and it is strictures. It can show the stricture and periurethral not only of diagnostic value but also of therapeutic fibrosis as well. Its results are not so good for value as dilatation can be performed. Catheter may posterior urethral strictures. it can show the length of

1 be passed through it and internal urethrotomy can blind stricture as well . Sonourethrography is an also be done with the urethrotome.accurate predictor of stricture length and periurethral

strictures. It is unsatisfactory in visualizing the

posterior urethral strictures.

Urinary flow rate is reduced.

It is not performed commonly because of expenses

and less availability.

Urethrogram Urethrogram Urethrogram

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INVESTIGATIONS

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MANAGEMENT STEROIDS

INTERNAL URETHROTOMYOPTICAL & BLIND URETHROTOMY

DILATATION

ND-YAG LASER THERAPY

EXTERNAL URETHROTOMYSELF DILATATION

There are three aims of treatment in patients with The use of local steroid creams after urethral injuries

stricture urethra ; or dilatation has been tried, but results have not been

! Treatment to improve urinary flow rate so great as one would have thought.

! Treatment of symptoms as of acute retention.

The acute retention is relieved by suprapubic

puncture of the bladder with disposable This is the longitudinal slitting of the stricture sterilized vesical catheter surgically from inside the urethra by urethrotome ! To avoid complicationseither optical or blind one.! Adequate assessment of the site and size of the

stricture and its effects on the bladder and upper Otis urethrotome is used blindly and is quite useful. urinary tract. The healing of surgical wound is by first degree. ! Definitive treatment of the stricture.

Optical urethrotome is used to do selective The site and size of stricture and its effects on urinary urethrotomy of the stricture under vision. Cold knife tract can be assessed by various direct and indirect or hot loop can be used for this propose. investigations.

The results of this operation are reasonably Gradual dilatation of urethra is still the most common satisfactory in most of the strictures. Endoscopic and most useful method of its treatment. It is resection of the callus (stricture scar) improves the

5traditional treatment. Gentleness is very important results of urethrotomy alone by 15% .while performing the urethral dilatation as rough

dilatation or urethral injury leads to worsening of the

stricture. Urethral dilatation can achieve upto 30% The laser is used for treatment of strictures 3

good results over 5 years in patients with stricture . endoscopically. It can achieve upto 73% successful

results over 2 years period. It is better than internal The urethral dilatation can help to avoid surgery in 6urethrotomy with hot loop or cold knife .patients with sphincter strictures which can

4endanger the urinary continence after resection .

This is the opening of the urethra onto the skin. It is The patient is trained to lubricate and insert it used as first stage procedure for urethroplasty. In this regularly to keep the urethra dilated. It has the procedure, the stricture is opened up externally into advantage of avoiding the complications being perineum and free flow of urine is established relatively safe option. proximal to the stricture.

TREATMENT

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STENTING

URETHROPLASTY

techniques have been used to make a urethral tube

Walls stent is a self expanding resident prosthesis. It but satisfactory procedures have not been

is inserted endoscopically into the stenosed part of developed yet. Anastomotic urethroplasty for post 7

urethra. It has shown excellent short term results . traumatic strictures and "Patch" urethroplasty for

post infective strictures give satisfactory results. The

incidence of impotence is higher after urethro-8,9This is reconstruction of the urethra. Different plasty .

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.REFERENCES 32 cases with a follow up exceeding 5 years. Annals D-

Urologie. 1989. [JC:6ad] 23(6)-2.1. Fernandez Fernandez A. Ramirez Estaban A. Gil Fabra J.

et al . Diagnostic efficacy of echographic 6. Vicente J. Salvador J. Caffartti J. Endoscopic urethrography in the study of urethral stenosis. Actas

urothrotomy versus urethrotomy plus ND-YAG laser Urologicas Espanolas.1992 Sep. [JC:2a1] : 16(8): 627-30.in the treatment of urethral stricture. European Urology.

1990. [JC:enm] 18(3):166-8.2. Gupta S. Majumder B. Tiwari A. Gupta RK. Kumar B. Gujral

RB. Sono-urethrography in the evaluation of anterior 7. Resel L. Blanco E. Platas A. Mohammad Z. Mendez S. urethral strictures: correlation with radiographic

Tobio R. New permanent expendable prosthesis for the urethrography. JCU-Journal of Clinical Ultrasound. 1993 treatment of urethral stenosis. Actas urologicas May. [JC:htv] 21(4): 231-9.Espanolas. 1990 Nov-Dec. [JC:2a1] 14(6): 422-6.

3. Hermanowicz M. Manande J. Rossi D. Serment G. 8. Mundy AR. Results and complications of urethroplasty Richaud C. Ducasson J. Long term evaluation of the

and its future. British Journal of Urology. 1993 Mar. treatment results of male urethral stenosis. Annals D. [JC:b3k] 71(3): 322-5.Urologie. 1990. [JC:6ad] 24(1): 68-72.

9. Charles J Devine Jr. Gerald H Jordan. Steven M 4. Mundy AR. The treatment of sphincter strictures. Schlossberg. Surgery of penis and urethra. Mundy AR. British journal of urology. 1989 Dec. [JC:b3k] CAMPBELL'S urology sixth edition. Walsh.Retik. Stamey. 64(6): 626-8.Vaughan. W B Saunders Company London, 1992. P: 2957-

3032.5. Guillenin P. L Hermite J. Chopin G. Hubert J. Internal

urethrotomy with endoscopic resection of the callus.

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