Urethral stricture

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Urethral structure
Classification and external resources
Gray1142.png
Urethra is tube at center.
ICD-10 N35
ICD-9 598
DiseasesDB 13562
MedlinePlus 001271
eMedicine med/3075
MeSH C12.777.767.700.700

A urethral stricture is a narrowing of the urethra[1] caused by injury or disease such as urinary tract infections or other forms of urethritis.

Signs and symptoms[edit]

Pain during urination can be experienced during the early stages of the illness accompanied by 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[edit]

Causes[edit]

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, urethral strictures can result from inflammation following a circumcision and may not be noticeable until toilet training when a deflected stream is observed or when the child must strain to produce a urinary stream.

Diagnosis[edit]

Urethrography showing an urethra stricture in man.

Treatment[edit]

Instrumental treatment[edit]

  • Urethral dilatation with urethral sounds or filiform catheter and followers. This may be performed as necessary; or at prescribed intervals, depending upon the severity and location of the stricture and the age and health of the patient, usually every three to six months. Urethral dilatation may be performed as an office procedure under topical anesthetic.

Emergency treatment[edit]

  • Urethral dilatation, as described above, and drainage of the urinary bladder through the follower catheter or lumen. This procedure may occur in an Emergency Department or practitioner's office.
  • Cystoscope-guided insertion of filiform catheter and followers, and drainage of the urinary bladder through the follower catheter or lumen. This procedure may occur in an Emergency Department or practitioner's office.
  • Visual Internal Urethrotomy with placement of Foley catheter and urinary drainage system for seven days post-procedure. This procedure is performed in an Operating Room under local or general anesthesia.
  • Insertion of a suprapubic catheter with catheter drainage system (prior to surgical resolution). This procedure is performed in an Operating Room, Emergency Department or practitioner's office.

Surgery[edit]

  • 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 [2]

Ongoing care[edit]

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 and 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 medical 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.[3] Patient education and counseling is an important aspect of the successful resolution, and continued care for the stricture patient.

Bioengineered urethral tissue research[edit]

The Wake Forest Institute of Regenerative Medicine has pioneered the first bioengineered human urethra, and in 2006 implanted urethral tissue grown on bioabsorbable scaffolding (approximating the size and shape of the affected areas) in five young (human) males who suffered from congenital defects, physical trauma, or an unspecified disorder necessitating urethral reconstruction. As of March, 2011, all five recipients report the transplants have functioned well.[4]

References[edit]

  • Santucci RA, McAninch JW, Mario LA, et al. (July 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. 
  • Kizer WS, Armenakas NA, Brandes SB, Cavalcanti AG, Santucci RA, Morey AF (April 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. 
  • Essentials of Surgery 4th Edition 2007 by Professor Muhammad Shamim

External links[edit]

See also[edit]