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 spongiofibrosis Endoscopic 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 Technique Reserved for patients in whom multiple procedures have failed. Conducted as two stage procedure Success 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