1. URETHRAL STRICTURE DR AMU

2. OUTLINE DEFINITION EPIDEMIOLOGY PATHOLOGY CLASSIFICATION PATHOPHYSIOLOGY CLINICAL PRESENTATION INVESTIGATION TREATMENT CONCLUSION

3. DEFINITION Defined as Urethral stricture is a common urologic problem, with the highest prevalence in underdeveloped countries. Urethral strictureshave a significant economic impact and burden. Economics and resource availability can influence stricture treatment.

4. EPIDEMIOLOGY The true incidence of urethral stricture disease can only be estimated. However, in the United States, male urethral strictures occur at rates as high as 0.6% in susceptible populations and results in more than 5000 inpatient visits across the United States per year.

5. AETIOLOGICAL CLASSIFICATION Idiopathic Iatrogenic – Endoscopic procedures/ trans urethral surgery – instrumentation (e.g., traumatic catheter,placement/removal, chronic indwelling Foley catheter, Inflammatory – Gonococcal – Non gonococcal Traumatic: blunt and penetrating injuries – Straddle injuries – Pelvic fractures – Penetrating injuries : gun shot, stab wounds

6. OTHER CLASSIFICATION ANTERIOR – Bulbar – Penile – Meatal stenosis POSTERIOR – Membranous – prostatic

7. PATHOLOGY urethral stricture is a fibrotic processwith varying degrees of spongiofibrosis that resultsin poorly compliant tissue and decreased urethrallumen caliber. The normal urethra is a lined mostlyby pseudostratified columnar epithelium. Beneaththe basement membrane there is a connective tissuelayer of the spongiosum rich in vascular sinusoids and smooth muscle. The connective tissue iscomposed of mainly fibroblast and an extracellularmatrix that contains collagen, proteoglycans, elasticfibers and glycoproteins. The most dramatic histologic changes of urethral strictures occur in theconnective tissue. Strictures are the consequence of epithelial damage and spongiofibrosis.

8. pathophysiology urethral stricture patients annually have high rates of UTI (42%) and urinary incontinence (11%). Common complications from untreated urethral stricture disease can result in minor-to-severe complications, among them urethral discharge, urinary tract infection, stones, chronic prostatitis or epididymitis, periurethral abscess (a rupture of an infected glands of Littre outside the spongiosum), urethral diverticulum (an abscess thatforms but does not communicate with the overlying skin and often results in a outpouching, where a urethral stone may often form), and urethral

9. cancer (historically, one-third to one-half of men with urethral cancer have a history of stricture disease. Other complications can include urethrocutaneous fistula, where as long as there is a distal stricture, the urinary fistula will persist. When a maze of fistula channels link, it is often referred to as a “watering pot perineum.” Urine extravasationof urine into the perineum or scrotum typically is confined by Colle’s fascia and can result in devastating sequela. Infected hypertonic urine is particularly virulent and can cause fat and fascia necrosis of the scrotum, penis, and perineum, or even abdominal wall, as in Fournier’s gangrene

10. Clinical presentation Features of lower urinary tract symptoms Features of complication of strictures

11. investigations Antegrade and retrograde urethrogram Urethrocystoscopy Urethral ultrasound Abdominopelvic ultrasound Urine m/c/s s/e/u/c

12. treatment Urethral dilatation Direct visual internal urethrotomy Urethroplasty – End to end anastomosis – Substitution urethroplasty

13. Complications of treatment Uti, penile andscrotal oedema, Flap necrosis Urethrocutaneous fistula recurrence