1. Urethral strictures

2. 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 .

3. Causes
Traumatic
Iatrogenic :post instrumentation( including catheter ,urethral endoscopy)
Post operative :open prostatectomy ,amputation of the penis.
Congenital
Malignancies

4. Presentation :
Obstructive voiding symptoms ,urine retention(decreased force of stream incomplete bladder emptying ,dribbling ,intermittency)
UTI s

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

6. Management
Principles of treatment
Proper understanding of the relevant anatomy
Accurate diagnosis
Skilled surgical technique

7. Making diagnosis Suggestive history Findings on physical exam
Radiographic technique

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. Contra indications to surgery
Active urinary tract infection.
Must rule out malignancy ,endoscopic biopsy done in case of luminal mass.

19. 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 %
2-4cm % increased to 75% at 48 months.
> 4cm %

20. Stents Long term success rate of 84% at 5 years .
And increased patient satisfaction.

21. 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

22. 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

23. 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

24. Foreskin 50% at 1 year retractable
90% at 3 years
99% at 17 years
Whitish ring of indurated skin.

25. 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.

26. RX/ Betamethason 4-6 weeks Betamethason dipropionate 0.05% for 2 weeks
Operation
Circumcision

27. 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

28. Treatment:
Manual
Dorsal slit
Circumcision

29. 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

30. treatment
medical
local measures to soften the scab and alkalinization of urine .
Meatotomy

31. 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 .

32. Complications Posterior urethritis Prostatitis Epidydimorchitis
Periurethral abcess
Urethral strictures
Gonoccocal strictures
Iridocyclitis
Septicemia and endocarditis

33. Treatment
Antibiotics
Ciprofloxacin
Pencillin
Contact For control

34. 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

35. 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

36. 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

37. Arthiritis
Anterior uveitis
Treatment
Topical steroids and mydiatrics for the eye
Antibiotics and systemic steroids