Stricture Urethra

Stricture Urethra Treatment

Urethral stricture is a disease process associated with a narrowing or stenosis of the involved segment of the urethra. The consequence of urethral stricture is obstructive urination.

Signs and symptoms

During the condition’s early stages, the patient may experience pain during urination and the inability to empty the bladder fully. It is not uncommon for the bladder’s capacity to significantly increase due to this inability to completely void

Obstructive voiding symptoms, namely:

Decreased force of the 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 backpressure

Complications

Urinary retention
Urethral diverticulum
Periurethral abscess
Urethral fistula
Bilateral hydronephrosis
Urinary infections
Urinary calculus
Hernia, haemorrhoids or Rectal prolapse from straining

Causes:

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, maybe 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. 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.
Trauma: The urethra runs between the legs very close to the skin, leaving it vulnerable to trauma. Simply falling off a bike and getting hit between the legs or a major road traffic accident leading to a fracture of the pelvic bone may result in scar tissue formation within the urethra tract.
Kidney stones: passage through the urethra can abrade its mucosa and can subsequently lead to urethral strictures.
Lichen Sclerosus = Lichen Sclerosis (LS): This is also known as Balanitis Xerotica Oblitarans or BXO. This is often debilitating disease of unclear etiology. Men with LS have whitish discolouration of the penile skin and can develop strictures involving the meatus alone or longer strictures.

Diagnosis:

DIAGNOSTIC EVALUATION

Uroflow: It is a computerized graphic representation of the flow of urine, which gives a rough estimate to the surgeon about the speed and force of the urinary flow.

Urethroscopy/Cystoscopy and Calibration

Calibration

Using a soft urethral catheter (usually 14 Fr) urethra is calibrated to see its adequacy.

Urethroscopy

This is a procedure where a small (14 French) lubricated telescope is gently placed into the urethra with advancement to the stricture. This instrument is called a cystoscope or a “scope”. With this, the stricture location and size can be assessed, and if the patient is under anaesthesia, endoscopic treatment is also done.

Urethral X-Ray Imaging (RUG-VCUG)

The standard procedures for urethral imaging are a retrograde urethrogram (RUG) and a voiding cystourethrogram (VCUG). Films are taken during injection and during voiding.

Retrograde Urethrogram (RUG)

The RUG is performed with the patient in the oblique position. This means that the patient is tilted 45 degrees. An initial film (called a scout film) is obtained to confirm that the position and exposure are correct before any contrast is instilled. Then, contrast is gently instilled into the urethra using a specialized adaptor that gently forms a seal at the tip of the penis. It is usually a painless procedure. This study gives a good overall view of the anterior urethra.

Voiding Cystourethrogram (VCUG)

The VCUG is the best study to evaluate the posterior urethra. After a scout film, dye is instilled into the bladder using a small urethral catheter or the suprapubic catheter, which is often present in patients with stricture disease. The patient is then asked to urinate, and during urination, a film is obtained. During urination, the bladder neck and external sphincters of the posterior urethra are supposed to relax and open as the bladder is contracting. If the posterior urethra is widely patent during voiding, this confirms that this portion of the urethra is normal.

The following is a RUG and VCUG in a patient with a bulbar stricture. Graphics are superimposed (on the VCUG) to show the location of the prostate and external sphincter muscle (posterior urethra). Notice how the posterior urethra is closed off at rest but wide open during urination. This confirms that the posterior urethra is normal.

DILATION, INTERNAL URETHROTOMY, URETHRAL STENTS

Urethral Stricture Dilation

Van Buren Sounds

This treatment is generally performed in the office and involves stretching the stricture using progressively larger dilators. Distal strictures towards the tip of the penis are often dilated using progressively larger metal instruments called urethral sounds.

Internal Urethrotomy (DVIU)

The internal urethrotomy procedure is performed in the operating room using an endoscopic instrument (a telescope advanced through the penis). There is a small blade towards the instrument’s tip that can be deployed once the stricture is reached to cut the stricture internally to “open it up” in one or more places. Since internal urethrotomy is performed using a telescope, it is often called an optical urethrotomy, visual urethrotomy, or a DVIU, which refers to direct vision internal urethrotomy.

PICTURE OF URETHROTOME

Subsequently, an indwelling catheter is placed to stent the urethra open for some time (often 1-2 weeks) as the urethra heals. When the urethra is incised, the cut extends through the cells lining the urethra into the surrounding tissues. The urethra is wider, but the incision is simply a cut, and a catheter is deployed. The success rate of this procedure may range from 35-to 70%.

URETHRAL STRICTURE TREATMENT WITH MEATOTOMY OR PERINEAL URETHROSTOMY

Meatotomy

An excellent option for treating discreet, short strictures of the urethral meatus, which is the opening of the urethra at the tip of the penis, is a meatotomy. A meatotomy is an incision of the urethral opening with subsequent placement of sutures at the edges, or sometimes a skin flap (Blandy’s Flap) can be raised to repair the stenotic area.

It is important to know the extent of the stricture before performing a meatotomy, as this is not necessarily a good option for longer strictures if the goal is to have the urethral opening within the glans penis and not the undersurface of the penis. A meatotomy is a simple outpatient procedure.

Patients who sustain these injuries must often be maintained with a suprapubic tube as the tear heals and the tissues become supple. It is generally not appropriate to formally repair the urethra until at least three months after the injury. At that time, the evaluation of patients with posterior urethral disruptions included imaging during the simultaneous injection of contrast through the urethra from below (RUG) and a scope inserted through the tract established by the suprapubic tube from above.

As contrast is instilled, the prostatic urethra fills up to the point of blockage, and the bladder is backfilled. The gap between the two ends can be measured, and the above study will allow the exact length and location of the defect to be determined.

A perineal urethrostomy is an opening under the scrotum connecting the skin to the urethra. The urine exits from the urethrostomy during urination and therefore does not have to travel through the narrow distal stricture. This is particularly appealing to older patients with multiple medical problems who desire relatively simple definitive treatment.

Younger patients do not choose this option as they do not want to sit to urinate or have semen exit from under the scrotum during ejaculation. This procedure, especially if not performed properly, can be complicated by narrowing at the opening, and stenosis of the urethrostomy can be challenging to repair.

OPEN RECONSTRUCTION: URETHROPLASTY

Urethroplasty

The open reconstruction of urethral stricture disease also called urethroplasty, may involve surgery to remove the involved segment and re-attach the two normal ends. This is called excision and primary anastomosis. This procedure is best suited for short strictures involving the bulbar or membranous urethra. When this repair is not possible, tissue can be transferred to augment and widen the narrow segment to a normal calibre. For example, the urethra can be augmented using penile skin. Other issues that can be used to reconstruct the urethra include a graft of buccal mucosa (skin inside the cheek). When the above procedures are not an option, alternatives include a two-stage repair where a buccal mucosa and/or a split-thickness skin graft is placed along the undersurface of the penis and later rolled into a new urethra (neo-urethra). The choice of repair is individual and influenced by the length and location of the stricture, the availability of local tissue, and other factors.

Recovery after Urethral Stricture Surgery

After surgery, the length of hospitalization varies but generally does not exceed five days. Patients seldom have any significant pain or swelling in the penis or scrotum. However, if a buccal mucosa graft is harvested from the inside of the cheek, it is not uncommon for the mouth to be sore. This slowly resolves daily, and pain medications are given as needed. Patients can immediately resume a normal diet after surgery. However, patients who undergo buccal mucosa graft harvests generally prefer a soft diet initially. When patients are discharged, they are encouraged to remain inactive for several weeks. Often, catheters remain for 2-3 weeks.

Follow-up after Urethral Reconstruction

Our patients return three months after surgery for a urethroscopy to assess the calibre of the repair under direct vision using a camera. When the urethra is widely patent four months after surgery, this confirms the technical success of the surgery, and the patient can be assured that it is likely that he will never have a problem with stricture disease in the future. However, late recurrences are possible, especially when the surgery requires a “re-do” repair or tissue transfer. Patients with Lichen Sclerosis, in particular, are at risk for late recurrence. Therefore, we recommend that patients have follow-ups annually by their local referring Urologist (or at our institution) indefinitely. Our protocol is an annual assessment of any symptoms or problems, an exam, urinalysis, Uroflow flow rate assessment, and post-void residual volume ultrasound check. If there is any suggestion of a problem, we advise cystoscopy to definitively evaluate the calibre of the urethra.

PELVIC BONE FRACTURE ASSOCIATED WITH POSTERIOR URETHRAL DISRUPTIONS

Evaluation of pelvic fracture trauma associated with urethral injuries

Pelvic bone fractures from motor vehicle trauma or crush injuries can be associated with urethral tears or disruptions. Often, the urethra is completely transected or torn, usually in the area of the membranous urethra, and the ends separate (generally from 1-4 cm). In general, patients are transported by ambulance to the nearest Emergency Room and are found to have blood at the tip of the urethra. Appropriate evaluation is with a retrograde urethrogram (RUG), which confirms the diagnosis.

Imaging showing extravasation

Once the patient is adequately resuscitated, suprapubic tubes are placed. These tubes enter the bladder directly through the lower midline abdomen and allow the urine to drain through the tube into a collection bag.

Suprapubic (SP) tube

We occasionally ask why we do not just fill the bladder with contrast using the suprapubic tube to obtain the imaging from above. The reason is that when a patient is not urinating, a normal bladder neck is closed at rest. Therefore, only the bladder will be filled, and the normal prostatic urethra will not be seen.

Those patients who suffer traumatic urethral injuries often have associated vascular, and nerve damage affecting the penis and urethra, and over half suffer erectile dysfunction due to the injury. So a good history and counselling are done for any post-operative complication.

Posterior Urethroplasty

Patients are admitted to the hospital to receive intravenous (IV) culture-specific antibiotics the day before surgery.

The surgery to repair the urethra, also called Progressive Perineal Urethroplasty or urethral reconstruction, is performed in the lithotomy position. An incision is made under the scrotum, and the urethra is identified and dissected free of surrounding tissues. The urethra is then transected at the distal point of the obliteration. At that point, very hard scar tissue is encountered, and the objective is to excise the scar until the healthy normal urethra is encountered on the other side of the scar. This requires guidance so that the dissection proceeds in the proper direction towards the normal urethra and not towards the rectum, the bladder, or other structures.

A common technique to provide this guidance of the dissection is to remove the suprapubic tube, place a solid “U” shaped instrument through the established tract between the skin and the bladder, and advance the sound through the bladder neck into the posterior urethra until the scar prevents further advancement.

This is a blind manoeuvre performed by “feel”. When the surgeon’s finger feels the impulse of the tip of the sound as the sound is manipulated, the tissue is then excised until the sound is reached.

Posterior urethral reconstruction is a very difficult surgery, and however, these injuries are amenable to repair with a very high success rate when properly performed. Our patients are maintained with urethral catheters and suprapubic tubes for three weeks after surgery and then return for imaging. In general, at that time, both tubes are then removed, and our patients generally resume normal urination without the need for further intervention.

LICHEN SCLEROSUS – BALANITIS XEROTICA OBLITERANS – BXO

Lichen sclerosus of the penis and urethra is also known as Lichen Sclerosis, Lichen Sclerosus et Atrophicus and Balanitis Xerotica Obliterans (BXO). This is generally an acquired disease of the penis and urethra, and it is not cancer and is not contagious or sexually transmitted. The cause is unknown. Men who develop this chronic and often debilitating disease are generally found to have one or more abnormalities on physical exam, including white penile skin colour change, especially along the skin towards the head (glans) of the penis, a smoothing of the indentation between the head of the penis and the shaft of the penis often with the appearance of penile skin fusion to the head of the penis, also called phimosis, and the urethra may feel indurated.

URETHRAL STRICTURES CAUSED BY BALANITIS XEROTICA OBLITERANS

BXO strictures can damage the entire anterior urethra.

BALANITIS XEROTICA OBLITERANS TREATMENT

The best management for very short strictures is a meatotomy or extended meatotomy, and the most appropriate treatment for longer strictures is urethroplasty (open urethral reconstruction).

The most complex structures are pan-urethral strictures involving the entire anterior urethra. Options for the remainder of the urethra include a one-stage repair using penile skin or buccal mucosa graft or a two-stage repair where in the first stage urethra is laid open in Stage 1, and the patient may have to pass urine in a sitting position till the time stage 2 is done. In stage 2, which is usually done after six months, the urethral tube is reconstructed over a catheter which is usually removed after three weeks.

Urethral Stricture Recurrence

The most common complication of open urethral stricture surgery is stricture recurrence. Although very discreet band like strictures can be successfully treated with a simple incision, failed repairs are often very troublesome as subsequent re-do repairs are complex, and the reconstructive surgical options are often limited.

It should be emphasized that the success of open urethroplasty depends on the surgical technique and the surgeon’s expertise. When urethral surgery is not properly performed, early stricture recurrence is a very common complication.

When penile or scrotal skin is taken for repair, hairs may grow inside the tube, leading to infection and recurrence, which may require surgery.

Positioning Complications

Bulbar and membranous stricture repair is generally performed through an incision in the perineum, the area under the scrotum. This requires that the patient be placed with the legs in stirrups. This is called the lithotomy position. When patients are placed in the lithotomy position for an extended period, it is not uncommon for the top of the feet to be numb or tingle for 1-2 days. This is not a significant problem as normal sensation then returns. However, there can also be a very prolonged sensation change, and several of our patients have experienced this complication. In general, these were patients who presented with complex strictures after prior surgery required extensive re-do reconstruction.

More serious complications include damage that prevents foot or other leg movement and compartment syndrome. There can be a buildup of pressure in a closed space within the lower leg called compartment syndrome when there is prolonged compression of the calves. This is a surgical emergency and is treated by making long deep incisions in the legs to relieve the pressure, and these incisions are called fasciotomies.

Other Complications

There are many potential complications of urethral reconstructive surgery, such as bleeding, infection, wound breakdown, tightness with erections (generally temporary), dribbling, and other complications. Some patients may have erectile dysfunction or incontinence. All surgery is associated with risk. However, these risks are very low when urethral surgery is properly performed, and blood loss is generally minimal. In general, the risks of not treating a stricture are far greater than repair risks.