IntroductionA narrowing of the urethraCaused by injury or disease including UTIs.and other forms of urethritisAbove insult leads to scar tissue formationwhich contracts hence reducing the caliber.of the urethral lumenEnd 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 treatmentProper understanding of the relevantanatomyAccurate diagnosisSkilled surgical technique
Making diagnosisSuggestive historyFindings on physical examRadiographic technique
:Radiographic imagingContrast studies achieved by retrograde and.antegrade cystourethrographyUltrasonography : A transducer placed. longitudinally along the penis Can evaluate Stricture lengthDegree and depth of spongiofibrosis Endoscopic evaluationDone using either rigid or flexiblecystourethorgraphy
TreatmentNote : no medical therapy exists for urethral stricture:Surgical therapy Uretharal dilatation Internal urethrotomy Permanent utrethral stents Open reconstruction Primary repairTissue transfer ,repair techniques
Urethral dilatation The objective in patients with isolated strictures DrawbacksIt‘s a blind procedure hence false passages can be created recurrence rateinfection Internal urethrotomyStricture is incised under direct vision using endoscopic. equipmentObjective is to incise the stricture and ensuringepithelialization 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 lumenMost useful in short strictures located in the bulbar urethra and in elderly.patients Draw backsIf 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 repairHold standard against which other procedures are.compared toInvolves complete excision of the strictures with .reanstomosis Technical points to be observed Complete excision of the areas of fibrosis Widely patent Tension free anastomosisYoung patients have an additional benefit of havingcompliant tissues hence wide strictures can be safely.excised and primary anastomosis done
Complications •Post operative chordae Penile shortening Ejaculatory dysfunction Decreased glans sensitivityThe repair is usually stented with a silicon catheterand urine delivered using a suprapubic catheter.as healing takes place
Tissue transferTechnique •Reserved for patients in whom multiple.procedures have failedConducted as two stage procedureSuccess depends on the blood supply of the.local tissues at the site of placementGraft is harvested from desired non hairbearing location e.g. Buccal mucosa .,rectal or bladder
1st stageUrethra is opened via a ventral midlineincision and the scarred urethra is excised.completelyDartos fascia is mobilized bilaterally and.closed over the urethral bedDesired skin is harvested and sutured to. the dartos covered ventral urethral bed.Catheter is placed for suturing
2nd stageTakes place 6-9 months after the initial.operationSkin 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 fistulaAbove can be minimized by having the appropriate.experience and surgical techniqueOral complications : pain ,persistent numbness.,tightness or coarseness over donor site
Contra indications to surgery.Active urinary tract infectionMust 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 retractable90% at 3 years99% at 17 yearsWhitish 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.
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
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• .
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
Reiters 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 ••