power point discussing urethral stricture. for undergraduate and postgraduates

1. Discuss the principles of
management of urethral
stricture
Presenter Dr Isaac MBBS, aFMCS, MWCS
02/04/2023

2. outline
• Introduction
• Statement of surgical importance
• Epidemiology
• Relevant anatomy
• Classification
• Aetiology
• Pathogenesis
• Diagnosis
• Treatment
• Current trend
• Prevention
• Conclusion
• Reference

3. Introduction
• This is the narrowing of urethral lumen or loss of dispensability of any
part of the urethra resulting from healing by fibrosis
• It occurs predominantly in male

4. Statement of surgical importance
• Urethral stricture either partial or complete would ultimately lead to
urinary retention which therefore must be relieved to save the
patient from pain and other deleterious effect on other vital organs of
the body like the kidney
• Patient cannot therefore remain on urinary diversion for ever hence
the need for definitive surgical intervention

5. Epidemiology
• It is the commonest cause of urinary retention in tropical Africa
• Its prevalence is 229-627 per 100,000 males or 0.6% of at risk
population

6. Relevant anatomy

7. Relevant anatomy

8. Aetiology
• Congenital and non congenital
• Congenital
• Pin hole meatus
• Non meatal stricture

9. Aetiology
• Non congenital
• Traumatic
• External trauma
• Urethral instrumentation
• Foreign body
• Urethral calculi
• Urethral catheterization
• Post operative
• Transurethal surgical procedures

10. Aetiology
• Non congenital
• Inflammatory
• Acute or chronic gonorrhoea
• Non specific urethritis
• Tuberculosis urethritis
• schistosomiasis

11. Pathogenesis
• Urethral stricture usually result form fibroplasia of the urethra usually
occurring in response to an inflammatory process which can be infective
or non effective
• Healing by fibrosis result in replacement of the damaged urethral tissues
with fibrous tissues which contracts leading to the narrowing of the
lumen
• This usually leads to dilatation of the urethra proximal to the stricture

12. Pathogenesis
• Compensatory changes in the bladder wall usually resulting in
hypertrophy trabeculations sacculations and diverticulum
formations
• Hypertrophy of the uretro-trigonal complex causing hydroureters or
hydronephrosis
• There is stasis of the urine which ultimately lead to UTI

13. Pathogenesis
• Post inflammatory stricture usually occurs in the anterior urethra
• They may be single or multiple and most (about 60- 70%) occurs in the
bulbous urethra because of the dilatation and angulation of this part of the
urethra which result in diminution of the flushing power of the urinary
stream
• The pendulus urethra is next and the glandular urethra is least
• Stricture following Instrumental injury usually occurs in the bulbar urethra
while that following prostatic surgery usually occurs in the bladder neck

14. Diagnosis
History
Clinical examination
investigation

15. • History
• History of symptoms
• History of progressive diminution of urine stream
• History of
• improvement of urinary stream upon straining
• frequency
• hesitancy
• dribbling
• forking of urine
• splaying of urine
• AUR
• CUR

16. • History of aetiology
• History of
• trauma
• STD in the past
• urethral instrumentation
• trans urethral surgeries and vaginal repairs
• introduction of foreign bodies to the urethra by the patient for the purpose of
sexual gratification
• passage of stone
• chronic cough contact with persons with chronic cough and drenching night
sweats
• weight loss and family history of malignancies

17. • History of complications
• Decrease in the quality of life of the patient
• History of UTI (cystisis, prostatitis, epididymitis, pyelonephritis)
• History of periurethal abscess, periurethral, scrotal or perineal fistulae
• History of uraemia
• History of treatment
• Medications
• suprapubic tapping
• Urinary diversion
• Definitive care given

18. • Examination
• GPS:
• patient clinical state, fever, pallor, jaundice, level of hydration, pedal
oedema
• Abd: scars, suprapubic cystotomy, suprapubic distension and
tenderness, renal angle tenderness,
• External genetalia: scars, periurethal induration, periurethal abscess,
watering can perineum, perineal fistula

19. Investigation
• Investigation
• Confirm diagnosis
• IPSS
• Peak urine flow rate
• Post void residual urine
• RUG + MCUG
• Instrumental examination
• Urethroscopy
• Complication
• Urinalysis
• E/u/Cr
• IVU
• Plain abdominal x-ray
• KUB + P Uss
• Urine m/c/s
• FBC + differentials

20. Treatment
• Temporary measures
• Specific measures
• Temporary measures
• SPC
• Urethral catheter (partial stricture)
• Specific measures

21. • Specific measures
• Dilatation
• Flexible filiform bougies and followers,
• Curved steel bougies
• Flexible bougies made of plastic or gum elastic
• Complication
• Bleeding
• Clot retention
• Urethral rupture
• False passage
• UTI
• Endoscopic Direct visual internal urethrotomy
• Use of cold blade urethrotome
• Complications
• Bleeding
• Clot retention
• UTI

22. Treatment
• Meatotomy
• meatoplasty
• Done when stricture is at the urethral meatus
• Urethroplasty
• Indication
• Urethral stricture with spongiofibrosis
• Complicated strictures with periurethral abscess, fibrosis calculi or neoplasia
• Short or long segment stricture
• Complete urethral stricture

23. treatment
• Urethroplasty
• Anastomotic
• Substitution
• Anastomotic
• Excision and end to end anastomoses
• Indication
• Short complete stricture ≥ 2cm
• Short complicated stricture
• Bulbar urethral stricture

24. Treatment
• Substitution
• indications
• Long complete urethral stricture
• Long complicated urethral stricture
• Types of substitution urethroplasty
• Grafts
• BMG
• Post auricular full thickness graft
• Flaps
• Ventral longitudinal island flap
• Dorsal transverse preputal island flap
• Hairless scrotal island flap

25. • Complications of urethoplasty
• UTI
• Haematoma
• Fistulae
• Resenosis
• Hair balls
• Urethal calculi
• Carcinoma of the uretha
• chordae

26. • Current trends
• Urethral stents
• Complications
• Perineal pain
• Erectile pain
• UTI stent obstruction
• Stent encrustation
• Stent migration
• Laser urethrotomy
• Carbon dioxide laser
• Argon laser
• Nd Yag laser

27. prevention
• primodal
• Public enlightenment campaign
• Primary
• Use of protective barriers during sexual intercourse
• Avoiding vaginal douching
• Avoiding harmful sexual practise
• Use of safety ware in the work place
• Secondary
• Timely treatment of infections
• And predisposing factors
• Tertiary
• Timely presentation for definitive treatment

28. conclusion
• Urethral stricture which is partial or complete occlusion of the
urethral lumen resulting from fibrosis. It is preventable however the
aim of treatment is restoration of the luminal continuity of the
urethra

29. Reference
• Alan J., Wein-Louis R., Kavoussi et al Campbell-Walsh Urology. 11th ed.
Elservier press 2016
• Jack W., McAninch, Tom F. Lue Smith & Tanagho’s General Urology.
18th ed. McGraw Hill Company 2013.
• Bailey & Love’ Short Practice of Surgery. 27th ed. CPR Press 2012.
• E. A Badoe, E.O Archampong, J.T da Rocha-Adafu Principles and
Practice of Surgery in the Tropics. 4th ed. AGLC Ltd 2009.
• E - medicine