urethral stricture36 slides

1. URETHRAL STRICTURE
POPOOLA O.P

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• AETIOLOGY
• CLASSIFICATION
• PATHOGENESIS
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT OPTIONS
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Urethral stricture is an abnormal narrowing or loss of distensibility of
any part of the urethra as a result of fibrosis at the site of injury or
inflammation.
• It is a common cause of urinary retention in tropical Africa.

4. EPIDEMIOLOGY
• Urethral stricture is a relatively common disease in men with an
associated prevalence of 229-627 per 100,000 males
• It is commoner in males due to the length of the male urethra
• Mean age of occurrence is 50 years

5. RELEVANT ANATOMY OF THE MALE URETHRA
• The male urethra extends from the bladder neck and terminates at
the external urethral meatus.
• The male urethra measures about 20.5cm in length and comprises
two(2) part – the anterior and posterior urethra.
• The longer anterior urethra measures about 15cm and comprises the
bulbous and penile urethra
• The shorter posterior urethra comprises the prostatic and
membranous urethras.

6. RELEVANT ANATOMY OF THE MALE URETHRA

7. RELEVANT ANATOMY OF THE MALE URETHRA
• The epithelium of the urethra is stratified or pseudo stratified in the
glans and transitional proximal to the glans.
• Lymphatics from the deep urethra drain into the hypogastric and
common iliac nodes while those of the meatus drain into the inguinal
nodes.
• Arterial supply is from the inferior vesical and internal pudendal
arteries with concomitant venous drainage.

8. AETIOLOGY
1. CONGENITAL : Pin hole meatus
Non meatal Stricture
2. TRAUMATIC: External trauma
Urethral instrumentation
Foreign body or urethral calculus.
3.POSTOPERATIVE:Transurethral procedures
4.INFLAMMATORY: Post gonococcal (70%)
Non specific urethritis
Schistosomiasis
Tuberculous urethritis

9. CLASSIFICATION
• Based on aetiology
• Proximal or Distal
• Permeable or Impermeable
• Passable or Impassable
• Single or Multiple

10. PATHOGENESIS
• Urethral stricture forms when the urethra heals by proliferation of
fibroblasts which later contracts.
• Post inflammatory strictures are usually confined to the anterior
urethra particularly the bulbous urethra.
• Instrumental injury usually occurs at the bulb but stricture following
prostatic surgery is found at the bladder neck.
• Urethral stricture following pelvic injuries usually occurs at the
membranous urethra

11. PATHOLOGY
Urethral stricture leads to
1. Dilatation of the urethra proximal to the stricture
2. Compensatory changes in the bladder musculature resulting in
hypertrophy, trabecculation, sacculation and diverticular formation.
3. Hypertrophy of the uretero-trigonal complex or vesicoureteral
reflux causing hydroureters and hydronephrosis.
4. Stasis of urine and subsequent infection of the urinary tract

12. PATHOLOGY

13. CLINICAL FEATURES
• Although stricture following urethritis is formed within a year, it takes
on an average of about 20 years for symptoms to become apparent.
• Traumatic strictures on the other hand are symptomatic in two
months.
• Symptoms are usually insidious in onset and are usually LUS which
include poor stream, forking and spraying of urine, frequency,
hesitancy, dribbling, acute and chronic retention.

14. CLINICAL FEATURES
• It may present as a periurethral abscess, periurethral,scrotal or
perineal fistulae with dribbling of urine and as extravasation of urine.
• When infection occurs, symptoms of cystitis, prostatitis, epididymitis
and pyelonephritis can occur.
• In untreated cases uraemia may result from pyelonephritis and
hydronephrosis

15. CLINICAL FEATURES
• Examination of the external genitalia may reveal periurethral
induration, periurethral abscess, perineal urinary fistulae or
extravasation of urine.
• A visible or palpable bladder may be found if urinary retention
occurs.
• Digital rectal examination is done for the state of the prostate.

16. INVESTIGATIONS
• Urinalysis, Urine microscopy and culture.
• Blood urea and serum creatinine.
• IVU to see hydronephrosis and function of kidney.
• U/S abdomen.
• Plain pelvic or abdominal xrays

17. INVESTIGATIONS
• Urethrosonography
• Retrograde urethrogram and voiding cystourethrogram
• Urethroscopy

18. INVESTIGATIONS

19. INVESTIGATIONS

20. DIFFERENTIAL DIAGNOSES
• BPH
• Prostate cancer
• Bladder cancer

21. TREATMENT OPTIONS
TEMPORARY MEASURES
• Suprapubic Cystostomy
(i) Urinary retention
(ii) Urine diversion in fistulae
(iii) Temporary measure in uraemia
• Antibiotics for UTI
• Correction of electrolyte imbalance

22. TREATMENT OPTIONS

23. TREATMENT OPTIONS
• SPECIFIC MEASURES
1. INTERMITTENT DILATATION : It is palliative but adequate for most
patients. This is done using bougies which could be
(i) flexible filiform bougie
(ii) flexible gum elastic bougie
(iii) metal bougie (lister’s, Clutton’s and straight)
Indication – passable incomplete strictures
Intermittent dilatation is done at increasing intervals starting with a
small sized bougie .

24. TREATMENT OPTIONS

25. TREATMENT OPTIONS
• Complications of Intermittent Dilatation
(i) Infection
(ii) Bleeding and clot retention
(iii) Extravasation of urine
(iv) Fistulae
Given the above complications, it is of utmost importance dilatation is
done under strict asepsis and bougies should be passed gently.

26. TREATMENT OPTIONS
2. VISUAL INTERNAL URETHROTOMY
This involves incising of the stricture under direct vision using a
cystoscope and a cold blade urethrotome e.g. Sachse urethrotome.
Indication – short, uncomplicated impassable strictures
• After internal urethrotomy, it is advisable to splint the urethra with in
indwelling catheter for 2-7 days and longer 14-21 days for difficult
strictures.

27. TREATMENT OPTIONS

28. TREATMENT OPTIONS

29. TREATMENT OPTIONS
3. URETHROPLASTY
It is an open plastic repair of the urethra.
Indications
(i) Failed conservative management i.e Intermittent dilatation and
urethrotomy
(ii) Very long strictures or complete strictures with extensive spongiofibrosis
(iii) Complicated strictures with periurethral abscess, calculi or neoplasia.

30. TREATMENT OPTIONS
• Urethroplasty can be anastomostic or substitutional.
• Grafts include the buccal mucosa, bladder mucosa, penile skin, scrotal skin, prepuce, post
auricular skin.
• Meatal Stenosis : Meatoplasty
• Anterior urethra Strictures :
(i) Two stage urethroplasty such as the Swinney technique which involves the initial laying open
of the stricture and subsequent reconstruction of the urethra using a graft/flap.
(ii) Free Graft urethroplasty
(iii) Skin island flap implantation
(iv) End to end anastomosis

31. TREATMENT OPTIONS

32. TREATMENT OPTIONS
• Posterior urethra strictures
(i) anastomostic urethroplasty
(ii) Skin island flap implantation
• Newer trends include laser urethrotomy and urethral stenting

33. TREATMENT OPTIONS
• PROBLEMS OF URETHROPLASTY
(i) Infection
(ii) Prolonged hospital stay
(iii) Necrosis of flap/graft
(iv) Leakage and fistula formation
(v) Restenosis

34. CONCLUSION
• Urethral strictures arise from various causes and can result in a range
of manifestations, from an asymptomatic presentation to severe
discomfort secondary to urinary retention
• Establishing effective drainage of the urinary bladder can be
challenging, and a thorough understanding of urethral anatomy and
urologic technology is essential
• Hence, early consultation of a urologist is of utmost importance

35. REFERENCES
• SRB’s Manual of Surgery (3rd Edition)
• Principles and Practice of Surgery by E.A. Badoe et al
• https://emedicine.medscape.com/article/450903-overview

36. THANK YOU FOR YOUR LISTENING