? STRICTURE URETHRA STRICTURE URETHRA Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon) STRICTURE URETHRA STRICTURE URETHRA ? POSSIBLE QUESTIONS LEARNING OBJECTIVES To be able to learn; Anatomy Etiology Investigation Treatment Discuss various parts of urethra. Discuss investigations for urethral stricture. Discuss various options for treatment. RELEVANT SCENARIO(S) l A fifty seven years old man had history of urethral surgery one year ago, now presents with slowing of stream and incomplete bladder evacuation. Discuss relevant anatomy, investigations and management
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l A fifty seven years old man had history of urethral surgery one year ago, now presents with slowing of stream and incomplete bladder evacuation.
Discuss relevant anatomy, investigations and management
Anatomy of male urethra
Stricture urethra is the narrowing of urethra. It is a Both prostatic and membranous urethra form scar resulting from tissue injury or destruction posterior urethra.leading to shortening of the circumference. These changes result in reduced area of the urethral lumen
It is the part of urethra covered by the midline fusion and significant urodynamic effects. Its length varies of bulbo-spongiosis muscles. Its proximal end is from 1cm to more than 4cm. It is not so uncommon in continuous with membranous urethra at the lower males and very rare in females. It is more common in end of external urethral sphincter and it ends at young or middle aged men and is equally common in penile urethra distally.all races.
It is the pendulous part of urethra distal to bulbous It is the part of urethra from bladder neck (urethro- urethra. It lies distal to suspensory ligaments of vesical junction) to verumontanum. It is surrounded penis. It is also covered by corpus spongiosum. It by the prostatic glandular tissue. ends at fossa navicularis.
It is the terminal part of urethra which is embedded in It is the part of the urethra which traverses deep the erectile tissue of the glans penis terminating at perineal pouch. It starts from (prostatic urethra) the external urethral meatus. The bulbous urethra, verumontanum proximally and ends at bulbous penile urethra and fossa navicularis from the anterior urethra distally. It is surrounded by external urethral urethra.sphincter. It is not attached to fixed tissue structures.
BULBOUS URETHRA
PENILE URETHRAPARTS OF URETHRAPROSTATIC URETHRA
FOSSA NAVICULARISMEMBRANOUS URETHRA
ANATOMY
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Muhammad Shuja Tahir, FRCS(Edin), FCPS (Hon)
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Urethral stricture Urethral stricture
ETIOLOGY CONGENITAL
POST OPERATIVE
NEOPLASTICTRAUMATIC STRICTURES
CLINICAL FEATURESIATROGENIC
GUN SHOT WOUNDS
INFLAMMATORY STRICTURES
! Tuberculosis (rarely)The congenital conditions having narrowing of ! Bilharziasis.urethra are not true strictures but have similar urodynamic effects. These are ;
! Post prostatectomy! Double barrel urethra or anterior urethral valves.
! Post amputation of penis! Posterior urethral valves.
Carcinoma of prostate or bladder tumor spreading to Fracture pelvis is most commonly associated with
urethra.injury to urethra which follows to stricture urethra.
! Reduced urinary flowDuring catheterization! Dysuria (Painful urination)During cystoscopy! Spraying of urine (Double stream)During transurethral resection! Straining to pass urine
! Frequency of micturition! Closed anterior urethral injuries. ! Pooling of urine in bladder! Rupture of membranous urethra.
! Urinary tract infection! Combined urethral, perineal and rectal injuries.
! Peri urethral abscess
! Pain lower abdomen
! Urinary retention! Acute urethritis and its aftermath.
! Dribbling of urine (Gonococcal and non specific urethritis.)! Incontinence (Residual urine)! Chronic urethritis.
!
!
!
Urethrogram
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URINE EXAMINATION EXCRETORY UROGRAPHY
RETROGRADE URETHROGRAPHYBLOOD EXAMINATION
SONOURETHROGRAPHY
URETHROSCOPY
RESIDUAL URINE MEASUREMENTSURODYNAMICS STUDIES
MRI URETHROGRAPHY
Microscopic. This is extremely helpful to see the effects of stricture
Macroscopic. on the upper urinary tract and for measurement of
Chemical (Sugar, albumen). the residual urine.
Microbiological (culture and sensitivity).
It is the contrast medium radiological visualization of Haemoglobin percentage
the interior of urethra. It is the most important and Total leucocyte count
helpful investigation. It shows the site and size of the Differential leucocyte count
stricture. It also shows the relationship of stricture Urea and electrolytes
with urogenital diaphragm. It has its own limitations. Creatinine clearance
Radiourethrography under estimates the length of 2strictures in most of the cases .
It is the sonographic visualization of the urethra. It is
an excellent investigation for the anterior urethral It is the endoscopic visualization of stricture and it is strictures. It can show the stricture and periurethral not only of diagnostic value but also of therapeutic fibrosis as well. Its results are not so good for value as dilatation can be performed. Catheter may posterior urethral strictures. it can show the length of
1 be passed through it and internal urethrotomy can blind stricture as well . Sonourethrography is an also be done with the urethrotome.accurate predictor of stricture length and periurethral
strictures. It is unsatisfactory in visualizing the
posterior urethral strictures.
Urinary flow rate is reduced.
It is not performed commonly because of expenses
and less availability.
Urethrogram Urethrogram Urethrogram
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INVESTIGATIONS
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MANAGEMENT STEROIDS
INTERNAL URETHROTOMYOPTICAL & BLIND URETHROTOMY
DILATATION
ND-YAG LASER THERAPY
EXTERNAL URETHROTOMYSELF DILATATION
There are three aims of treatment in patients with The use of local steroid creams after urethral injuries
stricture urethra ; or dilatation has been tried, but results have not been
! Treatment to improve urinary flow rate so great as one would have thought.
! Treatment of symptoms as of acute retention.
The acute retention is relieved by suprapubic
puncture of the bladder with disposable This is the longitudinal slitting of the stricture sterilized vesical catheter surgically from inside the urethra by urethrotome ! To avoid complicationseither optical or blind one.! Adequate assessment of the site and size of the
stricture and its effects on the bladder and upper Otis urethrotome is used blindly and is quite useful. urinary tract. The healing of surgical wound is by first degree. ! Definitive treatment of the stricture.
Optical urethrotome is used to do selective The site and size of stricture and its effects on urinary urethrotomy of the stricture under vision. Cold knife tract can be assessed by various direct and indirect or hot loop can be used for this propose. investigations.
The results of this operation are reasonably Gradual dilatation of urethra is still the most common satisfactory in most of the strictures. Endoscopic and most useful method of its treatment. It is resection of the callus (stricture scar) improves the
5traditional treatment. Gentleness is very important results of urethrotomy alone by 15% .while performing the urethral dilatation as rough
dilatation or urethral injury leads to worsening of the
stricture. Urethral dilatation can achieve upto 30% The laser is used for treatment of strictures 3
good results over 5 years in patients with stricture . endoscopically. It can achieve upto 73% successful
results over 2 years period. It is better than internal The urethral dilatation can help to avoid surgery in 6urethrotomy with hot loop or cold knife .patients with sphincter strictures which can
4endanger the urinary continence after resection .
This is the opening of the urethra onto the skin. It is The patient is trained to lubricate and insert it used as first stage procedure for urethroplasty. In this regularly to keep the urethra dilated. It has the procedure, the stricture is opened up externally into advantage of avoiding the complications being perineum and free flow of urine is established relatively safe option. proximal to the stricture.
TREATMENT
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STENTING
URETHROPLASTY
techniques have been used to make a urethral tube
Walls stent is a self expanding resident prosthesis. It but satisfactory procedures have not been
is inserted endoscopically into the stenosed part of developed yet. Anastomotic urethroplasty for post 7
urethra. It has shown excellent short term results . traumatic strictures and "Patch" urethroplasty for
post infective strictures give satisfactory results. The
incidence of impotence is higher after urethro-8,9This is reconstruction of the urethra. Different plasty .
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urothrotomy versus urethrotomy plus ND-YAG laser Urologicas Espanolas.1992 Sep. [JC:2a1] : 16(8): 627-30.in the treatment of urethral stricture. European Urology.
1990. [JC:enm] 18(3):166-8.2. Gupta S. Majumder B. Tiwari A. Gupta RK. Kumar B. Gujral
RB. Sono-urethrography in the evaluation of anterior 7. Resel L. Blanco E. Platas A. Mohammad Z. Mendez S. urethral strictures: correlation with radiographic
Tobio R. New permanent expendable prosthesis for the urethrography. JCU-Journal of Clinical Ultrasound. 1993 treatment of urethral stenosis. Actas urologicas May. [JC:htv] 21(4): 231-9.Espanolas. 1990 Nov-Dec. [JC:2a1] 14(6): 422-6.
3. Hermanowicz M. Manande J. Rossi D. Serment G. 8. Mundy AR. Results and complications of urethroplasty Richaud C. Ducasson J. Long term evaluation of the
and its future. British Journal of Urology. 1993 Mar. treatment results of male urethral stenosis. Annals D. [JC:b3k] 71(3): 322-5.Urologie. 1990. [JC:6ad] 24(1): 68-72.
9. Charles J Devine Jr. Gerald H Jordan. Steven M 4. Mundy AR. The treatment of sphincter strictures. Schlossberg. Surgery of penis and urethra. Mundy AR. British journal of urology. 1989 Dec. [JC:b3k] CAMPBELL'S urology sixth edition. Walsh.Retik. Stamey. 64(6): 626-8.Vaughan. W B Saunders Company London, 1992. P: 2957-
3032.5. Guillenin P. L Hermite J. Chopin G. Hubert J. Internal
urethrotomy with endoscopic resection of the callus.