Urethral Stricture Disease dd by MikeJenny

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									  Urethral Stricture Disease
The urethra is the tube that carries urine from the bladder (through the penis in males) to
the outside of the body. A urethral stricture can occur anywhere in the urethra. A urethral
stricture is a scarred or hardened area that causes narrowing of the caliber of the urethra.
The stricture eventually reduces or obstructs the flow of urine out of the bladder, making
it difficult to urinate. The bladder therefore must work harder to push the urine through
the narrowed area of the urethra (the stricture).




There are many causes of urethral strictures:

• Trauma to the urethra or penis - blunt or penetrating urogenital trauma
•Urethral injury associated with traumatic pelvic fractures - motor vehicle accidents, falls,
industrial injuries, etc.
•Straddle injury or direct trauma to the perineum
•Recurrent urinary tract infections
•Sexually transmitted diseases
•Lichen sclerosis (Balanitis Xerotica Obliterans or BXO)
•Congenital abnormalities of the urethra or penis
•Catheterization or instrumentation of the urethra
•Surgical procedures:
- prior treatment for urethral diseases, such as urethral stricture or urethral cancer
- prior reconstructive surgery for congenital abnormalities of the urethra or penis
(hypospadias, chordee, epispadias)


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- prior gender reassignment surgery
- prior urologic surgery
• Unknown causes of urethral scarring (idiopathic)

If a urethral stricture is not treated appropriately, the increased strain on the bladder can
damage and weaken the bladder muscle. This can lead to a number of serious health
problems such as urinary retention (inability to pass urine), urinary incontinence (leakage
of urine), inflammation or infection of the urinary tract, reflux (urine backs up into the
kidneys), and kidney failure.

Symptoms and Signs:

   1- Weak or slow urine stream,
   2- Hesitation or trouble starting urination.
   3- Taking a long time to urinate and empty the bladder.
   4- Sense of incomplete emptying, dribbling, urgency
   5- Irritation or burning during urination.
   6- Urinary frequency during the day and at night.
   7- Urinary retention.
   8-  Sometimes one may intermittently or continuously leak urine because the bladder
      is full beyond its capacity and overflow incontinence occurs.
   9- Sometimes a urethral stricture is diagnosed when a healthcare provider cannot
      insert a catheter through the urethra into the bladder.

Utilizing contemporary philosophy and state of the art techniques in urologic diagnostics
and reconstructive urologic surgery, our goal in managing urethral strictures and related
urologic conditions is to allow the patient to urinate as normally as possible, with the best
quality of life and outcomes possible.



Diagnosis:

Evaluation of men with urethral injury or with a known or suspected urethral stricture
may include a combination of:

• Physical examination
• Urinalysis, urine culture, urine cytology - examination of the urine for signs of
infection, blood, and other abnormalities
• Uroflowmetry - mechanical measurement of urine output and flow rate
• Ultrasound postvoid residual -measures the residual urine in the bladder after one tries
to empty completely
• Radiologic imaging – x-rays to identify anatomy of the urethra, bladder and urinary
tract




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   -   retrograde urethrogram (RUG)
       - cystogram
       - voiding cystourethrogram (VCUG)
       - ultrasound (US)
   -    • Fiberoptic urethroscopy and cystoscopy
   -    visual inspection of the interior of the urethra and bladder using a flexible
       instrument (cystoscope) that is inserted into the urethra using local anesthesia
   -   • Laboratory studies (blood tests) - BUN, creatinine, others




It is very important to have an accurate diagnosis and evaluation of the length and
location of a urethral stricture. Once a urethral stricture is diagnosed, your urologist will
determine any further evaluation that is needed. Options for treatment will be presented
and discussed with you. Several treatment options are available for men with urethral
strictures. Some urethral strictures can be managed using a single procedure. If a stricture
returns after one or more treatments, it is called a recurrent stricture. Without appropriate
treatment, a stricture will recur almost 100 percent of the time. Strategies for prevention
of a recurrent stricture will also be discussed with you.

Some urethral strictures can be very complicated. The techniques utilized in their surgical
repair continue to evolve. Modern reconstructive surgical procedures used to treat
strictures are varied, may be complex and multi-staged. No single technique is
appropriate for all patients and situations. Individual clinical circumstances require
accurate evaluation and diagnosis with careful planning of management and surgical
reconstructive procedure(s).




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Temporary management:

Temporary management options for urethral strictures include:
• Catheterization
- a thin, flexible, plastic tube (catheter) is inserted into the urethra to temporarily drain
urine from the bladder
• Suprapubic catheter
- a thin, flexible, plastic tube (catheter) is inserted into the bladder through the abdomen
to temporarily drain urine

Treatment options:

Treatment options for urethral stricture disease include:

• Dilation- a balloon catheter or dilators(plastic or metal) are inserted into the urethra to
gradually stretch (dilate) the strictured area in the urethra




• Obturation - a thin, flexible, plastic tube (catheter) is inserted into the urethra on a
regular basis to keep the stricture open

• Urethrotomy (Endoscopic internal urethrotomy or incision)

- a minimally invasive procedure where an incision is made in the scar tissue in the
urethra               to                open               the               stricture
- this is done through a fiberoptic cystoscope (endoscope) placed in the urethra with
anesthesia

• Urethroplasty or Open urethral reconstruction


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   -   Anastomotic urethroplasty
   -   o the narrowed section of the urethra is surgically removed and the spliced ends of
       the urethra are reconnected
   -   Substitution urethroplasty
   -   o the narrowed section of the urethra is surgically opened or removed, and the
       urethra is repaired with a tissue graft or flap
       o Buccal mucosa graft (BMG)
       o Genital or other full-thickness skin grafts
       o Vascularized preputial or genital skin flaps
   -   One, two or multiple-staged reconstructive procedures
   -   • Perineal urethrostomy
   -   a surgical procedure that creates a permanent and wider opening in the urethra in
       the perineum (the space between the anus and the scrotum)




Long-term Follow-up

After the urethral stricture has been treated, frequent follow-up exams will be needed
during the first year and then periodically thereafter to ensure that the stricture does not
recur.




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