Urethral Stricture - Modern Aspect

Modern Aspect

URETHRAL STRICTURE:

Etiology:

Urethral stricture divided into two varieties:

A. Congenital :

1. Urethral Stenosis : Distensibility of urethral wall is reduced or it may be due decreased laxity of paraurethral tissues.
2. Meatal Stenosis

B. Traumatic :

1. Rupture of bulbous urethra due to RTA
2. Rupture of membranous urethra (Intrapelvic rupture), rupture of pelvis and Rupture of bladder.

C. Inflammatory :

1. Post gonorrhoreal :- Urethritis
2. Post gonorrhoreal chancre – primary syphilitic chancre at meatus usually head with fibrosis resulting in meatal stenosis.
3. Non specific infections : may spread from bladder or during catheterization, cystoscopy or surgery
4. Instrumental :

• Indwelling catheter repeated and prolonged catheter necessary in post operative cases and motor dysfunction may cause repeated friction of the mucosa carry urethritis causes stricture.
• Endoscopy : Following caliber of large endoscope notably a resectoscope causes stricture.
• Post prostatectomy : Post operative bladder neck stenosis.
• Amputation of penis : post amputation scarring of remaining urethra and periurethral tissues.

Pathogenesis :

1. Partial loss of uroepithelial lining.
2. After dilatation and internal urethrotomy – base areas are created slow epithelial proliferation cleft closure and spongiofibrosis result in a tendency to restenosis.

Post gonorrhoreal stricture :

Clinical Features :

1. Passage of flakes (desquamated epithelium) in urine.
2. Urethral discharge at early morning.
3. Dysurea
4. Straining
5. prolonged micturition
6. Dribbling occur due urine trickling from dilated urethra above stricture.
7. Frequency of micturition is increased at day and night.
8. Possible to palpate the stricture from outside as an induration in the urethral floor.
9. Burning micturition.
10. Occasionally haematuria secondary to localized inflammatory changes instrumentation and passage of calculi.
11. Retention of urine.
12. Incontinence of urine.
13. Strangury.
14. Decreased stream of micturition.

Effect of Urethral Stricture :

1. On Urethra :

• Urethra above the stricture may get dilated or diverticulum may be found due to increased pressure from bladder due to straining.

2. On Bladder :

• Musculature of bladder is hypertrophied.
• Trabeculation and divertiulum may be found.
• Calculi are prone to form in stagnant pool and residual urine.
• Long standing cases bladder atony may occur.

3. On Ureter and Kidney :

• Bil. Hydronephrosis.
• Chr. Interstitital nephritis due to back pressure.
• Acute or chr. Pyelonepritis.

4. On Sexual Organ :

• Seminal vesiculits.
• Prostatitis.
• Orchitis.

Effect of Straining:

Herniation, haemorrhoids, prolapse etc.

Diagnosis:

A) Routine Investigation

• Blood for HB, TLC, DLC, ESR, V DRL
• Urine Routine
• X ray KUB
• Urodynamic study / volumetric study.

B) Specific Investigations

• Kidney function test
• Urine culture and sensitivity.
• IVP
• Retrograde urethrography
• Cystoscopy

Retrograde Urethrography :

It is helpful to confirm the diagnosis -

• localize the lesion.
• understand the extent and nature of stricture.
• for comparison between before and after treatment.