Urethral stricture

*May be congenital or acquired.*Acquired urethral sricture is common in men but rare

in women.Aetiology

1. congenital2. Traumatic

by forcefull catheterization or urehtral instrumentation or external trauma(e.g.) pelvic fracture which produces posterior urethral injury or straddle injury which produces anterior urethral injury.

3.Infection rercurrent urethritis secondary to long term indwelling

cathetres or specific urehtral infections as gonococcal urethritis(rare) .

4. Malignant urethral stricture.Most aquired urethral strictures are secondary to trauma &infection.PathologyUrethral stricture is a fibrotic narrowing in the urethra composed of dense collagen & fibroblasts.It may extend to the surrounding corpus spongiosum.It causes restricted urine flow, proximal urethral dilation ,bladder wall trabeculations & hypertrophy & later postvoid residue .

Clinical picture1 .Reduced urine stream.

2. Disturbed stream(double stream) with post void dribbling.3. Chronic urethral discharge

4. Irritative urinary symptoms & dysuria due to cystitis.5. Acute or chronic urine retention.

6.Complications due to urethral stricture:a. Chronic prostatitis b. periurethral abscess & urethrocutaneous fistula.c. Urinary bladder decompensation causing vesicoureteral reflux,hydroureteronephrosis & renal failure.d. Urine stasis causing UTI& vesical stones. e.Urethral cancer.

7 .Palpable induration at the site of the stricture.

Investigations1. GUE / urine culture.2. Renal function tests.

3. Uroflowmetry : to assess urine flow rate & the pattern of urine flow.

4.Urethrogram or cystourethrogram to assess the site,no. & extent of the stricture + to show some complications as bladder trabeculation,vesical stones & urethral fistula.

5. Urethrocystoscopy for direct visualization of the stricture & its complications.

Differential diagnosis BPH ,prostatic carcinoma, bladder neck contracture

secondary to prostatic operations & urethral carcinoma.Treatment

1. Urethral dilation *It only temporarily dilate the stricture by fracturing thr scar

tissue.*It needs good lubrication & can be done using either

filiforms & followers of variable sizes or by using urethral sounds.

*This dilation is done blindly & may cause bleeding & pain.2. Optical urethrotomy( urethrotomy under endoscopic direct

vision).It has a good short term results but a lower longterm success rate.

The advantages of this operation:1. Minimal anaesthesia

2.Easily repeated for recurrent stricture.3. Safe with few complications.

3. Surgical reconstruction(urethroplasty)Done if the previous steps failed.a. For short anterior urethral stricture(< 2 cm) excision of the stricture& primary anastomosis.b. For longer stricture(>2 cm) patch graft urethroplasty using penile skin or buccal mucosa.

c. For posterior urethral strictureA perineal approach is uesd , excision of the stricture & direct anastomosis is done. Sometimes, partial pubectomy is needed to allow urehtral approximation without tension.

4. Rx. of complications *UTI by antibiotics then long term

prophylactic Rx. *Periurethral abscess needs

drainage+antibiotics. *Urethral fistula needs surgical repair .

PrognosisUrethral stricture should not be considered cured untill after 1 year from the last Rx .

*During this period,observation is needed for recurrence.

*Follow up by uroflowmetry & uethrogram to assess the extent of the stricture .