Urethral stricture disease refers to an abnormal narrowing of the tube that leads from the bladder through which urine flows. Most cases of urethral strictures occur in men, although it can occur in women; and the bulk of the discussion following will refer to the anatomy and repair of men with urethral stricture disease. Women with urethral stricture disease often can undergo similar treatments, but the evaluation may be somewhat different. Our practice specializes in the repair and management of urethral stricture disease and we often treat patients that come to us after having undergone multiple procedures in the past.
The most important piece of advice that we can give patients with urethral stricture disease is to feel comfortable in the experience of their surgeon who is capable of performing open surgery, if necessary. Only in that way can you be assured that the proper treatment is being offered to you.
Causes and Anatomy
Urethral strictures can be caused by sexually transmitted disease, but are more commonly caused by trauma to the penis or to the pelvic area. Trauma that leads to the breakage of the pelvis can lead to severe stricture that can require extensive surgery to repair. Common types of injuries include penetrating trauma to the penis or urethra or straddle injuries in which the urethra is crushed between the pubic bone when the patient is injured between the legs.
The causes of the strictures as well as length of the strictures are two very important components that help determine what treatment is most appropriate. In addition, prior procedures done to open the stricture or widen it are important to note because multiple such procedures can make the repair much more difficult. Many patients can obtain a 95% or higher rate of cure with a single procedure for a urethral stricture rather than being managed with lifelong dilation of the urethra which can be painful and cause further damage. Symptoms of the urethral stricture can include pain with urination and incomplete bladder emptying, recurrent urinary tract infections, urinary incontinence, the need to urinate frequent at night and many severe cases can result in kidney failure and need for chronic use of a catheter.
The urethra is made up of several different parts. The first part is the initial part that exits the bladder and it is called the bladder neck. The bladder neck can develop a stricture after prostate surgery and is usually seen best through the use of camera called cystoscope placed into the penis.
The prostatic urethra is the port that is surrounded by the prostate gland and where semen is deposited into the urethra for reproduction. It can be the side of urethral stricture after prostate surgery as well as after an injury often involving breakage of the pelvic bone which can share the urethra at the prostatic urethra.
The bulbar urethra is a location that is frequently injured with a straddle injury in which the pubic bone will crush the urethra when patient is injured between the legs.
The penile urethra involves all of the urethra that is contained within the penile shaft up until about the last 1 cm and can be injured with penetrating trauma or from sexually transmitted disease. The end of the penis includes the fossa navicularis of the meatus and these areas of the urethra can be scarred with inflammatory conditions of the skin such as balanitis xerotica obliterans BXO, or can be strictured from birth.
Symptoms and Evaluation
Men who are very young and are referred for urinary retention or slow urine flow should be suspected of having a urethral stricture if they have history trauma or if they have a very narrow and slow stream. Oftentimes, prostate medications are given to these men thinking that they might have prostate disruption and these medicines will do no benefit. The patients are often discovered during attempts at placement of a Foley catheter into the urethra during a surgical procedure or hospitalization for some other cause.
Evaluation of men with suspected urethral stricture disease may begin with a cystoscopy which involves placement of flexible small camera in the urethra to identify that a stricture is present. Virtually, all patients will then require a retrograde urethrogram which is an x-ray that is performed in the hospital which Dr. Mistry is present for and performs himself. This test will involve the injection of dye in the urethra to identify the location as well as the length of the stricture and to make sure that only one stricture is present as many times patients will have multiple strictures.
Treatment and Follow-up
Strictures that are less than 2 cm in length and have never been treated before oftentimes can be initially treated with dilation where the stricture is stretched open or incision where the stricture is incised. Both these procedure are done through the penis and sometimes through the use of a cystoscope to help in visualization. A balloon catheter can be used to widen the stricture and this is preferable to other forms of dilation that uses progressively larger catheters to make the stricture larger as it is felt to cause less damage. A knife can also be used through the cystoscope to incise a stricture but generally this technique is used only one time and oftentimes patients will need to dilate the stricture themselves postoperatively for a number of months.
In very rare instances, a stent can be placed in the urethra to open up the stricture. Although this procedure is fairly easily and well tolerated by the patient, it is not a very good long-term solution, and is used best in patients who would not be able to tolerate more extensive surgery.
After a procedure to widen the stricture or to cut the stricture has failed or if the stricture is longer than 2 cm or is located in a location not amenable to one of the prior procedures, often an open urethroplasty is recommended. This type of procedure often involves an incision where the disease segment of the urethra is either removed or enlarged with tissue from another location to allow for a wide open channel for urination. This procedure is recommended after other less invasive types of procedures have failed or when the segment of stricture is longer than 2 cm. Also strictures of the prostatic urethra especially when due to pelvic trauma are often best treated with an open urethroplasty. In most cases the urethroplasty can be performed without the use of tissue from other parts of the body, especially those that are shorter and located in the penile urethra. In some cases whether the stricture is longer or those located in the bulbar urethra, tissue may be harvested either from the inner side of the cheek called a buccal mucosal graft or from other parts of the genital area to allow for reconstruction of the urethra without shortening of the penis.
These procedures require specialized training and often will require a stay in the hospital up to two or three days. This stay in the hospital is for assurance of healing of the graft and the pain control.
After urethroplasty is performed, a repeat imaging can be required but mainly patients are monitored by measuring the urine flow rate and making sure that they are not retaining any urine.
The management of the urethral strictures from the initial diagnosis is crucial to avoiding unnecessary procedures and leading to a long-term successful outcome. Patients managed improperly or after surgery fails can be debilitated with abnormal looking urethras and having to void in unnatural ways.