Case: A patient who underwent transurethral resection of the prostate had a significant deterioration in urination more than 3 months after surgery and was barely able to urinate on the day he came to the clinic. The patient was hospitalized and diagnosed as having “urethral stricture”. As the name implies, urethral stricture is a narrowing of the part of the urethra where we urinate, resulting in a series of complications due to reduced urinary flow or obstruction.
In the picture above, the urethra has become a small hole at the site of the original surgery, and the surrounding urethral scar has formed so that the cystoscope cannot pass through, so how can urination be good? Our treatment for urethral stricture is to find a way to make the urethra spacious.
Our urethra
Since strictures occur in the urethra (the tube that connects the bladder to the outside of the body), let’s first understand this organ. The urethra is different for men and women: men have a longer urethra that passes through the penis; women have a shorter urethra that opens above the vaginal opening. In men, the urethra not only excretes urine, but also serves as a channel for ejaculating semen out of the body.
Urethral stricture
Narrowing of any section of the urethra is called urethral stricture, and strictures can occur in any part of the urethra. Strictures are often due to scarring around the affected urethra and can be long or short, ranging from less than 1 cm to spreading the entire length of the urethra. The good news is that most strictures are not long and do not occur at a high rate, but strictures occur much more frequently in men than in women. Therefore, we focus on urethral strictures in men.
What causes urethral strictures?
Various urethral injuries can be scarring of the urethra and thus stricture. Injuries include many kinds, such as urethral surgical operations (cystoscopy, insertion of a urinary catheter, after transurethral surgery – prostate, etc.), trauma (pelvic fractures in car accidents, straddling injuries), radiotherapy to the lower abdominal perineal area, etc.
Infection: another common cause, such as sexually transmitted diseases (gonorrhea, chronic urethritis), inflammatory reaction to foreign bodies (complications of infection from long-term indwelling urinary catheters), periurethral infection invasion. Although most infections do not lead to strictures, however, although the infection can be controlled by treatment, some scar tissue is often left at the site of the inflammatory reaction and leads to strictures. Stricture may therefore be a complication of the infection. Congenital malformations: Some children are born with urethral strictures.
Tumors: Very rarely, urethral tumors narrow the urethral outflow tract blocking the flow of urine
What causes a patient with urethral stricture to see a doctor?
In other words, the symptoms of urethral stricture. Initially, the symptoms may not be obvious, although some become more pronounced as the condition worsens.
The first symptoms tend to be a weakening of the urine flow and the appearance of straining to urinate, but it is not uncommon to be unable to urinate at all. Urine will drip halfway through or at the end of urination. Frequent urination may also occur. Complication of urinary tract infection. The power of ejaculation becomes worse.
What can urethral stricture cause?
Urethral stricture is like a bottleneck, and the bladder then needs more pressure to urinate. When this is not possible, excess urine collects in the bladder and is called residual urine. Residual urine can predispose to infection, making the bladder, prostate and kidneys more susceptible to infection. Also, persistent infections above the stricture can damage the urethra and surrounding tissues, worsening the stricture. Prolonged difficulty in urination can also impair the contractile function of the bladder, as well as lead to conditions such as bladder stones, bladder diverticula, and fluid retention in the upper urinary tract. Of course, urinary retention has also occurred. The patient above had urinary retention the day after her hospitalization where she could not pass urine and the ureter would not go down and a small eyelet had to be made in the lower abdomen to put in a tube to drain the urine (suprapubic cystostomy).
What tests should I do to deal with strictures?
When stricture is suspected, test the urine flow, including the total volume of urine voided and the volume of urine voided per second. In strictures, this value decreases.
A direct visual examination of the urethra is necessary and is called a urethral cystoscopy.
Special X-rays – Urethrography is very important in relatively complex strictures to help understand the site and length of the stricture.
How is urethral stricture treated?
It is important for the patient and the treating physician to define the goals of treatment, which generally encompass three, namely improving urinary flow, relieving symptoms, and preventing complications. However, it is important to be clear that the goals may not all be achievable and that each patient has to develop realistic goals and plans.
The urologist is the main body that performs the treatment and will choose the treatment based on factors such as the nature, location and length of the stricture, taking into account the patient’s age and general condition, including
1. Urethral dilation
Under local or general anesthesia, a special plastic or metal urethral probe is applied to pass down the urethra through the stricture, gradually enlarging the urethral lumen with increasing thickness of the probe. This approach is mechanical dilation, but the stricture will reappear as the scar shrinks, so the dilation has to be repeated frequently. It can be tried in patients with less severe strictures and less long stricture segments, but the discomfort is high and is mostly clinically indicated for patients who are regularly maintained after stricture surgery.
2. Endourethrotomy
The stricture is seen by direct endoscopic vision under anesthesia, and a special blade or laser fiber is extended through the endoscopic working channel to open the urethral lumen by cutting the stricture and its surrounding scar tissue from within the urethral lumen. Such a procedure is suitable for patients with short strictures and not heavy scarring, and has a certain rate of restenosis. Some time of urethral dilation is often required after surgery.
3. Urethroplasty
If the results of the above-mentioned modalities are unsatisfactory or cannot be performed, it is necessary to choose a molding procedure in a very wide range of modalities. If the stricture is short, the posterior urethra can be removed and then reanastomosed. If it is longer, a transfer or graft of skin or mucosa is needed to replace the defective urethra.
Since restenosis can occur after urethral strictureplasty, an experienced surgeon and a reasonable surgical approach are the best way to guarantee the success of the procedure.
Post-operative care
Since infection is a major component of the primary and aggravating factors of urethral stricture, a long course of postoperative antibiotic treatment is very important for the outcome of the surgery. If urethroplasty is performed, the degree of anastomotic patency and the presence of urinary fistula need to be observed and reviewed in a timely manner. Some patients have to undergo a certain cycle of urethral dilation according to the doctor’s orders. Your doctor knows best and it is important to maintain a good relationship.
Eating, drinking and sleeping are the basic needs of life, and urethral strictures can seriously affect the quality of life, although the incidence is not high and there are many causes of urethral strictures, some of which are completely avoidable. Although once a problem occurs with the slender urethra and stricture, it is more difficult to deal with clinically and requires an appropriate approach by the doctor to deal with it.