URETHRAL STRICTURES
CONTENT
Introduction
Definition
Relevant anatomy
Epidemiology
Causes
Pathophysiology
Clinical Presentation
Diagnosis
Management
• Urethra is the channel below the bladder that
transports urine and semen out through the penis
INTRODUCTION
• This tube is a crucial part of the urinary system and
plays a big role in our daily lives
DEFINITION
A urethral stricture is the narrowing of the urethra due to scarring of
the epithelium and its surrounding corpus spongiosum or can be defined
as a urethral stricture is a scar in the sub epithelial tissues of the corpus
spongiosum which constricts the lumen of the urethra
RELEVANT ANATOMY
The male urethra extends from the bladder neck and terminates at the external
urethral meatus
• It measures about 20.5 cm in length and comprises two(2) parts – the anterior and
posterior urethra
• Longer anterior urethra measures about 15 cm and comprises of the bulbous and
penile urethra
• Shorter posterior urethra comprises the prostatic and membranous urethra
In females it measures about 4cm in length
EPIDEMIOLOGY
Gender Differences
Female urethra strictures <3% of all strictures
Age
Mean age of 45.1
Incidence
200-650 cases per 100,000 population which represents 4.2%
CONT
• 92% are anterior strictures
• Bulbous urethra 40.2%
• Membranous urethra 35.7%
• Penile urethra – 14.43%
• Prostatic urethra 4.63%
• Female urethra 3.10%
CAUSES
INFLAMMATORY CAUSES
Post-infectious inflammatory causes
Gonococcal urethritis
Non-specific Urethritis (e.g. Chlamydia sp.)
Schistosomiasis
Tuberculosis
CONT
TRAUMATIC CAUSES
Blunt Injury
Straddle injuries - e.g. falling onto a bicycle crossbar.
Road Traffic Accidents and Industrial Accidents
Penile fractures
Constriction penile bands or rings
Penetrating injury Gunshot wounds
Stab wounds
CONT
IATROGENIC CAUSES
Urethral Instrumentation for diagnostic or therapeutic purposes
Transurethral Catheterization
Urethroscopy
Transurethral Resection of the Prostate (TURP) or Bladder Tumors (TURBT)
Urethral dilatation
Radical Prostatectomy
Hypospadias repairs
Circumcision
CONT
Non-infective inflammatory causes
Allergic reactions-latex catheters
PATHOPHYSIOLOGY
1. Injury to the Urethral Lining
-Cause: Trauma (e.g., catheterization, pelvic fracture), infection (e.g., gonorrhea), or inflammation.
- What happens: The inner lining (epithelium) and spongy tissue (corpus spongiosum) of the urethra
get damaged.
2. Healing with Scar Formation (Fibrosis)
- Instead of normal tissue repair, the body lays down dense collagen fiber which will lead to
spongiofibrosis.
- This scar tissue is less elastic and contracts over time which leads to narrowing the urethral lumen.
3. Obstruction & Increased Pressure
- Urine flow hits the "speed bump" (stricture) leading to a weak
stream, straining
- The bladder works harder (detrusor hypertrophy) to push urine
past the blockage.
4. Secondary Complications
- Urinary stasis leading to a Higher risk of UTIs, stones.
- Chronic obstruction Hydro nephrosis (if backpressure reaches the
kidneys).
- Severe cases: Acute urinary retention (can’t urinate at all!).
CLINICAL PRESENTATION
History of urethritis, trauma or urethral catheterization
LUTS, divergent or diminished stream, straining to void, urgency, frequency
Hematuria
Recurrent UTI
Storage symptoms
Urinary retention acute or chronic
INVESTIGATIONS
General Investigations
Hematological- Full Blood Count(FBC),Hemoglobin(HB), Total White Cell Count (WCC)
Differential Count(DC)
Renal Function Test- Urea and Electrolytes, Creatinine levels
Urinary Tests – Routine urine Microscopy , Midstream Urine sample with Culture and
sensitivity if indicated.
HIV Test- There is a strong association with STIs and Urethral stricture disease over 65%
with Urethral stricture disease are HIV positive.
Specific Investigations
Urine Flowmetry if available
-Retrograde urethrography; Gold standard for dx and staging of USD
-Voiding cystourethrography; Gold standard for determining the
presence or absence of strictures
-Urethrosonography ; used to stage the stricture, pick the location and
the caliber
-MRI, CT scan; best for assessing post traumatic pelvic anatomy and
evaluate the configuration of pelvic fractures
Other supportive: Post void residual urine measurement
Table 4.1: EAU classification according to the degree of urethral narrowing
Category Description Urethral lumen (French Degree Clinical Management
[Fr]) added by
KOB
0 Normal urethra on - - nil none
imaging
1 Subclinical strictures Urethral narrowing but ≥ Low Frequency None
16 Fr low only
2 Low grade strictures 11-15 Fr Frequency Dilatation
high only
3 High grade or flow 4-10 Fr High Frequency DVIU
significant strictures & thin
stream,
splitting
and
spraying
4 Nearly obliterative 1-3 Fr No DVIU
strictures frequency
Urethroplasty
Stream
drops Anastomotic
5 Obliterative strictures No urethral lumen (0 Fr) No Urethroplasty
frequency
Substitution
No stream
MANAGEMENT
General Management
There are general management principles which include making sure the patient is fit for an
operation, and dealing with any medical complications of the conditions, such as infection or
Renal Failure. The patient cannot have surgical or operative management which is specific until
the general health is restored and corrected.
Some of these include treating Urinary Tract infection or Uro sepsis as well as treating Renal
Failure.
Specific Management
This will depend on the site, length and caliber of the stricture. This determines the surgical
treatment as outlined above. In general the short stricture less than 1 cm will be treated by
closed methods. The longer Stricture greater than 2cm will be treated by open methods.
THANK YOU
BOKA HAMWENDA AND SAMUEL SIWALE
