Generality
Urethral stricture is the narrowing of the urethra, which is the channel through which the urine accumulated in the bladder is expelled.
The main symptom is difficulty in urinating, which, in the long run, can give rise to various complications, including serious ones.
The therapy of urethral stricture is based exclusively on surgery. In fact, there are no less invasive treatments capable of reducing the stricture. However, it is comforting that the techniques in use today provide satisfactory results.
What is the urethra?
For further information: Urethra - Anatomy and Functions
The urethra is a tubular channel, which allows urine to flow outwards; it originates from the bladder and ends in a small opening, called the urinary meatus.
Figure: urinary and male genital system. Urethral stricture can affect both men and women, but is much more common in men.
The urethra is much longer in men than in women; the male one, in fact, measures 18-20 cm and crosses the penis up to the tip of the glans; the female one, on the other hand, is much shorter and ends at the vulva (vulvar vestibule), anterior to the vaginal opening and posterior to the clitoris.
In "man, the urethra also has" another function: it is the way through which the sperm passes during ejaculation.
What is urethral stricture
Urethral stricture consists in the narrowing of the urethra in any point of its path. The consequences of this narrowing concern the flow of urine, the passage of which is obstructed, and the affected subject may therefore experience more or less severe difficulties in urination.
The stenosis of the urethra is determined by the formation of a mass of scar tissue in correspondence with the narrow area. The greater this mass, the greater the occlusion of the urethral canal.
EPIDEMIOLOGY
The precise incidence of urethral stricture is unknown. However, it has been observed that this disorder is much more common among males over 50. In fact, women and children represent only a small percentage of cases.
Furthermore, another important statistic concerns the causes. Today, Neisser's gonococcal urethral strictures are on the decline, as a wide range of antibiotics have reduced the chances of contracting this infection and developing associated complications.
Causes
What determines the formation of the scar mass that occludes the urethra? The causes of urethral stricture are different and concern:
- Trauma or injury, which damages the urethra
- Infections
- Congenital defects
- Tumors
TRAUMAS AND INJURIES
Trauma or accidental bumps to the urethra can damage this canal. When this occurs, the urethral lesions heal, creating a mass of scar tissue around them. In the most unfortunate cases, or if the trauma is considerable, it can happen that the scar mass comes to occlude the urethra.
The classic trauma situations potentially responsible for the consequences described above are represented by falls (from cycles, motorcycles or horses) and some surgical operations on the urinary tract (bladder and prostate) and genitals (hypospadias).
INFECTIONS
Scar tissue can also form as a result of a "pathogenic infection. This is the case of two infectious diseases, sexually transmitted, such as gonorrhea and chlamydia, or infections caused by" prolonged use of a urinary catheter; or, again, due to an inflammatory state of the prostate or the tissues surrounding the urethra.
It should be noted that an "infection of the urethral canal does not always translate into a stricture. However, in its presence, the chances of this happening increase, especially when the pathology is neglected.
CONGENITAL DEFECTS
Despite being very rare, some babies can be born with a congenital defect of the urethral canal.
CANCERS
Tumors in the urethra can narrow the urethral canal. However, this is also very rare.
Symptoms and complications
For further information: Urethral stricture symptoms
Symptoms of urethral stricture depend on the degree of stricture itself. Less severe cases are asymptomatic, that is, they do not have obvious symptoms; conversely, the most severe cases are characterized by increasingly severe disorders. For example, the classic symptom of urethral stricture, ie difficult urination, from a slight discomfort in mild cases, becomes a very serious problem in the most worrying cases.
The patient with urethral stricture complains:
- Reduced urine flow, the so-called reduced mitto
- Painful urination
- Mitto to "spray"
- Drip shortly after urinating (post-voiding)
- Incontinence
- Incomplete emptying of the bladder
- Need to urinate often
- Urinary infections
- Blood in the urine and semen
- Reduced jet ejaculation
DIFFICULT ORINATION: FEATURES
The main symptoms of urethral stricture concern the flow of urine. The patient feels difficulty, and sometimes pain, already in starting urination. The jet (mitto), then, is reduced and the quantities of urine expelled are lower than normal. . This explains why the sensation of a failure to empty the bladder is felt and why a few drops of urine are lost immediately after urinating.
It may also happen that the jet takes the form of a spray ("mitto a spray") or that it is double.
COMPLICATIONS
A first complication, which characterizes urethral stricture, concerns the failure to empty the bladder after each urination. The recurrence, over time, of this circumstance can turn into serious infections of the bladder, prostate and kidneys. Not surprisingly, the stagnation of urine inside the bladder is considered one of the main causes of urinary tract infection.
The other noteworthy complication concerns the mitto (the jet of urine) and the size of the occlusion. In fact, if the conditions of a stricture worsen, the patient could suffer from complete urinary retention, ie total inability to urinate.
WHEN AND WHO TO CONTACT?
When the symptoms described are accompanied by pain and the general situation affects the standard of living, it is good to consult a specialist: the urologist.
Diagnosis
The diagnosis of urethral stricture involves the execution of numerous tests. Part of them is used to evaluate the severity of the disorder; another part helps the doctor to understand the triggering cause. All this is essential to establish which therapeutic path is most appropriate.
It begins with a physical examination for urological evaluation and an "investigation of the patient's clinical history (anamnesis). It then continues with a urine culture test (urine culture), a urethral swab and instrumental tests, such as:
- Ultrasound of the urethra
- Retrograde urethrography
- Cystourethrography (or antegrade urethrography)
- Cystoscopy (or cysto-urethroscopy)
UROLOGICAL EVALUATION AND CLINICAL HISTORY.
During the urological examination, it is the doctor's duty to question the patient about the symptoms felt and his / her clinical history, trying to trace the moment of the onset of the disorder. In fact, since a urethral stricture can be a direct consequence of a surgery or a fall from the bicycle, the fact of being aware of it represents, for the doctor, the first step towards a correct diagnosis.
Furthermore, it is equally important that the urologist relies on a test that is easy to perform and not at all invasive: uroflowmetry. Through the latter, the quantity of urine emitted in the unit of time is measured, in other words the extent of urination. In patients with urethral stricture, the flow rate value is lower than normal.
Uroflowmetry is a practical exam, but its limits should not be overlooked: low values also characterize other pathologies of the urinary system.
CULTURAL EXAMINATION OF URINE AND URETHRAL SWAB
Urine culture and urethral swab are two tests aimed at detecting particular pathogenic microorganisms, respectively, in the urine and in the lower urinary tract. They are used by the doctor if he suspects the presence of a "bacterial infection in progress.The detection of certain bacterial strains (and of the relative infection) has important diagnostic meanings, since it allows to:
- Go back to the causes of stenosis, such as, for example, in those cases due to gonorrhea and chlamydia
- Check for a stagnation of urine in the bladder
- Establish the most appropriate antibiotic therapy, based on the bacteria involved.
IN-DEPTH INSTRUMENTAL EXAMINATIONS
- Ultrasound of the urethra. This is a non-invasive radiological examination, for which no special preparation is required. A probe is used, which the doctor runs along the affected area. It is very useful if the patient is a man, as the probe provides clear images relating to the degree of stenosis. Conversely, when the patient is a woman, the examination has little use and application.
- Retrograde urethrography. It is also a radiological examination, which allows to analyze the integrity of the final tract of the urethral canal. The examination involves the injection, inside the urethra, of an iodized contrast medium. This is done with a catheter. Once injected, the contrast medium flows down the urethral duct, adapting to the cavity it passes through. Therefore, if there are any constrictions, it penetrates inside and passes through them. The path taken by the contrast medium is revealed by a series of X-ray images.
- Cystourethrography or antegrade urethrography. It is a very similar exam, in execution, to the previous one. The only difference is where the contrast medium is injected in the urethra: in this case, it is near the bladder.
- Cystoscopy. This is an endoscopic examination of the urethral canal. An instrument, called a cystoscope, equipped with a camera is used. The cystoscope is inserted inside the urethra and, through a monitor connected to the instrument, the urethral lumen is observed. If there are lesions, abnormalities and narrowings, these are highlighted. In addition, a small tissue sample (biopsy) can also be taken.
Therapy
Treatment of urethral stricture is mainly based on surgery and the administration of antibiotics. If the latter are used to deal with bacterial infections of the urinary tract, surgery is the only countermeasure capable of repairing the damage to the urinary tract. urethral canal.
There are several possibilities of intervention:
- Urethral dilation, by catheter
- The urethrotomy
- Surgical correction of the urethra
- The placement of one stent urethral (stenting urethral)
The choice of one procedure, rather than another, depends on several factors, such as: age, sex, general state of health of the patient, severity of the stenosis and experience of the surgeon. The following table, on the other hand, reports the clinical conditions, which oblige the operation.
When is it necessary to operate?
- Serious difficulty urinating
- Urinary retention
- Serious kidney and bladder problems
- Recurrent urinary tract infections
- Stagnation of urine in the bladder
- Unbearable pain
URETHRAL EXPANSION
Urethral dilation is performed under local or general anesthesia, by inserting increasingly larger catheters into the urethra. Progressively increasing the diameter of the catheters serves to widen the narrowing in a gradual and non-traumatic way. The patient undergoes this operation several times. Repeating the operation is essential for its success. In some cases, to facilitate the insertion of the catheters, the use of lubricating gels is used.
THE URETHROTOMY
The urethrotomy uses an endoscope, equipped with a camera, which serves to recognize the exact point of the stenosis. Once the area has been identified, the urologist takes a tiny blade and cuts and reopens the occlusion. While waiting for this incision to heal, a Foley catheter (with one end inflatable), in order to keep the urethral canal open.
It has been seen that the success of the urethrotomy depends on the size of the stenosis. In fact, the smaller the size of the stenosis, the greater the chances of success, and vice versa.
THE SURGICAL CORRECTION OF THE URETHRA
The surgical correction techniques of the urethra are different and depend on the size of the stenosis.
For small strictures, the surgeon first cuts and removes the area of scar tissue; after which, it reconnects the two separate flaps of the urethra.
In the case of severe strictures, however, after removing the scar mass, a buccal tissue transplant is performed to reconstruct the missing urethra tract.
Surgical correction has a good success rate. However, it is an invasive procedure, to be performed under general anesthesia.
URETHRAL STENTING
The stenting urethral is another endoscopic procedure, such as urethrotomy. A small tube is introduced in the point where the urethra is narrow stent, which serves to keep the channel open.
If the health conditions of a patient do not suit any of the previous three operations, stenting is a valid alternative. This is the case, for example, in very elderly patients.
Prognosis
The prognosis of urethral stricture depends on several factors.
If left untreated, there is no chance of recovery. In fact, taking antibiotic drugs serves to cure any bacterial infections, but all other symptoms remain.
Surgery, therefore, becomes a necessity.
The success of the operation depends on several factors. The main ones are:
- Age
- Severity of the stricture
- Surgical procedure best suited to the patient's health conditions
The outcome of the intervention is usually favorable. However, in severe cases and in very elderly patients, relapses may occur that will require a second surgery to resolve the urethral stricture.
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