Urethral stricture is a pathological narrowing of the internal lumen of the urethra, leading to urination disorders of varying severity. Urination becomes difficult, frequent and painful, accompanied by a spray of urine and a feeling of incomplete emptying of the bladder. Diagnosis requires urodynamic studies, urethrography and urethroscopy, ultrasound of the bladder with measurement of the volume of residual urine, laboratory tests. It may be necessary to augment the urethra, resection of the stricture site with the implementation of anastomotic or replacement urethroplasty.
ICD 10
N35 Urethral stricture
Meaning
Strictures of the urethra in practical urology occur in 1-2% of men and 0.5% of women. The predominant spread of pathology among men is explained by the greater length and complexity of the structure of the male urethra, as well as its easier exposure to injuries and other damaging factors. The potential danger of unrecognized or not fully cured urethral stricture is the likelihood of developing urinary tract infections (cystitis, pyelonephritis), urolithiasis, bladder diverticula, hydronephrosis, renal failure.
Causes
Congenital urethral strictures are quite rare (about 2%) and are mainly caused by anterior valvular narrowing of the urethra. Much more often, urologists have to deal with acquired narrowing, which can be caused by:
- injuries (70%). Posttraumatic strictures of the urethra, as a rule, develop as a result of blunt injuries of the perineum, penetrating wounds of the urethra, sexual excesses (foreign bodies of the urethra, penile fractures), fractures of the pelvic bones (as a result of auto injuries, falls from height, industrial injuries), chemical, thermal damage to the urethra.
- inflammatory processes (15%). Urethral strictures of inflammatory genesis can develop as a result of transferred urethritis (with gonorrhea, chlamydia, tuberculosis), balanitis, nonspecific degenerative-dystrophic processes (sclerosing lichen), etc.
- iatrogenic causes (13%). Iatrogenic strictures of the urethra can be caused by careless urological manipulations and operations – urethroscopy, cystoscopy, augmentation, catheterization, removal of concretions or foreign bodies, prostate TUR, radical prostatectomy, falloprosthetics, brachytherapy. In women, narrowing of the urethra can occur after birth trauma, vaginal hysterectomy, amputation of the cervix, etc.
The formation of pathology may be associated with diseases accompanied by deterioration of blood supply and metabolism of tissues of the urethra – systemic vascular atherosclerosis, coronary artery disease, diabetes mellitus, arterial hypertension.
Pathogenesis
In pathogenetic terms, the development of urethral stricture goes through several stages: damage to the urothelium and violation of the integrity of the mucosa, formation of urinary congestion, layering of secondary infection, proliferation and granulation of tissues, resulting in scar-sclerotic processes.
Classification
According to the etiology, there are congenital and acquired urethral strictures (traumatic, inflammatory, iatrogenic). According to the pathomorphosis, primary, recurrent and complicated course of urethral stricture is distinguished. Violation of the patency of the urethra can be partial or complete. Stricture can be localized in the anterior urethra (in the area of the external opening – the meatus, cephalic, penile or bulbar section) or the posterior urethra (in the prostatic or membranous section).
According to the length of the stricture , they are divided into:
- short (up to 2 cm)
- long (extended – over 2 cm)
With a lesion of 2/3 of the length of the urethra, they talk about subtotal stricture; with narrowing of the lumen of almost the entire urethra, they talk about total (panurethral) stricture. Complete loss of the urethral lumen and its obstruction is regarded as urethral obliteration.
Urethral stricture symptoms
Patients are concerned about the impossibility of adequate urination, characterized by a weak flow of urine, the need to strain the abdominal muscles during the injection, the spraying of a stream of urine, the feeling of incomplete emptying of the bladder, urine leakage. There may be pain, blood in the urine or semen, a decrease in the ejaculate ejaculate force. The presence of urinary infections is manifested by pathological discharge from the urethra and painful urination. With severe stricture, urine can be released drop by drop, in some cases, acute and chronic urinary retention develops, requiring immediate help.
Diagnostics
When analyzing the anamnesis, it is necessary to find out the possible causes – diseases and circumstances that preceded the development of symptoms of urethral stricture. Patients with suspected inflammatory narrowing are shown:
- Laboratory examination. A study of smears for sexual infections is carried out using the methods of PIF, PCR diagnostics and bacteriological seeding. A general urinalysis allows you to detect erythrocyturia, leukocyturia, pyuria and other deviations from the norm. With the help of urine backseeding, the causative agent of urinary tract infection is detected, the antibiotic sensitivity of the isolated flora is determined.
- Urodynamics research. A routine screening method for suspected urethral stricture is uroflowmetry, which allows to assess the rate of urine flow. With urethral constrictions during uroflowmetry, a characteristic curve with a plateau phase and an extension of the miction time is obtained. Cystometry, profilometry, and video-dynamic examination play an important role in the complex of the examination.
- Ultrasound of the bladder. Allows you to determine the volume of residual urine, get an idea of the degree of decompensation of functions.
- X-ray diagnostics. An X-ray assessment of the localization and extent of the stricture is obtained during urethrography, anterograde cystourethrography, multispiral cystourethrography. Radiopaque techniques also allow you to determine the presence of false passages, urethral diverticula, kidney stones and bladder.
- Endoscopy. Endoscopic diagnostic methods (urethroscopy, cystoscopy) make it possible to examine the stricture zone, establish probable causes, and perform tissue biopsy for morphological examination.
Urethral stricture treatment
The choice of treatment method is carried out strictly individually, depending on the localization, degree and extent of scar-sclerotic processes.
- Urethral augmentation. With simple, single and non-strained strictures, treatment, as a rule, begins with urethral augmentation. For this purpose, boogie dilators of various diameters and shapes (straight, curved) or urethral balloon catheters are used. The disadvantage of bougie is the high frequency of relapses.
- Urethral stenting. To prevent repeated narrowing of the urethra, they resort to installing a urethral stent capable of maintaining an adequate lumen of the stenosed part of the urethra. However, frequent cases of displacement or migration of urethral stents make the spread of the method quite limited.
- Urethrotomy. With short (less than 0.5 cm long) strictures located in the bulbar or bulbomembranous part of the urethra, dissection of the stenosed area can be performed – internal urethrotomy under visual endoscopic control.
- Urethral resection. In areas of constriction with a length of 1-2 cm, it is preferable to perform an open resection of the urethra with end-to-end anastomotic urethroplasty. Excision of the urethral stricture with a length of more than 2 cm requires urethroplasty using a graft from the patient’s own tissues (foreskin skin, cheek mucosa).
Prognosis and prevention
The lowest percentage of relapses is noted after reconstructive operations on the urethra. After urethral augmentation or urethrotomy, the probability of repeated stenosis is more than 50%. After treatment, patients should be monitored by a urologist and monitor the nature of urination. Prevention of the development of pathology consists in the prevention of STDs, timely treatment of urethritis, careful endourethral procedures, exclusion of injuries and other adverse factors. Prevention of recurrence of stricture requires the choice of an adequate method of pathology treatment.