Bulbar Urethral Stricture - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The obstruction of the urine flow through the urethra results in urethral strictures. Bulbar meaning bulb-shaped. Depending on the etiology, the urethral strictures are classified as traumatic and non-traumatic. Traumatic injuries are caused due to trauma, whereas non-traumatic injuries are caused by infection. The traumatic strictures result in disruption of the urethra with blockage of the urethral lumen, ending with fibrotic gaps between the urethral ends. In contrast, non-traumatic strictures result in fibrosis of the segment of the urethra involved.

What Is Bulbar Urethral Stricture?

Bulbar meaning bulb-shaped. It is a bulb-shaped narrowing of the urethra- that is connected to the bladder. The narrowing of the urethra reduces the flow of urine and makes it more painful to pass the urine. This condition is more common in men due to longer urethra.

What Are the Causes?

• Injury.

• Urethral instrumentation.

• Infection.

• Non-infectious inflammatory conditions.

• Congenital abnormality.

• Malignancy.

• Idiopathic.

What Are the Signs and Symptoms?

• Weak urinary flow.

• Splaying of the urinary stream.

• Frequent urination.

• Urinary urgency.

• Straining while urinating.

• Pain during urination.

• Prostate infection.

• Inability to empty the bladder completely.

• In severe cases, they are unable to urinate.

What Are the Types of Urethral Strictures?

Urethral strictures after blunt trauma are classified into two types:

• Pelvic Fracture-Associated Urethral Strictures: It occurs in fifteen percent of severe pelvic fractures. They are treated with suprapubic tube placement and delayed urethroplasty (surgical repair of the urethral defect) three months later. Instead of suprapubic tube placement, earlier intervention with endoscopic realignment may be used. But the majority of individuals require urethroplasty (surgical repair of the urethral defect).

• Blunt Trauma-Associated Urethral Strictures: Blunt trauma to the perineum results in compression of the bulbar urethra against the pubic symphysis and causes crush injury. These individuals are treated with suprapubic tubes and delayed urethroplasty (surgical repair of the urethral defect).

How to Diagnose?

• The physician asks for thorough medical history that the individual experiences regarding any of the symptoms of urethral strictures.

• Magnetic resonance imaging, computed tomography, and ultrasound are also helpful in detecting urethral strictures.

• Cystoscopy - Endoscopic procedure done with the help of a cystoscope that is carried through the urethra.

• Urethrography - Radiographic procedure that records the integrity of the urethra. It is a retrograde procedure that helps in identifying urethral strictures.

How to Select an Individual for Surgery?

The treatment plan depends on the following features:

Selection of Surgical Technique: The selection of appropriate surgical technique depends on the individual and stricture features.

Selection Criteria of an Individual:

• Age: Older individuals are preferred candidates for end-to-end anastomosis instead of grafting, whereas grafting is a preferred choice for younger individuals.

• Body Mass Index: Obese individuals are not preferred for grafting as it increases the risk of bleeding and sexual dysfunction.

• Previous Surgery: In individuals with a history of previous surgery, the retrograde blood supply to the bulbar urethra is compromised, which causes necrosis (cell death) and results in earlier recurrence.

Stricture Features:

• Etiology: Urethral strictures due to blunt trauma require end-to-end anastomosis.

• Site: Urethral strictures in the distal side require grafting as end-to-end anastomosis may cause sexual dysfunction.

• Length: Urethral strictures up to two centimeters are ideal for end-to-end anastomosis.

What Is the Treatment Plan?

Initial treatment involves widening the urethral tube by cutting the urethral strictures with the help of a cystoscope.

Dilatation and Urethrotomy:

• Urethral dilatation using endoscopic approaches includes- direct vision internal urethrotomy, laser urethrotomy, and self-intermittent dilation.

• But these approaches worsen the strictures and make it difficult for further surgical repair.

• Hence, these approaches have a low success rate.

• From the review, it is found that performing intermittent self-dilation may reduce the recurrence rate after an endoscopic procedure.

Urethroplasty:

• Urethroplasty refers to the open reconstruction of the urethra.

• This procedure has eighty to ninety-five percent success rates.

• The success rates depend on clinical factors such as cause, length, and location of the strictures.

• Urethroplasty can be performed safely for all age groups.

• For treating bulbar urethral strictures, anastomotic (with or without preserving bulbar arteries and corpus spongiosum) urethroplasty is performed.

• The replacement is done either with a buccal mucosal graft, full-thickness graft, or split-thickness skin graft and is done in a single visit.

Urethral Stent:

• The use of urethral stents has been banned in recent days.

• In 1996, a permanent urethral stent was approved for men with bulbar urethral strictures.

• In Europe, a thermo expandable urethral stent is available for use which is not approved by the United States.

What to Do in Case of an Emergency?

When in case of acute urinary retention, emergency treatment is performed. These include the following options.

1. The first approach is urethral dilatation and catheter placement. This procedure is done in an emergency department or an operating room.

2. The advantage of this approach is that the urethra remains patentable for a period of time.

3. The success rates are relatively low.

4. The second approach is the insertion of a suprapubic catheter with a drainage system. It is done in the emergency department or an operating room. The advantage of this technique is that it does not disrupt the scar and interfere with future definitive surgery.

5. Following urethroplasty, the individual must be under supervision for a period of one year since the recurrence occurring possibility is higher during this period.

What Are the Tips and Tricks for Performing Bulbar Urethroplasty?

Preparing the Individual for Surgery:

• It is suggested that the individual should lie in the simple lithotomy position using the Allen stirrups.

• This reduces the compression on the popliteal fossa, which causes neuro-muscular problems.

• The use of inflatable compression sleeves reduces the risk of vascular problems in the legs.

• Furthermore, they provide relaxation of the muscles of the lower limb.

• Performing under general anesthesia with controlled blood pressure reduces bleeding during the procedure.

Preparation of Urethra for Surgery:

• It is recommended to insert three French scale guidewires through the urethra to avoid problems during surgery.

• It also helps in the faster, easier, and safer urethral opening.

Conclusion:

Nowadays, it is difficult to choose the exact surgical management for strictures that are not obliterated. Indeed, different surgical techniques have evolved, and none has emerged as the best solution for repair as they have similar success and complication rates. The final choice is still based on the individual's characteristics and the surgeon's preference.