What Is Urethral Stricture?
When scar tissue develops and narrows the urethra, it is called a urethral stricture. This narrowing restricts urine flow from the bladder and can lead to various medical problems in the urinary tract, such as inflammation or infection.
There are various reasons behind development of urethral strictures due to the formation of scar tissue. These include:
-
Medical procedures that involve insertion of instruments, such as the use of catheters over an extended period or intermittently, endoscopes into the urethra.
-
Trauma or injury to the pelvis or urethra,
-
Previous surgery to remove or reduce an enlarged prostate gland,
-
Enlarged prostate,
-
Cancer of the urethra or prostate,
-
Sexually transmitted infections,
-
Radiation therapy.
Symptoms of urethral stricture include:
-
Incomplete bladder emptying.
-
Decreased urine stream.
-
Difficulty, straining.
-
Pain during urination.
-
Spraying of the urine stream.
-
An increased urge to urinate or more frequent urination.
What Is Panurethral Stricture?
Long-segment urethral stricture, also known as panurethral stricture disease, affects different anatomic segments of the anterior urethra and is less common than bulbar stricture. It poses a significant surgical challenge for reconstructive urologists due to its complex nature. The etiology of the condition varies depending on age and geographic location, with lichen sclerosus (chronic skin condition that mainly affects the genital and anal areas) being the most common cause in some regions of the world. Other common causes include previous endoscopic urethral manipulations, urethral surgery, trauma, inflammation, and idiopathic factors.
Various surgical procedures have been developed and used worldwide, including one or more staged surgeries with the use of adjunct tissue transfer maneuvers. A one-stage, minimally invasive technique, performed through a single perineal incision, has become popular due to its effectiveness and reproducibility. However, the success of any surgical procedure depends on the experience and expertise of the reconstructive urologist.
What Causes Panurethral Stricture?
-
The causes of panurethral strictures may differ between developed and developing countries.
-
As panurethral strictures are rare, there was no specific description of their etiology.
-
Panurethral or multifocal anterior urethral strictures can generally be caused by urethral catheterization, TUR (transurethral resection), and idiopathic factors.
-
Other rare causes include prostatectomy, hypospadias, pelvic fracture, urethritis, lichen sclerosus, cystoscopy, and tumor.
-
In contrast, it is believed that these long strictures are due to inflammation caused by previous catheterization, instrumentation, or infection, as well as lichen sclerosus.
-
It remains unclear whether penile strictures in lichen sclerosus develop due to extension of glandular disease into the penile urethra or due to chronically obstructed voiding or instrumentation.
How Is Panurethral Stricture Diagnosed?
Panurethral stricture is diagnosed through a combination of patient history, physical examination, and imaging tests.
-
Patient History: The urologist will enquire about the patient's symptoms, previous medical conditions, surgical procedures, and any history of urethral trauma.
-
Physical Examination: The urologist will perform a physical examination of the genitalia and urethra to look for any signs of swelling, redness, discharge, or scarring. A digital rectal exam to check the prostate gland is undertaken for examination.
-
Uroflowmetry Test: This is a non-invasive test that measures the rate of urine flow and the volume of urine voided. It can help identify narrowing or obstruction of the urethra.
-
Retrograde Urethrography: This is an X-ray procedure where contrast dye is injected into the urethra and X-rays are taken to visualize any narrowing or obstruction.
-
Cystoscopy: This is a procedure where a flexible and thin tube with a camera on the end is inserted into the urethra to visualize the urethra and bladder. It can help identify the location and severity of the stricture.
-
Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) Scan: These imaging tests may be ordered to further evaluate the urethra and surrounding tissues.
How Is Panurethral Stricture Treated?
-
When planning the treatment of panurethral stricture, one of the main concerns is to undertake a single- or two-stage procedure.
-
If a single-stage repair is planned, the availability of adequate tissue for reconstruction must be considered.
-
Most experts recommend laying-open of the urethra if the disease has caused significant narrowing with an unsalvageable urethral plate if there is a history of multiple failed repairs, or if the stricture is associated with complications such as abscess and stone. In most other situations, substitution urethroplasty is preferred, which can be done using either a flap or a free graft, or a combination of both.
-
However, as there are no prospective studies available, there is no consensus on the best option. The surgeon must tailor the treatment plan based on the individual merits of each case.
Use of Grafts and Flaps - Panurethral strictures can be treated using either flaps or grafts. The choice of procedure depends on the availability of tissue for reconstruction. Flaps are segments of tissue that are rotated or transposed into the area of the urethra that requires reconstruction. Grafts, on the other hand, are pieces of tissue that are harvested from another part of the body and placed in the area of the urethra that requires reconstruction. Both flaps and grafts have their advantages and disadvantages.
Flaps provide good vascularized tissue that can resist infection, but they may not be available in cases where there is a limited amount of healthy tissue. Grafts, on the other hand, can be harvested from various sources and are associated with a lower incidence of complications, but they may not provide adequate vascularization and may require a longer healing time.
Conclusion:
Panurethral strictures are commonly caused by factors such as previous catheterization, urethral surgery, and lichen sclerosus. However, the treatment of each individual case should be tailored based on the specific cause of the stricture, as well as the patient's history of previous urethral surgeries, the availability of local tissues for flap harvesting, the availability of appropriate donor tissue, and the expertise of the treating surgeon. For patients with complicated strictures, and those who have previously undergone failed urethroplasties, or those with poor quality of urethral plate, two-stage surgery may be a more appropriate option. In other situations, a flap or graft urethroplasty may be used, and in cases where adequate tissue is not available, a combination of flap and graft may be used, which has shown reasonable success rates.
