Ureteral Stricture- Common Sites, Causes, Symptoms, Diagnosis, Treatment, and Complications

What Is Ureteral Stricture?

The primary function of the urethra in men and women is to excrete urine outside the body. This tiny tube also plays a vital role in ejaculating sperm. If the scar of inflammation, injury, or infection blocks or restricts urine flow to the tube, it is called urethral stricture. Some people experience pain with urethral tightness. Stiffness of the urethra is characterized by narrowing of the lumen of the ureter, resulting in obstruction of the function. The most common type of ureteral stricture is obstruction of the ureteropelvic junction (UPJ), which is a birth defect or acquired at the UPJ level.

What Are the Common Sites for Formation of Ureteral Strictures?

1. UPJ Obstruction: This is usually a congenital disorder that may not appear until adulthood. Symptoms include back pain, infections, and kidney stones.

2. Proximal Ureteral Stricture: These layers are usually associated with kidney stones or previous fixation of UPJ obstructions. Proximal is the tightening near the top of the ureter and kidneys.

3. Pan-Ureteral Strictures: These layers extend from the kidneys to the bladder or have multiple narrowing areas throughout the ureter. They are often seen in cases of recurrent kidney disease.

4. Distal Ureteral Stricture: This stricture is close to one or more levels of the ureter. Injuries during other surgeries, stones, or radiation to the pelvic organs may cause distal stiffness. If constipation occurs at the level of the urethra orifice, it is usually caused by birth or occurs during the treatment of bladder ulcers.

What Causes Ureteral Stricture?

1. Congenital Causes: When patients are born with congenital malformations, they are usually diagnosed early but are sometimes presented as adults. Obstruction can occur either at the level of the ureter and another (called the ureter orifice) or at the junction of the ureter and kidneys (called the ureteropelvic junction-UPJ).

2. Strictures Due to Kidney Stones: If a person passes through a kidney stone or undergoes kidney stones, or through surgery to remove stones may develop stricture.

3. Iatrogenic: This is an injury caused during some abdominal surgery. In most cases, functional damage to the ureter is immediately apparent during surgery and repair. However, in some cases, the injury is missed, and the patient develops symptoms at a later stage. Iatrogenic benign strictures can occur for a variety of reasons, including the following:

   1. Ureteroscopy- A small telescope called a ureteroscope is sent up the ureter to the point where the stone is placed during ureteroscopy, a treatment for kidney stones.

   2. Open or Laparoscopic Injuries- A surgical technique known as laparoscopy enables a surgeon to access the abdomen and pelvis from the inside without having to make significant skin incisions.

   3. Radiation Therapy- Radiation therapy, often known as radiotherapy is a treatment that uses ionizing radiation to control or destroy cancerous cells.

   4. Urinary Incontinence- Urinary incontinence, or the inability to control one's bladder. The degree of urgency might range from occasionally dribbling pee when people cough or sneeze to having a sudden, powerful need to urinate that prevents them from reaching a toilet in time.

   5. Kidney Transplantation- The organ transplant of a kidney into a patient with end-stage kidney disease is known as a kidney transplant or renal transplant.

4. Radiation: Radiation treatment of stomach cancer can narrow the ureter.

5. Idiopathic: This means that the cause of urethral obstruction is unknown.

6. Retroperitoneal Fibrosis: In some cases, there may be inflammation near the ureter from an unknown source, causing narrowing of the ureter.

7. Dangerous Blockage: Sometimes untreated or curable cancer can compress the ureter, causing complications. This cannot be considered true stricture, but the symptoms may be similar.

What Are the Symptoms of Ureteral Strictures?

• Pain and Fullness in the Side or Back: Ureteral congestion usually occurs near the kidneys. When urine cannot pass easily through a narrow tube, you may experience pain near the kidneys, which are found on both sides of your lower back. Pain may be limited to one side or, if you have obstructions in both ureters, it occurs on both sides. Additionally, you may feel a sense of fullness as your swollen kidneys press on other organs. Compression of the urethra and tightening can also make you feel nauseous.

• Blood in the Urine: If you see blood in your urine or semen, It can be an indication of;

  • Tumors.

  • Urinary tract infection (UTI).

  • Kidney infection.

  • Kidney stones and bladder stones.

• Nausea: Compression of the urethra by the pressure of swollen kidney can make you feel nauseous.

• Urinary Tract Infections: If urine can not pass freely into your bladder, it can back up into the kidneys, causing inflammation and infection. The infection can affect your entire urinary tract. Symptoms of a UTI include impaired urination and pain and burning when you urinate. Women are about four times more susceptible to UTIs than men because of their shorter urethras (i.e., the tube that runs from the bladder to the outside of your body). However, both women and men can develop a UTI.

How Do You Diagnose a Ureteral Stricture?

The diagnostic tests for ureteral stricture include:

• Medical and physical examination of the patient.

• X-rays: The electromagnetic energy produces images of bones and internal organs.

• Ureteroscopy: This is a small visual aid (ureteroscope) that extends into the urethra and the ureter.

• Retrograde Pyelogram or Nephrostogram: Uses a special agent (dye) to produce detailed X-ray images of the ureter and kidneys.

• Ultrasound: Technique in which high-frequency sound waves create an image of internal organs.

• Computed Tomography (CT) Scan: It is a rare imaging procedure that can detect abnormalities on X-ray.

• MRI: Magnetic resonance imaging (MRI) is a procedure that produces two-dimensional views of an internal organ or structure.

What Are the Treatment Options for Ureteral Strictures?

The urologist will decide the best treatment option for you after evaluating your ureteral stricture. Treatment may include:

• Balloon Extension: The first most common treatment for benign ureteral strictures is balloon extension, followed by stent placement for four to six weeks.

• Laparoscopic or Robotic Surgery: Laparoscopic and surgery assisted by robots are increasingly being used to replicate the results provided by open surgery. These methods require longer operating hours and may involve higher costs but often reduce blood loss and more extended hospital stay.

• Percutaneous Nephrostomy: This is a needle inserted through the back into the kidney to drain urine.

• Ureteral Stent: Drain the urine from the kidney to the bladder, bypassing the stricture. A long-term stent may be more appropriate for a patient who has a terminal illness or has a high risk of surgery and is well tolerated for a stent.

What Are the Possible Complications of Ureteral Strictures?

The possible complications or risks include:

• Bleeding (which might require a blood transfusion).

• Infection.

• Urine leakage from the ureter or bladder.

• Stricture returning after surgery.

• Kidney damage.

• Blood clots.

Monitoring and Follow-up: You will have a follow-up visit with your doctor. Suture removal is done one to two weeks after surgery. The stent in the ureter will be removed in four to six weeks. About three months after surgery, you may have a photo test to see if the ureter is open and the kidneys are working normally.

Conclusion:

Depending on whether the kidneys were harmed when the urine could not drain, the prognosis for ureteral obstruction will vary. Ureteral obstruction typically does not have major long-term repercussions if doctors treat the blockage before serious kidney damage begins. Quickly identifying and fixing the issue can help stop kidney function from declining. Most patients have quick and complete recovery following surgery with no lingering issues. In a tiny number of patients, the afflicted kidney may still become infected or produce kidney stones. If individuals notice any ureteral obstruction symptoms, they need to contact their doctor straight away. Though they may start out minor, symptoms can soon worsen and become extremely serious.