URETHRAL STRICTURES
DEFINITION AND CAUSES
• It is a narrowing of the urethral lumen caused by fibrosis of the urethral
epithelium and surrounding corpus spongiosum, leading to obstruction to urine
flow.
• Causes:
iatrogenic (post catheter and/or instrumentation);
sexually transmitted diseases (gonorrhoea);
post radiation;
traumatic;
idiopathic;
congenital.
CLASSIFICATION
• Classification I: Aetiologically.
• 1. Congenital.
• 2. Inflammatory:
• a. Post-gonococcal is most common (70%).
• – Gonococcal stricture occurs one year after infection.
• – Retention develops only 10–15 years later.
• – Common in the bulb of urethra especially in the roof.
• – Here multiple strictures are common, proximal stricture is the narrowest.
• b. Tuberculous.
• c. Other infection (urethritis).
• 3. Traumatic: Bulbous, membranous.
• 4. Post-instrumentation: Catheter, dilator, cystoscope.
• 5. Postoperative: Prostate surgery (4%), urethrostomy.
• Classification II:
• 1. Proximal: Common in bulbous urethra (70%).
• 2. Distal: Congenital (in the external meatus). Often traumatic
• in children.
• Classification III:
• 1. Permeable: Permits urine to pass.
• 2. Impermeable.
• Classification IV:
• 1. Passable: Allows catheter to pass.
• 2. Impassable.
• Classification V: It can be single or multiple.
• Classification VI: According to the part involved.
• In the roof (most common) or in the floor.
CLINICAL FEATURES
• Poor urinary stream; Incomplete emptying
• Forking and spraying of the stream; Frequency,
dysuria
• Retention and often with overflow
• Pain, burning micturition, suprapubic tenderness
• Thickening and button-like feeling in bulbar urethra
• The patients may complain of recurrent UTIs.
INVESTIGATIONS
• Urine microscopy and culture
• Blood urea and serum creatinine
• Intravenous Urography(IVU) is used to see hydronephrosis and function of kidney.
• Ultrasound abdomen
• X-ray of pelvis to see old fracture with history of trauma
• Ascending urethrogram is an essential investigation to see the site, type, extent and false
passage
• The dye is injected through suprapubic needle puncture into the bladder and visualisation is
done using C-Arm image intensifier.
• Urethroscopy
• Urodynamic Studies
MANAGEMENT
• Intermittent dilatation:
Gradual dilatation, initially with thin dilators, later with thicker dilators of increasing size.
Dilatation should be done in OT under aseptic precaution.
Dilators used:
a. Lister’s dilator [has got olive tip (blister)].
b. Clutton’s dilator.
c. Filiform bougies.
• Visual internal cystoscopic urethrotomy or stricturotomy (DVIU):
Here using cystoscope, stricture is visualized and is cut at 12 o’clock position, until it bleeds.
After that Foley’s catheter is passed and kept in position for 48 hours.
• Urethroplasty: Stricture is excised and urethra is reconstructed using prepuceal skin or
scrotal skin (Johanson’s
urethroplasty).
There are two types of urethroplasty: anastomotic and augmentation. Anastomotic
urethroplasty is performed for bulbar urethral traumatic strictures where there is a gap in the
urethra. Augmentation urethroplasty is performed for non-traumatic and long strictures. In
this type of urethroplasty the structured segment of urethra is incised and augmented with a
patch (graft). The usual choice of patch being buccal mucosa.
