Urethral stricture refers to narrowing of the urethra due to formation of scar tissue. It obstructs the free flow of urine through the urethra.
Anatomy of the Urethra
The urethra is the conduit for urine from the urinary bladder into the exterior. The male urethra is longer, around 17 to 20 cm in length. Besides urine, it also carries semen. It can be divided into two parts:
The posterior urethra which consists of:
The anterior urethra which consists of:
The urethra in females is smaller (about 4 to 5cms long or about 2 inches) and is less susceptible to injuries and strictures.
Depending on their location, urethral strictures are classified as:
Most strictures occur in the bulbar urethra, and next commonly in the penile urethra. Strictures may occur in both the parts together as well or they may extend the whole length of the anterior urethra.
A urethral stricture consists of scar tissue that narrows the lumen of the urethra. Causes of urethral stricture include:
In some cases, the cause of urethral stricture cannot be determined.
Symptoms and signs of urethral stricture include the following:
These symptoms are similar to those experienced by patients with prostate enlargement. However, patients with urethral stricture are usually younger than those affected by prostate enlargement.
Most of the complications of urethral stricture arise due to incomplete emptying of the urinary bladder. These include the following:
Urethral stricture is diagnosed based on the medical history and examination of the patient, and certain tests. The patient may give a history of suffering from a previous gonorrheal infection, or prior injury or surgical procedure on the urethra. The stricture may be obvious on examining the penis. The following tests are required in a patient with suspected urethral stricture:
In antegrade urethrography, the contrast is introduced into the urinary bladder through a suprapubic catheter, a catheter directly introduced into the urinary bladder, or through the urethra, and images are taken while the patient passes urine
Emergency Treatment - If the patient suffers from acute retention of urine due to urethral strictures, an emergency suprapubic catheterization is required.
Endoscopic Stricture –
Endoscopic surgery can be done under local anesthesia as a day or overnight stay in the hospital. However long term results may not be the best. They are reserved for short segment strictures and re-strictures after open urethroplasty.
Open Urethroplasty Surgery
The open surgical procedure used to treat urethral strictures is called urethroplasty. Open surgery involves longer stay and needs to be done under regional or general anesthesia. The surgery itself can take 3 to 4 hours to perform. It is the preferred treatment for recurrent and failed endoscopic strictures. Its long term chances of success is better and has low chances of recurrence. Type of open surgery depends on length and type of stricture.
The types of urethroplasty include:
Pre-operative Care
Pre-operative Check-up - Routine tests as indicated above are ordered a few days before the surgery. Admission is required a day before the surgery.
Fasting before surgery - Overnight fasting is required and occasionally intravenous fluid maybe required to keep you well hydrated. Sedation is sometimes required for good overnight sleep before the surgery.
Shift from the ward or room to the waiting area in the operating room - An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley.
Once the surgical room is ready, you will be shifted to the operating room.
Type of Anesthesia -
Urethroplasty is done under regional or general anesthesia.
You will be usually asleep during the procedure and will not be aware of what is going on.
Shift to the Operating room - The ambience in the operating room can sometimes be daunting and a small amount of sedation can help overcome your anxiety.
From the trolley, you will be shifted on to the operating table. As you look up, you will see the operating light console and at the head end will be the anesthesia machine. There may also be monitors to check oxygen levels, ECG and other vital parameters. A constant beeping sound may be present from the monitors, which may sometimes be irritating.
Anesthesia before surgery - The anesthetist will inject drugs through an intravenous line and make you inhale some gases through a mask that will put you in deep sleep for anesthesia. Once you are in deep sleep, a tube will be inserted into your mouth and windpipe to administer the anesthesia gases to overcome pain and keep you comfortable.
Waking up from Anesthesia - Once the surgery is over you will wake up and the tube down the wind pipe will be removed. You will be asked to open your eyes before the tube is removed. You will be sedated and the voice of the anesthetist may be faint. Once the tube is out, you may have cough and sometimes nausea.
There will be an intravenous line. You will remain on oxygen. Once fully awake, you will be shifted on the trolley and taken to the recovery room.
Regional Anesthesia - It can be a spinal or epidural anesthesia. The spinal anesthesia involves injection of the anesthetic agent adjacent to the spinal cord or just outside it using a long needle. This renders the portion of the body beyond or below (as the case maybe) the point of injection numb and anesthetized, while the rest of the body remains unanesthetised.
The injection is usually administered in the lumbar (low back) spine. This form of anesthesia is easy to be administered and is ideally suited for surgeries performed in the lower parts of the body.
For this anaesthesia the patient is usually positioned in a sitting posture on the operating table. The forearms can be made to rest on the thighs to make the patient stable and comfortable. Alternatively, the procedure can be performed with the patient lying on their side with their hips and knees maximally flexed.
Following positioning, the anesthetist will clean the back region using anti-septic solution. He may administer a little bit of local anesthetic to numb the skin at the point where he is going to give the spinal, so that no pain is felt due to the spinal needle. The local anesthetic solution is then injected into the spinal space through a long needle. (Usually between L3 - L4, it is subject to change and vary from individual to individual). After successful administration, the patient is positioned in the required position and once again all your parameters will be checked by the anesthetist.
Recovery room - In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or a ward.
Post-operative Care
