Urethra is a tube that carries urine out of bladder. Narrowing or blockage of this tube is known as stricture urethra. This disease is more common in men than in females.

Aetiology

Stricture can result from various causes:

• Iatrogenic (45%): result from urethral manipulations (traumatic indwelling catheter, transurethral interventions, correction of hypospadias, prostatectomy and radiotherapy for pelvic tumors).
• Idiopathic (30%): reason not known. Probably some long forgotten infection or injury while riding a bicycle.
• Inflammatory (20-25%): Untreated bacterial infection (e.g. Gonorrhoea), Lichen sclerosus etc.
• Injury: Urethral rupture occurring with pelvic fracture or straddle injury to perineum.

Symptoms

The most common presenting symptoms are

• Thin urinary stream
• Straining during micturition
• Feeling of incomplete evacuation
• Increased frequency of micturition
• Urgency
• Urinary Tract Infections, Epididymo-orchitis
• Acute urinary retention.

Evaluation

Uroflowmentry:  Flow profile of a patient is often enough to clench the diagnosis. The graph from a stricture urethra patient has an extended urination time with a low-level plateau .The shape of this curve is pathognomonic of urethral stricture disease.

Retrograde Urethrogram and Voiding Cystourethrogram (RUG/VCUG): These are special dye radiograms (X-Rays) to determine the site and length of stricture.

Urethroscopy

Though required rarely, but may be helpful to diagnose stricture disease in unsuspected patients.

Management

If the patient presents with retention of urine or dilatation of the upper urinary tracts, the first step in the management is urinary diversion, usually by supra-pubic cystostomy. Definitive surgical procedure is done after management of urinary tract infection and correction of the hemodynamic and renal function parameters.

Surgical management of the urethral stricture disease can be endourological or open reconstructive surgery.

Endourological Management  (Optical Internal Urethrotomy)-  in this procedure the stricture scar is incised endoscopically using cold steel knife/ laser to obtain a widened urethral tube. The expanded wound margins heal with secondary intention. However there is a high chance of recurrence with this procedure, and thus it is now used only for first time short segment bulbar urethral strictures (<2cm).

Open Reconstructive Surgery (Urethroplasty)- Mainstay treatment of the urethral stricture disease. Various forms of reconstructive surgeries are employed depending on the length of the stricture disease, site of stricture and patient characteristics. These include-

• Stricture Resection and End to End Anastomosis. Procedure of choice for short segment bulbar strictures (<3cm).
• Urethroplasty with free graft – Most commonly free graft used these days is buccal mucosa due to two reasons. Firstly the inherent structure of buccal mucosa makes it uptake at the usage site easier thus leading to better outcomes as compared to other skin grafts. Second reason for its wide spread use is the ease of its harvesting procedure compared to bladder or colonic mucosa. In this procedure the stricture segment is longitudinally opened and widened using a patch of buccal mucosa.
• Urethroplasty with pedicled flaps. Reserved for cases with complex penile strictures or patients who had undergone pelvic radiotherapy.
• 2 Stage Procedures for Long Urethral Strictures. Useful in patients with complex large strictures. In the first stage urethra is laid open ventrally and the edges are sutured to the adjoining skin. A second procedure is undertaken after about 6 months wherein the resulting urethral palate is re-incised and fashioned in to a tube.
• Perineal Urethrotomy. Palliative procedure done for patients with recurrent strictures who do not wish to undergo further extensive surgery, or in patients with high surgical risk due to coexisting diseases. In this procedure bulbar urethra is sutured directly into the perineal skin beneath the scrotum. Distal urethra thus becomes superfluous.
• Bulboprostatic Anastomosis. Done for patients with urethral rupture defect at the level of urogenital diaphragm.