2Introduction A narrowing of the urethra Caused by injury or disease including UTIs and other forms of urethritis.Above insult leads to scar tissue formation which contracts hence reducing the caliber of the urethral lumen.End result is the resistance to antegrade flow of urine and semen .
3CausesTraumaticIatrogenic :post instrumentation( including catheter ,urethral endoscopy)Post operative :open prostatectomy ,amputation of the penis.CongenitalMalignancies
4Presentation :Obstructive voiding symptoms ,urine retention(decreased force of stream incomplete bladder emptying ,dribbling ,intermittency)UTI s
5ComplicationsRetention of urineUrethral diverticulumPeri urethral abcessUrethral fistulasUrethral calculiHernia ,heamorrhoides and rectal prolapse.
6ManagementPrinciples of treatmentProper understanding of the relevant anatomyAccurate diagnosisSkilled surgical technique
7Making diagnosis Suggestive history Findings on physical exam Radiographic technique
8Radiographic imaging: Contrast studies achieved by retrograde and antegrade cystourethrography.Ultrasonography : A transducer placed longitudinally along the penis .Can evaluateStricture lengthDegree and depth of spongiofibrosisEndoscopic evaluationDone using either rigid or flexible cystourethorgraphy
9Treatment Note : no medical therapy exists for urethral stricture Surgical therapy:Uretharal dilatationInternal urethrotomyPermanent utrethral stentsOpen reconstructionPrimary repairTissue transfer ,repair techniques
10Urethral dilatation The objective in patients with isolated strictures DrawbacksIt’s a blind procedure hence false passages can be createdrecurrence rateinfectionInternal urethrotomyStricture is incised under direct vision using endoscopic equipment .Objective is to incise the stricture and ensuring epithelialization before wound contraction reduces the lumen caliber.
11Complications Recurrence of stricture Bleeding Extravasation of the irrigation fluid into the perispongial tissues.]Permanent urethral stentsPlaced endoscopicallyDesignated to be incorporated into the wall to produce a patent lumen.Most useful in short strictures located in the bulbar urethra and in elderly patients.Draw backsIf placed distal to the bulbous urethra it can cause pain while sitting or during intercourse.Migration of the stentContraindicated in patients with dense strictures or prior urethral reconstruction.
12Open reconstruction Primary repair Hold standard against which other procedures are compared to.Involves complete excision of the strictures with reanstomosis.Technical points to be observedComplete excision of the areas of fibrosisWidely patentTension free anastomosisYoung patients have an additional benefit of having compliant tissues hence wide strictures can be safely excised and primary anastomosis done.
13Complications Post operative chordae Penile shortening Ejaculatory dysfunctionDecreased glans sensitivityThe repair is usually stented with a silicon catheter and urine delivered using a suprapubic catheter as healing takes place.
14Tissue transfer Technique Reserved for patients in whom multiple procedures have failed.Conducted as two stage procedureSuccess depends on the blood supply of the local tissues at the site of placement.Graft is harvested from desired non hair bearing location e.g. Buccal mucosa ,rectal or bladder.
151st stageUrethra is opened via a ventral midline incision and the scarred urethra is excised completely.Dartos fascia is mobilized bilaterally and closed over the urethral bed.Desired skin is harvested and sutured to the dartos covered ventral urethral bed .Catheter is placed for suturing.
162nd stage Takes place 6-9 months after the initial operation. Skin strip is mobilized along the urethra that will be used to fashion a neo urethra.Dartos fascia is not interfered with .Must be water tight closure.Catheter is left in site for stenting purposes.
17Complications : Post voiding dribbling . Post operative diverticulum. Skin retraction of the ventral skin of the penis.Urethra cutaneous fistula.Above can be minimized by having the appropriate experience and surgical technique.Oral complications : pain ,persistent numbness ,tightness or coarseness over donor site.
18Contra indications to surgery Active urinary tract infection.Must rule out malignancy ,endoscopic biopsy done in case of luminal mass.
19PrognosisProspective randomized comparison of internal urethrotomy and dilatation showed no significant difference in efficacy when used as the initial treatment.Recurrence rate is directly proportional to the stricture length.Rate at 12 months2cm %2-4cm % increased to 75% at 48 months.> 4cm %
20Stents Long term success rate of 84% at 5 years . And increased patient satisfaction.
21Excision with primary anastomosis Most successful .Tissue transfer graft have overall success rate of > 95% over one year however there is deterioration over timeExternal location and degree of scarringBenign or malignant prostate obstructionPost operative bladder neck contraction.ComplicationsChronic prostatitisChronic UTIEpidydimalDiverticulaUrethrocutaneous fistulaPeri urethral abscess.Urethral carcinomaVesical stones from stasisAscending pyelonephritis.Renal failure
22Circumcision Is the surgical removal of some or all of the foreskin. Indications : young boySocialReligionTherapeutic:PhimosisInfection: balanitis ,balanoposthitis ,posthitisXeroderma balanitis obliteransParaphimosis tight phrenulumUTIAdultsInability to retract foreskingTight frenulumBalanitisBefore radiotherapy
23Timing variesTechniquePlastibelOpen as in adultComplicationsBleedingInfectionMeatal ulcerMeatal stenosisPainPsychological traumaLose of glans sensitivityAn ulcerated meatus in the circumcised meatus is a frequent sumptom .The ammonical diaper is the cause of this lesion.Benefits
24Foreskin 50% at 1 year retractable 90% at 3 years99% at 17 yearsWhitish ring of indurated skin.
25PhimosisThe foreskin can not be fully retracted over the glans penis .Normal separation after 3 yearsNon-retractabilityPathology :acquired.Balanitis xertica obliteransScarringBalanitisRepeated catheterizationForeceful retractionUntreated diabeticPresentationPain during urination.Obvious ballooning of foresking with urination.
27ParaphimosisThe foreskin becomes trapped behind the glans penis and can not be reduced .Treated as medical emergency if-persists for several hours-signs of lack of blood flow.It can result in gangrene.Caused by-during penile exam-penile cleaning-urethral catheterization-Cystoscopy
29Ulceration of the urethral meatus Is quite common in circumcised boys.Delayed up to 2 years from circumcision.Lack of protective prepuceFrictionAmmonical dermatitisFrenular artery ligationUlcer form a scabProcess cause fibrosisAcquired pin hole meatusfollow up hypospedias repair .phimosissparing or dribblingchronic retentionrenal impairment
30treatmentmedicallocal measures to soften the scab and alkalinization of urine .Meatotomy
31STD Gonorrheal urethritis Gonorrhea is a STDCaused by gram Neisseria gonnorheaGram negative kidney shaped diploccoiInfect the anterior urethra of men.Cervix in womenPresentaion within 2 to 10 daysUrethral discomfortDysuria scaldingUrethral dischargeMay be slight discharge and white to yellowInvestigations :urethral smear gram staining.
33TreatmentAntibioticsCiprofloxacinPencillinContact For control
34Women ASymptomatic Increased vaginal discharge Painful urination Vaginal bleeding between periodsAbdominal painPelvic painComplicationsInfertilityWomen pelvic inflammatory dieseaseIncrease risk of HIV
35Non specific urethritis Non gonoccocal urethritis Diagnosed by exclusionChlamydia trachomatisUreaplasma urealytica50% unknown causeClinical featuresDysuria :a few days to 3 months dischargeEpididymitisRxDoxycycline
36Reiter's disease Sexually acquired reactive urethritis Subacute urethritis 4-6 weeks clean discharge.Cnojuctivitis 50%10 days to 2 weeks arthritisKeratoderma blennorhagicNodulrVesicularPusturlarIn the Sole of footPrognosis
37ArthiritisAnterior uveitisTreatmentTopical steroids and mydiatrics for the eyeAntibiotics and systemic steroids