Urethral Stricture

Urology

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Urethral stricture is an uncommon condition that results in blockage of the urethra or “peeing tube.” Stricture formation results in a narrow circular ring of scar tissue, which restricts the flow of urine.

Signs and symptoms

Most men will experience symptoms, such as slow stream, frequent urination, feelings of incomplete emptying, recurrent infections and straining to void. In severe cases, urinary retention may prevent individuals from urinating and may require emergency intervention. In severely injured patients, blood in the urine may also be seen.

Causes

The cause of the majority of urethral strictures is unknown. The most common cause is trauma from being struck in the area between the legs, known as the perineum. Other causes include: inflammatory diseases, i.e., lichen sclerosis and balanitis xerotica obliterans; infections, i.e., sexually transmitted disease; congenital abnormalities; instrumentation, i.e., surgery, catheter placement or pelvic fracture.

Diagnosis

Patient evaluation starts with a thorough history and physical. The majority of patients will require a retrograde urethrogram, or RUG. This is an outpatient x-ray test that shows the location, density, and length of the urethral stricture and is required for planning a repair. Other additional tests can include insertion of a camera into the bladder, called cystoscopy.

Treatment

The treatment for urethral stricture is customized to fit each individual patient. Most urethroplasties require an overnight stay in the hospital.

  • This can involve internally leading or dilating the scar with the aid of a camera. This requires no external incisions and can be performed on an outpatient basis. Unfortunately, for the majority of patients, this treatment is ineffective and may only produce temporary results. The majority will go on to require some form of open repair, which is accomplished in a variety of ways.

  • This technique involves harvesting a portion of skin from the penis in order to place a patch over the narrowed portion of the urethra. The skin remains connected to the muscle and underlying blood vessels.

  • This specialized technique is only performed by a few surgeons in the United States. The inner lining of the mouth is harvested to create a patch over the scarred area of the urethra. The buccal mucosa is transplanted to the area of repair, where it will grow new blood vessels. The tissue heals very well, is resistant to infection and seems to remain effective for many years after repair. The majority of patients are back to eating normal food after just 48 hours. This does not cause facial scaring or difficulty with speech.

  • This is the simplest form of urethroplasty in which the scarred portion of the urethra is removed and the two ends are sewn together.

  • A specialized technique to repair urethras that have been severely injured due to pelvic fracture, which causes a disruption of the urethra with massive scar formation. The scar must be carefully removed and the urethral ends reconnected.

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Buccal mucosal urethroplasty with Dr. Thrasher
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So the procedure that we just did today is actually a repairing a deep bulbar urethral stricture. So deep in this particular patient, he had an area that was starting to narrow and was not allowing him to urinate. So what we did is take a piece of the inside of his mouth, harvested by one of our ENT colleagues, we defatted that on the back table here.

Opened up the strictured area so the strictured area came down narrowed like an hour glass.

OK, so normal urethra is up here. Move. Right in there. That's wide open. In fact you see how nice that looks. Wide open.

Then you can see it starts getting diseased right in here and then you can actually see this little, it's almost like a little cliff sitting there, a little ledge. And that's the strictured area and then it gets normal again right back here. You see it? Suck there. Suck underneath here. So it's normal opening right there.

What we're doing is we're gonna put the flap in right in here. So we're gonna be putting this flap in right in here so you can see the little strictured area there. This is normal. This normal. We're going to be suturing it all in here. We opened that up, measured how much we needed. Sutured the inside of what's called buccal mucosa, which is the lining on the inside of the mouth.

That lining we measured and then sutured that with the skin side or the mucosa side, which is the portion you touch with your tongue in toward the urethra. We sutured all of that in and once that's sutured in we've now given a wider caliber to the urethra so this gentleman will be able to urinate.

Now, that graft has to take. In other words, it has to recruit its own blood supply so that will take two days or so while this patient is on bedrest. They have very little discomfort from it.

There aren't many places doing this in the country. In fact, we have one of the largest series in the country and so this is sort of a specialty specific procedure that we do that I think has been very successful. We actually have a 96 percent success rate and we followed our patients now for up to five years.