Urology stuff b.

Non-meatal stricture
4. Traumatic
URETHRAL STRICTURE DISEASE
a. Non-penetrating injuries
DEFINITION i. Blunt trauma to penis
ii. Penile fracture
Urethral stricture disease is an anterior urethral
b. Penetrating injuries
disease in which there is narrowing or obliteration
i. Pelvic fracture (from road traffic
of the lumen of the portion of the urethra
accidents) in which bone splinters
surrounded by corpus spongiosum, often as a result
lacerate the urethra
of a progressive scarring process involving the
c. Burns
subepithelial lining of the corpus spongiosum
i. Thermal
(spongiofibrosis)
ii. Chemical
Urethral stenosis is the term used for narrowing (or iii. Electrical
obliteration) of the posterior urethral segment (i.e. d. Radiation
the portion of the urethra not surrounded by e. Penile amputation
corpus spongiosum) f. Avulsion injuries of the genitalia
g. Foreign body or urethral calculus

ETIOLOGY
PATHOGENESIS
1. Infectious / Inflammatory
a. Gonorrhea: repeated episodes of gonoccal Healing of urethral injury is different from wound
urethritis. Features of gonococcal healing in other parts of the body
urethritis include:
With injury to the urethral epithelial lining,
i. Urethral discharge (purulent or
healing occurs by urethral metaplasia, in which the
mucopurulent)
normal pseudostratified columnar epithelium of
ii. Dysuria
the urethra is replaced by stratified squamous
iii. Pruritus
epithelium. This metaplasitc epithelium is non-
iv. Hematuria
resilient and non-distensible, with increased
v. Painful intercourse or ejaculation
hydrostatic pressure. So, hydrostatic pressure in
b. Urethritis
urethra causes this epithelium to break leading to
i. Non-specific
extravasation of urine into the subepithelial space
ii. Tuberculous
and into the adjacent corpus spongiosum tissue.
c. Schistosomiasis
This extravasation causes focal fibrotic reactions of
d. Balanitis xerotica obliterans (BXO)
the spongiosum. At first, this fibrosis may be
2. Iatrogenic or post-operative
asymptomatic, but with a continuous cycle of tears
a. Urethral instrumentation e.g.
and fissures of the metastatic epithelium and
endoscopy, boujie catheter
extravasation of urine into the corpus spongiosum,
b. Urethral catheterization
microfoci of fibrosis form and coalesce over a period
c. Transurethral surgeries e.g.
of years to form large spongiofibrosis that occlude
transurethral prostatectomy
the urethral lumen and progress longitudinally
d. Repair of hypospadias or epispadias
along the urethra or circumferentially into the
e. Perineal surgeries
surrounding structures.
f. Brachytherapy
3. Congenital/Idiopathic Post-inflammatory injuries & Instrumentation
a. Pin-hole meatus usu. occur in the bulbar urethra > penile urethra
 o Inability to pass urine (retention)
- Cause see above
PATHOPHYSIOLOGY
- Complications
Spongiofibrosis causes urethral stricture which in o Penile swelling, soft (periurethral
turn leads to: abscess)
o Fistulae in penis, perineal or scrotal area
- Dilation of urethra proximal to stricture
o Flank pain (hydronephrosis,
- Compensatory changes in the bladder
pyelonephritis)
muscualature = hypertrophy, trabeculation,
o Fever (infection)
sacculation, and diverticular formation
+ flank pain (pyelonephritis)
- Vesico-uretral reflux hydroureter and

hydronephrosis
o Uremic symptoms = nausea, vomiting,
- Infection of urinary tract due to stasis of
weakness, pruritus,
urine, leading to
-
o Peri-urethral abscess fistulae
o Prostatitis Examination
o Cystitis
- Induration upon palpation of ventral urethra
o Pyelonephritis,
- Periurethral abscess
o Calculi in urethra and bladder
- Fistulae (penile, perineal or scrotal) / Watery
can perineum (numerous fistulae)
- Visible or palpable urinary bladder (urinary
MANAGEMENT
retention)
Biodata - Ballotable kidney (hydronephrosis)
- DRE (to r/o prostate enlargement) normal
- Age < 50yrs
findings
Major Presenting complaints
Investigations
- Difficulty in micturition
- Imaging
- Inability to void urine (retention)
o Retrograde Urethrogram
HPC Delineates the stricture (length,
thickness, site, multiplicity,,,) and
- Insidious in onset
shows urethra proximal and distal
- Characters and associations
to the stricute
o Obstructive symptoms
o Retrograde urethrogram + voiding
Straining on passing urine, with
cystourethrogram
consequent streaming, in some
o USS of urethra (urethrosonography)
cases
Extent of the spongiofibrosis
Poor stream
o Urethroscopy
Hesitancy
- Instrument examination
Dribbling
o Arrest of catheter at site of stricture
Forking and spraying of urinary
- Peak urine flow rate (PFR)
stream
o Usu. < 10ml/s; normal is 20ml/s
o Irritative symptom
- E, U. Cr
Frequency
o Uremia and increased Cr
Urgency
- Urine MCS
Dysuria
 o Pus cells up to 8-10 WBC/HPF o Excision of urethral scar and
reconnection of the urethra
o For strictures of 2cm or less
Treatment - Substitution (augmented) Urethroplasty
o Involves using a flaps and grafts e.g.
- Conservative
Buccal mucosa
- Definitive
The best
Conservative Others
Bladder mucosa
- Suprapubic tap using suprapubic needle
- Stab/open suprapubic cystotomy using trocar Penile skin
and cannular Scrotal skin
Post-auricular skin
Definitive treatment

- Dilatation
o Using Bougie catheter
o Is palliative
o Done for passable incomplete strictures
o Done under aseptic conditions and
under local anesthesia (xylocaine gel) or
general anaesthesia
o Repeated at increasing intervals,
indefinetly
o Occasionally curative in minimal
stricture
o Complications
Bleeding, clot retention, rupture of
urethra, UTI (urethritis,
prostatitis, cystitis, epididymo-
orchitis, pyelonephritis, )
- Endoscopic Direct vision Internal
Urethrotomy
o Incising the stricture under direct
vision, using a cold blade urethrotome
o Done for short, uncomplicated
impassable strictures
o After the surgery, it is advisable to
splint the urethra with indwelling
catheter for 2-7 days or 14-21 days for
difficult strictures
o Complications
Bleeding, clot retention,
extravasation of irrigating fluid,
UTI
- Excision and Primary anastomosis (EPA)
OBSTRUCTIVE UROPATHY

DEFINITION:

O.U refers to pathological changes that occur in

the urinary tract secondary to impedance of the
flow of urine

EPIDEMIOLOGY

- Common worldwide
- Occurs at any age
- Causes varies

RELEVANT ANATOMY

Component of the Urinary System:

- Kidney, ureter, bladder, urethra

Division of U.T.

- Upper UT (kidney, ureter)

- Lower UT (bladder, urethra)

CLASSIFICATION OF O.U.

- Upper UT obstruction vs Lower UT

obstruction
- Complete vs Partial obstruction
- Acute vs Chronic
- Bilateral vs Unilateral

ETIOLOGICAL CLASSIFICATION

- Anatomical
o Intraluminal
o Intramural
o Extraluminal
- Source
o Intra-urinary
o Extra-urinary
E.g. ca of cervix, rectum,
- Congenital vs Acquired
o Congenital
Uretrocele, congenital urethra
valve, meatal stenosis, congenital
polyps, congenital cysts