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Mr. Kanaiyalal, Ahmedabad
I was way towards Shahibaug for family marriage function with my wife, my mother, two children (age 3 boy, age 7 girl) in a Santro car on 10th of December at 10 pm. I met with a fatal accident and immediately read more

Stricture Urethra

A urethral stricture is a scar and narrowing at one or more points in the urethra and of variable severity. This scar may compromise voiding and cause incontinence, bleeding, stones and even renal failure. This problem is almost invariably restricted to men and boys and is often secondary to injury (including catheter trauma) or inflammation. In many patients, no clear source of an event such as this can be recalled. Urethral strictures may be found in the urethra of women after severe pelvic trauma or after misguided urethral dilatations and over-stretching of the urethra.

The urethra's response to injury and/or inflammation and whether stricturing develops are extremely variable, as is the rapidity with which a urethral stricture develops after an insult.


Preventive Measures

The most important preventive measures are in catheterization of the urethra, where even the slightest amount of trauma can lead to lifelong protracted problems with strictures. Therefore, it is imperative to be extremely gentle, to liberally instill into the urethra xylocaine jelly to both anesthetize and lubricate the urethra, and to use the smallest possible silicone catheter necessary for the treatment. In addition, it should be removed as soon as possible. The catheter should also be changed in a timely fashion when left long-term, and there should be no pressure on the peno-scrotal junction.

Non-venereal and venereal inflammation may lead to strictures, so the judicious wear of condoms is appropriate in those facing this possible kind of exposure.

Evaluation

The most important test to evaluate and document the stricture is the retrograde urethrogram. This may be performed as an outpatient x-ray procedure for adult males, but in children it is ideally performed under an anesthetic. This x-ray can then document the number and position of the various strictures as well as documenting the degree of stricturing. Furthermore, the stricture may be located in more than one position and can be found at the meatus or in the penile urethra, penoscrotal junction, proximal bulbous urethra, posterior bulbous urethra, membranous urethra, or bladder neck.

Additional studies such as a voiding cystourethrogram, cystoscopy and biopsy in those in whom an irregularity is identified may be reasonable.


Treatment

Treatment options are extremely varied and provide some indication of the difficulty in guaranteeing a satisfactory result.

A. Watchful waiting.
Watchful waiting can be undertaken if the patient is reasonably comfortable and can tolerate his symptoms without developing UTIs, voiding difficulty or leakage.

B. Procedures relying on regeneration of the urethral lining.
1. Dilatation.
This should be done gently with graduated sounds, careful generous lubrication and without over-stretching the urethra in addition to covering the patient with appropriate antibiotics.

Self-obturation of the urethra by the patient This is an option in which the patient may elect to do the urethral dilatations periodically himself as needed after the appropriate instruction.

2. Internal urethrotomy.
This is usually done as an outpatient endoscopically, either blindly with the Otis urethrotome or through direct visualization with or without the aid of a camera, by incising the stricture and leaving a catheter in the bladder to allow healing about the catheter. The suggested length of time for leaving a Foley catheter draining after stricture treatment is extremely controversial and variable.

3. Buried strip.
Buried strip such as that using the Denis Browne principle.

C. Anastomotic procedures.
These are usually reserved for bulbous urethral strictures of 1 cm or less where the bulbous urethra can be reconstituted after excising the stricture and utilizing a 2 cm spatulated overlap anastomosis. Excised segments longer than 1 cm are likely to result in penile angulation.

D. Substitution procedures.
1. Grafts.
a. Full-thickness skin grafts. Skin grafts using non-hairbearing skin may be harvested from several sites, including that from behind the ear.
b. Bladder mucosal graft.
c. Buccal mucosal graft. These urethral grafts used to repair strictures may be either unsupported or supported. The graft is spongiosupported when the spongiosum is used as a support to reepithelialize the inner surface of the bulbospongy tissue.

2. Genital skin flaps.
a. Penile foreskin.
b. Scrotal skin. The scrotal skin may be used as a flap if a sufficient area can be found without hair-bearing follicles; otherwise, this skin will need careful epilation.

E. Staged procedures.
The first stage in a staged procedure focuses on opening the underside of the penis to expose the complete length of stricturing, securing these edges open to the external skin with or without various flaps and allowing the opened urethra, including its strictured area, to heal and mature over the succeeding months. During that time, the patient will void through this opened urethra.

The second stage is considered several months down the line once the urethral area is soft and pliable and tubularization has a high likelihood of success. During this procedure, it will also be important to remove any hair follicles that may have been inadvertently included in the first stage of repair.

F. Urethral stents.
These spiral-shaped devices are placed in the area of a stricture once it has been opened in an attempt to prevent restricturing. However, secondary inflammation has been a problem.

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