Male urethral strictures - Diagnosis

In some cases, diagnostics of urethral stricture in men does not provide comprehensive information about the disease. That is why there is a need for additional (optional) studies:

• urethroscopy;
• cystourethroscopy;
• sonography of the urethra;
• spongiography;
• TRUS of the prostate and urethra;
• magnetic resonance urethrocystography;
• fistulography.

Urethroscopy is necessary:

• in case of unclear results of retrograde urethrography and antegrade cystourethrography regarding the presence or absence of stricture and its characteristics;
• in case of unclear causes of stricture formation (idiomatic, urethral cancer, tuberculosis) for biopsy of the mucous membrane;
• as a stage of examination of the urethra before internal optical urethrotomy.

Cystourethroscopy is necessary in the presence of a vesical fistula in cases where:

1. visualization of the urethra by antegrade cystourethrography or by insertion of a proximal bougie failed;
2. there is a suspicion of stenosis of the bladder neck;
3. Symptoms and signs of prostate adenoma and possible associated obstruction are noted.

Endoscopic diagnostics of urethral stricture in men allows in all cases to solve diagnostic problems and clarify the tactics of patient management. As a rule, they are performed under general anesthesia as a stage of the operation preceding the restoration of the urethra. It is also advisable to use flexible endoscopes (or even children's) under local anesthesia, which causes minimal discomfort.

Contrast urethrography and endoscopy provide comprehensive information on the location, extent, and degree of stricture. However, it is very difficult to objectively assess the depth of the corpus spongiosum lesion and its density using palpation of the urethra and urethroscopy. To obtain objective information on the extent and severity of spongiofibrosis, ultrasound of the urethra and spongiography are performed.

Percutaneous urethral sonography and spongiography are indicated for the evaluation of spongiofibrosis in the following clinical situations:

• inflammatory stricture, including iatrogenic;
• complicated stricture, including recurrent;
• idiopathic stricture.

Of course, the urologist needs information about the condition of the periurethral tissues, which can be obtained using:

• TRUS of the prostate (prostate abscesses, adenoma);
• transcutaneous sonography (paraurethral abscesses, etc.);
• fistulography (assessment of the site of damage to periurethral tissues);
• MRI with contrast of the urethra and three-dimensional reconstruction in complex cases of bone fractures with distraction ruptures of the urethra and other pelvic organs, repeated recurrences of strictures as an alternative to standard urethrography (routine use of MRI for strictures of the urethra is not recommended).

When examining patients with suspected urethral stricture, other methods for diagnosing urethral stricture in men can be used:

• UFM (in the absence of obliteration):
• Ultrasound of the bladder (residual urine):
• MSCT of the kidneys with contrast (in the presence of symptoms of damage to the kidneys and upper urinary tract);
• bacteriological analysis of urine, scrapings or discharge from the urethra.

It is these studies that make it possible to assess the severity of the clinical course of stricture disease, determined by:

1. degree of reduction in maximum urine flow:
2. detrusor hypoactivity (residual urine volume):
3. activity of the infectious process of the urinary tract and genital organs.
4. spread of obstruction to the upper urinary tract (hydronephrosis, stones, etc.).

Indications for consultation with other specialists

In cases of urethral strictures caused by complex pelvic bone fractures, it may be necessary to discuss with traumatologists-orthopedists the timing favorable for performing plastic surgery on the urethra. Sometimes surgery on the urethra may be delayed due to complications in the treatment of pelvic bone injuries. In the presence of combined injuries to the rectum and the development of urethral fistulas, it is necessary to resolve issues jointly with specialists in the field of proctology.

Differential diagnosis of urethral stricture

It is performed with other obstructive diseases of the lower urinary tract (congenital or acquired stenosis of the bladder neck, prostatic hyperplasia, chronic prostatitis/chronic pelvic pain syndrome, prostate carcinoma, urethral cancer, urethral stone, specific inflammatory diseases of the urethra (tuberculosis, etc.). In some cases, differential diagnostics of urethral stricture in men with neurogenic lesions of the lower urinary tract, manifested by obstructive symptoms of urination, is necessary.

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Example of diagnosis formulation

• Inflammatory subtotal stricture of the spongy part of the urethra.
• Traumatic (iatrogenic) stricture of the glans urethra (short should not be indicated, since strictures in this section are always short).
• Idiopathic long stricture of the bulbous urethra.
• Traumatic obliteration of the membranous urethra.
• Traumatic (iatrogenic) long obliteration of the bulbomembranous prostatic urethra.

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