Urinary tract strictures in men

Stricture of the male urethra is a polyethyological obstructive lesion that encompasses the urethral epithelium, the spongy body of the body, and in some cases also the paraurethral tissues.

Because of cicatrical changes in the tissues in the walls of the urethra, the lumen diameter narrows.

Epidemiology

The frequency of the stricture of the urethra is directly related to the socioeconomic and cultural status of society. In developed countries, the frequency of traumatic and inflammatory stricture of the urethra is significantly lower than in developing countries, and even more so in poor countries. On the contrary, in developed countries this disease occurs after TUR and RP. Military actions cause gunshot and stabbing injuries of the male urethra. The cultural characteristics of peoples (the introduction of foreign bodies into the urethra) determine the frequency of penile strictures of the urethra.

[1], [2], [3], [4], [5]

Causes of the urethral stricture in men

[6], [7], [8]

Anatomy of the urethra

According to the International anatomical classification, the male urethra is divided into three segments:

• prostatic (prostate), passing through the prostate;
• membranous (membranous), surrounded by the urogenital diaphragm;
• spongy (spongy), located from the urogenital diaphragm to the external opening of the urethra.

Given the characteristics of strictures of various parts of the urethra and features of operational tactics and techniques for their treatment, it is inappropriate to apply a more detailed anatomical classification:

• prostatic department of urethra;
• membranous urethra;
• bulbose department of the urethra;
• the penile section of the urethra;
• glandular section of the urethra.

Each department of the urethra has its own peculiarities of the histological structure that determine the specific features of the appearance and course of the strictures of the urethra. Thus, strictures of the prostatic section of the urethra occur only with the development of total or periurethral fibrosis of the prostate. Consequently, endoscopic operations of prostatic stricture also presume an operation on the prostate. The strictures of the membranous urethra are always associated with a lesion in varying degrees of the urethral transverse striated sphincter, so open and endoscopic operations of this zone are associated with a risk of urinary incontinence.

New knowledge about the histology of the spongy body and its vascular system explains the specific features of the strictures of this localization, their propensity to spread along the wall of the urethra, the development of complications and relapses. It is established that the spongy body of the bulbose and penile sections of the urethra is an extensive venous plexus, and between the walls of the set of veins there are lacunary sinuses, the direct relationship of which with the arterioles of the onion artery {a. Bulbaris) explains the immediate erection of the bulb of the penile section of the urethra in general, as well as the glans penis in response to the corresponding stimuli.

That is why spongiform fibrosis with inflammatory strictures of the sub-diaphragmatic area of the urethra is a consequence of the phlebitis and periphlebitis of the spongy body: the process. Never having clear boundaries, but actively progressing in many patients. To a certain extent, this explains the progression of spongiofibrosis, i.e. Expansion of the boundaries of narrowing, including even after successful urethroplasty. This also explains the ineffectiveness of internal optical urethrotomy and resection of the urethra with a standard anastomosis with inflammatory stricture of the urethra.

[9], [10], [11], [12], [13], [14]

What causes the stricture of the urethra in men?

Any damage to the epithelium of the urethra and spongy body, resulting in the formation of a scar, can lead to the development of the stricture of the urethra.

At present, most strictures have a traumatic origin. Thus, dull or open trauma to the pelvic ring (fractures of the lobes and sciatic bones, symphysis and ileo-ligament joints) cause damage to the membranous urethra (a distraction rupture due to multidirectional muscle ruptures and tendon of the urogenital diaphragm with which the urethral mucosa is tightly connected) .

In addition, damage to the urethra can be caused by direct exposure to a broken bone. On the other hand, direct perineal trauma can be accompanied by damage to the bulbous urethra by crushing the tissues between the bony bones and the external traumatic factor.

This group includes iatrogenic trauma associated with intraurethral manipulation (catheterization, bougie, endoscopy, endoscopic surgery), as well as with unsuccessful outcomes of open surgery on the urethra with hypospadias and epispadias.

Symptoms of the urethral stricture in men

The urethral strictures are characterized by symptoms of lower urinary tract diseases; are clinically distinct from other obstructive lesions.

The most frequent and especially important symptom is a weak urine stream. With slowly progressing, gradual development of the disease, the predominant microthuric symptoms, then post-microscopic, and accumulative symptoms appear later than others.

With iatrogenic and inflammatory strictures of the urethra (after endoscopic surgery, operation on the penis, application of the urethral catheter), pain can be expressed both during urination and with erection and ejaculation. Especially the pain is expressed with the development of purulent-destructive complications (abscesses, fistulas, etc.).

The clinical picture of traumatic stricture of the urethra is characterized by symptoms of concomitant damage (pelvic bones, rectum) and their complications (chronic pelvic pain syndrome,  impotence  , etc.).

Forms

In accordance with the current understanding of urethral stricture, the following classification options are commonly used.

According to the etiologic factor:

• traumatic, including iatrogenic;
• inflammatory, including iatrogenic;
• congenital;
• idiopathic.

Comments: iatrogenic stricture is not separately isolated, as it is of its genesis and traumatic and inflammatory.

Pathomorphology:

• primary (uncomplicated, previously untreated);
• complicated (relapse, fistula, abscess, etc.).

Comments: do not separate recurrent stricture, since it in itself already has a complication of the structural illness of the urethra.

By localization:

1. prostatic stricture;
2. membranous stricture;
3. bulbose stricture;
4. penic stricture;
5. head stricture;
6. scaphoid stricture;
7. stricture of the external opening of the urethra.

By extension:

• short (<2 cm);
• long (> 2 cm);
• Subtotal spongy (defeat of 75-90% of the spongy part of the urethra);
• total spongy (defeat of the whole spongy part of the urethra);
• total (defeat of the entire urethra).

In count:

• single;
• multiple.

By degree of narrowing:

• Light (lumen narrowed to 50%);
• moderate (lumen narrowed to 75%);
• Heavy (lumen narrowed to more than 75%);
• obliteration (lumen absent).

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Diagnostics of the urethral stricture in men

The main methods of diagnosis of stricture of the urethra include:

1. the analysis of the patient's complaints and his anamnesis:
2. examination and palpation of the penis, urethra, scrotum and perineum;
3. finger examination of the anal canal, prostate and rectum;
4. retrograde urethrography;
5. antegrade cystourethrography.

General clinical  tests of urine  and blood, biochemical blood test, in particular determination of serum creatinine concentration.

Retrograde urethrography is performed by the surgeon responsible for the treatment of this patient. The method allows to determine the localization, extent and extent of the constriction while maintaining the passability of the urethra for the contrast medium. With obliteration, only the distal border of the lesion is visualized. In both cases it is important to immediately perform antegrade (mictional) cystourethrography.

When passing the urethra, the contrast medium fills the supra-indicative part of the urethra and visualizes the degree of dilatation of the latter.

With an impassable urethra and cystostomy during the tension of the anterior abdominal wall, the contrast material fills the proximal portion of the urethra to the stricture, which will determine the extent of the obliteration. Impossibility in this way to visualize the proximal part of the urethra makes it expedient to hold the buoy of Guyon through the fistula and neck of the bladder into the prostatic urethra, which also helps to characterize the extent of obliteration.

Thus,  urethrography  allows in most cases to determine the stricture of the urethra, its localization and degree of narrowing, to identify complications (fistulas, stones, diverticula, etc.). Obtained information is often enough to choose a method of treatment (observation, bougie, endoscopic or open surgery) and even the methods of surgical treatment (resection or urethroplasty).

[16], [17]

Treatment of the urethral stricture in men

The main goal is the complete cure of the stricture of the urethra and its complications. However, the achievement of this goal is impossible in a number of cases.

1. Unwillingness of the patient to undergo a complex plastic surgery and choice of patients with palliative treatment.
2. The presence of multiple and severe relapses of the disease, excluding the possibility of performing radical reconstruction of the urethra;
3. Curing from urethral stricture is not always accompanied by the possibility of eliminating complications (infertility, chronic infection of the prostate or urinary tract, urolithiasis, etc.).

Other purposes:

1. improvement of urination;
2. improving the quality of life.

Prevention

Prevention of inflammatory strictures of the urethra consists in the timely and adequate treatment of acute urethritis, primarily gonococcal nature. In case of traumatic ruptures of the urethra, medical personnel should strictly follow the standard of urgent surgical care, which, undoubtedly, will create the prerequisites for an optimal result of surgical treatment of future stricture of the urethra.

The high quality of transurethral endoscopic surgery of the lower urinary tract and upper urinary tract, as well as the high culture of work of medical personnel with urethral catheters are real measures to prevent iatrogenic stricture of the urethra.

[18], [19], [20], [21], [22]

Forecast

Short traumatic membranous and bulbous strictures of the urethra can be cured in more than 95% of observations by resection of the cicatricial segment with an end-to-end urethral anastomosis.

In some cases, after resection, anastomotic urethroplasty is necessary with a free graft or a vascularized flap. The strictures of the penile and long strictures of the urethra of bulbose segments are curable in 85-90% of cases with replaceable urethroplasty.

In this case, the best plastic materials are penile skin, buccal mucosa and vaginal membrane. Complicated and relapsing strictures may require multi-stage operations. The reconstruction of the prostatic section of the urethra is associated with a risk of urinary incontinence, and the plastic of the head of the urethra with possible cosmetic defects.

Achieving maximum effectiveness in the treatment of urethral stricture is not always possible due to the development of a number of complications, the prevention and treatment of which increases the chances of success.

Technical improvements in urethral surgery are necessary, but a breakthrough is possible with the development of free urethral grafts grown from the patient's tissue culture.

In the near future, the number of strictures of the urethra in men does not decrease due to a number of factors (traumatism, infection, iatrogenia). That is why the stricture of the urethra remains for a long time an actual urological problem.

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