Stricture Urethra: What Should the Rural Patients Know?

What is stricture urethra?

Urethra is the tube that connects the urinary bladder to the outside. It has a sphincter or valve near its attachment to the bladder and is longer in men and about one third the lengths in women. It has an inner lining of epithelium and also a muscle covering so that the urine is milked out.

What is a stricture?

Stricture is the medical term for narrowing. It is caused by injury or inflammation and is due to scarring. The cross section of urethra is circular and hence the narrowing will make the circle have a smaller diameter. It can have varying lengths depending on what caused the stricture.

What are the causes of urethral stricture?

The common causes include urethral injury, infection, and inflammation and it can also be present from birth. Very rarely they are due to cancers. The injuries could be external due to accidents or internal due to instrumentation. The instrumentation could range from just passing a catheter to procedures using scopes. The infections are often sexually transmitted infections. These could be Gonorrhea or Chlamydia infections or viral infections like Herpes Simplex or Cytomegalo virus. Organisms that cause urinary tract infection can cause urethral infection too. There is non-infectious urethritis also.

What is the problem with stricture?

The scarring starts in the epithelial cells or the inner lining of the urethra. Then they spread to the muscular layers. In addition to the narrowing of the diameter as mentioned above the scar prevents peristaltic movement or milking of the urine which in turn leads to more infection. When there is significant narrowing or diameter less than a third, the urinary stream is narrow and straining to pass urine can cause back pressure, changes in the bladder and upper urinary tract.

What are the symptoms of urethral stricture?

The stream becomes thin and straining improves the stream. However this happens only when the lumen is narrowed to less than a third of normal size. Initially there may be just spraying of the stream and terminal dribbling because of the lack of milking effect. Pus and blood might be present and may be more noticeable early in the morning. There might be burning pain while passing urine and mild infection can lead to frequent voiding. There might be infection of the prostate due to the block in the bulbar urethra or the bent portion of the urethra. Lower abdominal pain and penile swelling might also be noticed by the patients.

In women the symptoms are related to urinary tract infections and poor stream and taking much longer time to void. Women may have pain during sexual intercourse with urethral stricture because of inflammation.

How is urethral stricture diagnosed?

The diagnosis is by cystoscopy and if carried out under anesthesia could be combined with treatment too. Retrograde Urethrogram is carried out by injecting a contrast dye and taking x-rays. They do not offer any significant advantages and a good x-ray machine and aseptic techniques are necessary. Similarly Uroflowmetery does not offer much advantage other than quantifying and recording the poor stream. With good ultrasound machines the extent of scarring could be diagnosed using the ultrasound pictures and once again these do not add great value to the diagnosis.

Urine microscopy examination and urine cultures are often useful additive tests.

What are the treatment options available?

The disease has been reported as far back as the Greek literature that described bladder drainage by passage of catheters. Hamilton Russel reported the first surgical repair in 1914.

Urethral dilatation is a blind procedure using metal dilators to dilate the narrow passage. It is not encouraged because of the following:

1. It is a blind procedure and hence can cause serious injuries if not carried out properly.
2. The resultant scarring is usually more than the original scar tissue which always tear into the normal tissue.
3. It can cause severe bleeding and infection and sometimes retention.

Earlier periodic urethral dilatation is a well know treatment for stricture disease. Once a stricture, always a stricture and hence the patients were condemned to regular urethral dilatation till the time of introduction of the concept of self-catheterization. [1]

Open surgical methods were used earlier. [2] Excision of scar and primary anastamosis with spatulation was used earlier. What this means is that the scarred portion is removed and the opening is made wider than the original size so that when healing occurs it does not become narrow again. This might not be possible in most cases. Free grafts were used for repair [3]. They are from skin, buccal mucosa, and outer layer of the bladder. None of these were very successful. Various plastic surgical procedures like island flaps from scrotal or penile skins were tried too. Unfortunately these were not helpful either.

Endoscopic Internal Urethrotomy (EIU) or Visual Internal Urethrotomy (VIU) are a name for the procedure carried out through the urethral passage with special instruments to cut open the scarred tissue under vision and cutting only the scar tissue. After the procedure, a catheter is placed. When removed, self-calibration is started. At present this is probably the best option.

However if there is a total blockage the only available option might be is to put a catheter into the urinary bladder through the lower abdomen. This is called a SPC drainage or Supra–pubic which refers to the site and catheter drainage.

Permanent urethral stents are a new option that not popular and are very expensive too.

What are the available options for total blockage?

If the blockage is due to the fact that blood supply is interrupted during injury and healing is greatly impaired with infection then it is better to wait for at least six months before surgery is attempted.

A difficult but possible option in expert hands is called the “Core through EIU” this is where the surgery is carried out through endoscopes passed from above and below. It is a minimally invasive option if successful. If it’s not successful, then a complex open reconstruction is necessary and it’s a much longer surgery with a significant blood loss during the surgery.

How is self-calibration carried out and does it do any harm?

Self-calibration is carried out as follows:

1. A clean dry catheter is used.
2. Hands and genitalia are washed with water and soap.
3. Self-calibration is carried out with an almost full bladder.
4. After applying sufficient sterile lubricant the catheter [silicon or Foley’s or red rubber] is gently passed inside till urine starts coming.
5. Once this happens there are two options: the catheter could be used to empty the bladder completely or it’s removed immediately and bladder is emptied by passing urine.
6. The catheter is cleaned and dried.

It is good to remember the following:

1. Scarring can occur any time when the self-catheterization is stopped. It prevents the healing process and maintains the lumen and if healing occurs scarring and narrowing is bound to occur.
2. It is similar to brushing the teeth. Once started people get use to it and many children do it too.
3. The procedure need not be sterile but a clean and dry catheter is necessary.
4. Emptying the bladder immediately is also important as it clears the bacteria in the bladder. The doubling time of bacteria in the bladder is about 20 minutes and infection can occur if the level reaches over 100,000 per ml.

What are the facilities available at SEESHA?

The facilities for cystoscopy EIU and core through EIU are available at the SEESHA Karunya community hospital at Karunya at the SEESHA surgical camps at Bethesda Hospital Aizawl, Sielmat Christian Hospital at Churachandpur at Manipur, Family Health Hospital at Dimapur Adivasi hospital at Gudalur and the other places. Open surgical facilities are available too. During the last 5 years more than 20 people with total blockage have benefitted by the Core Procedure.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

Image: The male urethra laid open on its anterior (upper) surface. Source/Author: Henry Vandyke Carter/Henry Gray. Date: before 1858. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Gray1142.png