William Aiken
A urethral stricture is a circumferential narrowing of a part of the urethra (urine passage) by scar tissue. The scar is usually caused by an inflammatory response to a past infection or traumatic injury to the urethra.
However, in a proportion of cases no history of infection or injury is elicited. A urethral stricture may sometimes exist from birth. The sexually-transmitted infections, gonorrhoea and chlamydia, are common causes of strictures. In the acute setting, they cause urethritis (an inflammation of the urethra) usually manifested by pain and burning on passing urine, and a brown or yellow urethral discharge which may stain the underwear. After the inflammation has subsided, the urethra may heal by scarring resulting in a stricture which may manifest years after the infection.
Manhole cover
Traumatic injuries of the urethra occur during motor vehicle accidents, interpersonal violence, sporting events or during surgical procedures on the urethra. A special type of injury known as a 'fall astride injury', in which there is violent force applied to the perineum (area between the scrotum and anus) occasioned by a kick, stepping on a manhole cover that flips on its side, or slipping off the foot pedal of a bicycle, is well known to cause urethral strictures.
In the acute setting, these injuries may result in urethral bleeding presenting as blood at the tip of the penis and / or acute urinary retention (sudden, painful inability to pass urine). These injuries may heal by scarring causing a urethral stricture after an interval of time.
Urethral strictures cause obstruction to the flow of urine which may result in a number of serious complications. These include incomplete emptying of the bladder with increased risk of recurrent urinary tract infections and formation of bladder stones.
A back up of urine may occur causing the kidneys to become swollen and their function impaired. This can result in kidney failure. Other complications include infections of the prostate, testicles and epididymes (the tubes that initially transport sperm away from the testicles). Less commonly, the stricture may result in the urine diverting through multiple abnormal openings or tracts between the urethra, upstream of the stricture, and the perineum, resulting in a 'watering-can perineum', the term given to this distressing situation.
Weak stream
Strictures are more common in men and may result in the following symptoms: taking a long time to start urinating, having a weak or poor urinary stream, having to strain to pass urine, an interrupted flow of urine, a sensation of not completely emptying the bladder, getting up often at night to pass urine as well as going often during the day and not being able to hold the urine.
There may also be burning on passing urine, and pain and bleeding on ejaculation. A urethral stricture may also present with sudden stoppage of urine.
A stricture is suspected when the above symptoms are present, especially in the younger man who does not yet have prostatic enlargement. It is confirmed by doing special X-rays (urethrogram) or by performing urethroscopy in which the lumen of the urethra is visualised by looking at it through a special telescope inserted through the tip of the penis.
Treatment
Urethral strictures are treated by a number of methods. The method chosen is dependent on the nature, number, site and extent of the strictures as well as the fitness of the patient and the presence of complications. Strictures may be dilated periodically by metallic or rubber dilators. Patients may sometimes be taught to do periodic self-dilation with a special catheter. Strictures may also be cut internally to expand the lumen of the urethra. Finally, open surgery in which reconstructive techniques are employed is reserved for complex and difficult strictures.
Dr. William Aiken is the Head of Urology at the University Hospital of the West Indies and President of the Jamaica Urological Society; email: yourhealth@gleanerjm.com.
