Introduction
Urethral strictures arise from various causes and can result in a range of manifestations, from an asymptomatic presentation to severe discomfort secondary to urinary retention. Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential. Consultation with a urologist should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease.
Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy.
History of the Procedure
Urethral stricture disease has been cited as long ago as ancient Greek writings that reported establishing bladder drainage with the passage of various catheters. Historically, the treatment consisted of urethral dilation with sounds. Hamilton Russell described the first surgical procedure for repair of a urethral stricture in 1914. In contemporary times, several surgical options are available.
Problem
- Urethral strictures can result from inflammatory, ischemic, or traumatic processes. These processes lead to scar tissue formation; scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance to the antegrade flow of urine.
- The term urethral stricture generally refers to the anterior urethra and is secondary to scarring in the spongy erectile tissue of the corpus spongiosum.
- A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and usually results from a distraction injury secondary to trauma or surgery, such as radical prostatectomy. The focus of this article is anterior urethral stricture disease.
Etiology
The most common causes of urethral stricture today are traumatic or iatrogenic. Less-common causes include inflammatory or infectious, malignant, and congenital. Infectious urethral strictures are secondary typically to gonococcal urethritis, which remains common in certain high-risk populations.
Pathophysiology
- Urethral strictures occur after an injury to the urothelium or corpus spongiosum causes scar tissue to form.
- A congenital stricture results from inadequate fusion of the anterior and posterior urethra, is short in length, and is not associated with an inflammatory process. This is an extremely rare cause.
Presentation
The most common presentation includes obstructive voiding symptoms, urinary retention, or urinary tract infections. Obstructive voiding symptoms are characterized by a decreased force of stream, incomplete emptying of the bladder, urinary terminal dribbling, and urinary intermittency. These symptoms are progressive in many patients.
Indications
Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when conservative management fails.
Relevant Anatomy
- The urethra is divided into anterior and posterior segments. The anterior urethra (from distal to proximal) includes the meatus, fossa navicularis, penile or pendulous urethra, and bulbar urethra. The posterior urethra (from distal to proximal) includes the membranous urethra and the prostatic urethra.
- The urethra lies within the corpus spongiosum, beginning at the level of the bulbous urethra and extending distally through the length of the penile urethra. The bulbar urethra begins at the root of the penis and ends at the urogenital diaphragm. The penile urethra has a more central position within the corpus spongiosum in contrast to the bulbous urethra, which is more dorsally positioned.
- The membranous urethra involves the segment extending from the urogenital diaphragm to the verumontanum.
- The prostatic urethra extends proximally from the verumontanum to the bladder neck. The soft-tissue layers of the penis, from external to internal, include the skin, superficial (dartos) fascia, deep (Buck) fascia, and the tunica albuginea surrounding the corpora cavernosa and corpus spongiosum.
- The superficial vascular supply to the penis comes from the external pudendal vessels, which arise from the femoral vessels. The external pudendal vessels give rise to the superficial dorsal penile vessels that run dorsolaterally and ventrolaterally along the penile shaft, providing a rich vascular supply to the dartos fascia and skin. The deep penile structures receive their arterial supply from the common penile artery, which arises from the internal pudendal artery. The common penile artery gives off several branches, including the bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus spongiosum receives a dual blood supply via anastomoses between dorsal and urethral artery branches in the glans.
- The scrotum receives its vascular supply via branches from both the external and internal pudendal arteries.
Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy.
Contraindications
- Urinary tract infections should be adequately treated prior to treatment.
- Malignancy should be ruled out with an endoscopic biopsy.
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References
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Further Reading
Keywords
urethral stricture, urethral strictures, urethral obstruction, urethral scar, anterior urethral stricture disease, scarring in the corpus spongiosum, internal urethrotomy, permanent urethral stents, primary repair, full-thickness skin graft, split-thickness skin graft, buccal mucosal graft, bladder mucosal graft, pedicled skin flaps, skin island onlay flaps, hairless scrotal island flap, skin island tubularized flap
