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Urethral Strictures in Males

  • Author: Joshua A Broghammer, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Nov 21, 2015
 

Background

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. See the images below.

Urethral strictures. Cross-sectional diagram of th Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy. Urethral strictures. Schematic of penile anatomy.
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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.[1, 2, 3]

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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.[4] The focus of this article is anterior urethral stricture disease.

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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.

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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.

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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.

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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.

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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. See the images below.

Urethral strictures. Cross-sectional diagram of th Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy. Urethral strictures. Schematic of penile anatomy.
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Contraindications

Urinary tract infections should be adequately treated prior to treatment.

Malignancy should be ruled out with an endoscopic biopsy.

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Contributor Information and Disclosures
Author

Joshua A Broghammer, MD Assistant Professor, University of Kansas Medical Center

Joshua A Broghammer, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, American Association of Clinical Urologists, Society of Genitourinary Reconstructive Surgeons

Disclosure: Received consulting fee from American Medical Systems for consulting.

Coauthor(s)

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Daniel B Rukstalis, MD Professor of Urology, Wake Forest Baptist Health System, Wake Forest University School of Medicine

Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science, American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Jon Timothy Posey, MD; Angelo E Gousse, MD; and Daniel J Caruso, MD, MBA to the original writing and development of this article.

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Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy.
Retrograde urethrogram demonstrating bulbar urethral stricture.
Urethral strictures. Retrograde urethrogram demonstrating complete obliteration of the bulbous urethra.
Retrograde urethrogram demonstrating pan-urethral stricture disease.
Urethral strictures. Retrograde urethrogram demonstrating patent urethra after buccal mucosa urethroplasty.
Urethral strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary anastomosis.
Urethral strictures. Photograph of a permanent urethral stent.
Urethral strictures. A buccal mouth graft has been harvested from the inner aspect of the cheek. The graft size is measured to accommodate the length of urethra involved in the onlay.
Urethral strictures. The buccal mucosal grafts have been secured to the corpora cavernosa. The anastomosis will run along either side of the dorsum of the urethral edges to complete the dorsal onlay. The glans penis (distal) is at the top of the picture. The catheterized urethra with a dorsal urethrotomy is on the left.
Urethral strictures. Photograph of open urethroplasty depicting the pedicled flap.
Urethral strictures. Photograph depicting pedicled flap anastomosed to the left side of the urethra. Suturing of the right side of the pedicled flap to the urethra completes the anastomosis.
Urethral strictures. The anastomosis of the pedicled flap is complete. The pedicle of the flap (left side) originates from the dorsolateral aspect of the penis. The glans penis (distal) is at the top of the photograph.
 
 
 
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