Conservative / Medicinal Treatment of Urethral Stricture:
There are essentially no real medical treatments (medications) for urethral strictures other than Palliative and symptomatic treatment with antibiotics and urinary alkalisers to treat urinary tract infection-UTI.
Surgery remains the only treatment for individuals with uncontrolled symptoms of urethral narrowing.
Surgical Treatment of Urethral Stricture :
Urethrotomy (DVIU / VIU)
Thin rods of increasing diameters are gently inserted into the urethra through the opening of the urethra (meatus) to dilate urethral lumen without causing any further injury. It is carried out under local or general anesthesia. Dilatation needs to be repeated either daily or on alternate days or once a week or once a month or once a year. The interval between dilation is to be prolonged slowly. Occasionally, patients are advised self dilatations at home.
Dilatation rarely cures strictures. It may cure only shorter and transparent thin membrane like strictures which are rare in nature. Dilatation may cause pain, fever and bleeding due to false passages.
Urethrotomy (DVIU / VIU)
Direct Visual Internal Urethrotomy (Visual Internal Urethrotomy) is considered primary line of treatment for urethral stricture, now a days. DVIU / VIU is an endoscopic procedure and is carried out under general anesthesia. Endoscope is inserted into the urethra and the stricture is cut along its length with a small knife to open up the passage of urine. An indwelling Foley’s catheter is kept till the urethral incision heals.
DVIU / VIU is indicated in short Bulbar Stricture of length less than 1.5cms and is not indicated in Penile Stricture, Long Bulbar Stricture and Membranous Urethra.
The success rate of this procedure is about 25%, and shorter strictures generally have a better response to this procedure.
Urethral stent placement is an endoscopic procedure indicated in the patients with recurrent short bulbar stricture who are unfit for surgery or refuse surgery. The stent is inserted into the urethra and is opened at the stricture to form a patent tube or conduit for urine to flow.
Temporary or permanent stents are used which are made up of stainless steel or Nitinol. Absorbable stents made up of Vicryl are also available.
Penile urethral stents are painful during erection. Stents inserted into the membranous urethra after core through urethrotomy for pelvic fracture urethral distraction defects also get blocked due to over growth of fibrosis.
Urethral stents inserted in the bulbar urethra may migrate distally forming a stricture at the proximal end. Sometimes overgrowth of excessive epithelization may block the lumen and may need repeated resection. In those patients where the stent has to be removed, endoscopic removal of the stent may be possible with some single wire stents. Mesh stents need open surgery for removal and the patient may be left with a long defect in the bulbar urethra. Surgical repair of such urethral defect after stent removal may not be easy.
This could be temporary or permanent. Temporary diversion with Supra Pubic Cystotomy (SPC) is indicated in patients with complete retention of urine and pelvic urethral trauma. After successful repair of the stricture, the temporary diversion tube is removed. Permanent diversion in the form of perineal urethrostomy is recommended and may be acceptable to older unfit patients and failed urethroplasty. Rarely those patients with urinary incontinence and stricture urethra may need Mitrofanoff procedure or an Ileal conduit.
All of the above procedures involve opening the urethra surgically under general anesthesia to fix the stricture. In some, the area of scarring is cut out and the remaining urethra is reconnected. In others, after the scar tissue is removed, a graft from inside the cheek (buccal mucosa) or a skin flap may be used to form a reconstructed urethra. Although these techniques in general have a good response rate, they are more invasive with varying degree of risks and complications.
- Types of urethroplasty procedures.
- Bulbar Anastomotic
- Anastomotic Urethroplasty - Membranous urethra
- Augmented Urethroplasty (Barbagli)
- Ventral Onlay
- Augmented Anastomosis
- Substitution Urethroplasty
After procedures like dilatation or DVIU, patients are generally advised self intermittent catheterization to maintain the caliber of urethral lumen. The frequency of self catheterization is to be reduced gradually from daily to once in a week to once a month.
For self cath a 14F Nelaton catheter is used. Patients wash their hands with soap and water, lubricate the catheter with Xylocaine jelly and introduce it through the meatus into the bladder. After use the catheter is stored in the jar of antiseptic solution such as Betadine.
Some patients develop re-stricture quickly and some have difficulty in maintaining caliber themselves. Recurrent urinary tract infection, dysuria and bleeding could be the possible complications of self cath over a long period of time. The length of the stricture may increase and the spongio-fibrosis becomes severe due to repeated trauma.