2. Introduction
A narrowing of the urethra
Caused by injury or disease including UTIs
.and other forms of urethritis
Above insult leads to scar tissue formation
which contracts hence reducing the caliber
.of the urethral lumen
End result is the resistance to antegrade
. flow of urine and semen
3. Causes
• Traumatic
• Iatrogenic :post instrumentation( including
catheter ,urethral endoscopy)
• Post operative :open prostatectomy
,amputation of the penis.
• Congenital
• Malignancies
4. Presentation :
• Obstructive voiding symptoms ,urine
retention(decreased force of stream
incomplete bladder emptying ,dribbling
,intermittency)
• UTI s
5. Complications •
• Retention of urine
• Urethral diverticulum
• Peri urethral abcess
• Urethral fistulas
• Urethral calculi
• Hernia ,heamorrhoides and rectal
prolapse.
6. Management •
Principles of treatment
Proper understanding of the relevant
anatomy
Accurate diagnosis
Skilled surgical technique
8. :Radiographic imaging
Contrast studies achieved by retrograde and
.antegrade cystourethrography
Ultrasonography : A transducer placed
. longitudinally along the penis
Can evaluate
Stricture length
Degree and depth of spongiofibrosis
Endoscopic evaluation
Done using either rigid or flexible
cystourethorgraphy
9. Treatment
Note : no medical therapy exists for urethral
stricture
:Surgical therapy
Uretharal dilatation
Internal urethrotomy
Permanent utrethral stents
Open reconstruction
Primary repair
Tissue transfer ,repair techniques
10. Urethral dilatation
The objective in patients with isolated strictures
Drawbacks
It‘s a blind procedure hence false passages can
be created
recurrence rate
infection
Internal urethrotomy
Stricture is incised under direct vision using endoscopic
. equipment
Objective is to incise the stricture and ensuring
epithelialization before wound contraction reduces the
.lumen caliber
11. Complications
Recurrence of stricture
Bleeding
.Extravasation of the irrigation fluid into the perispongial tissues
[
Permanent urethral stents
Placed endoscopically
.Designated to be incorporated into the wall to produce a patent lumen
Most useful in short strictures located in the bulbar urethra and in elderly
.patients
Draw backs
If placed distal to the bulbous urethra it can cause pain while sitting or during
.intercourse
Migration of the stent
.Contraindicated in patients with dense strictures or prior urethral reconstruction
12. Open reconstruction
Primary repair
Hold standard against which other procedures are
.compared to
Involves complete excision of the strictures with
.reanstomosis
Technical points to be observed
Complete excision of the areas of fibrosis
Widely patent
Tension free anastomosis
Young patients have an additional benefit of having
compliant tissues hence wide strictures can be safely
.excised and primary anastomosis done
13. Complications
•
Post operative chordae
Penile shortening
Ejaculatory dysfunction
Decreased glans sensitivity
The repair is usually stented with a silicon catheter
and urine delivered using a suprapubic catheter
.as healing takes place
14. Tissue transfer
Technique •
Reserved for patients in whom multiple
.procedures have failed
Conducted as two stage procedure
Success depends on the blood supply of the
.local tissues at the site of placement
Graft is harvested from desired non hair
bearing location e.g. Buccal mucosa
.,rectal or bladder
15. 1st stage
Urethra is opened via a ventral midline
incision and the scarred urethra is excised
.completely
Dartos fascia is mobilized bilaterally and
.closed over the urethral bed
Desired skin is harvested and sutured to
. the dartos covered ventral urethral bed
.Catheter is placed for suturing
16. 2nd stage
Takes place 6-9 months after the initial
.operation
Skin strip is mobilized along the urethra
.that will be used to fashion a neo urethra
. Dartos fascia is not interfered with
.Must be water tight closure
.Catheter is left in site for stenting purposes
17. : Complications
. Post voiding dribbling
.Post operative diverticulum
.Skin retraction of the ventral skin of the penis
.Urethra cutaneous fistula
Above can be minimized by having the appropriate
.experience and surgical technique
Oral complications : pain ,persistent numbness
.,tightness or coarseness over donor site
18. Contra indications to surgery
.Active urinary tract infection
Must rule out malignancy ,endoscopic
.biopsy done in case of luminal mass
19. Prognosis
• Prospective randomized comparison of internal
urethrotomy and dilatation showed no significant
difference in efficacy when used as the initial
treatment.
• Recurrence rate is directly proportional to the
stricture length.
• Rate at 12 months
• 2cm ------ 40%
• 2-4cm -----50% increased to 75% at 48
months.
• > 4cm ------80%
20. Stents
. Long term success rate of 84% at 5 years
.And increased patient satisfaction
21. Excision with primary anastomosis
. Most successful •
• Tissue transfer graft have overall success rate of > 95% over one year however there
is deterioration over time
• External location and degree of scarring
• Benign or malignant prostate obstruction
• Post operative bladder neck contraction.
• Complications
• Chronic prostatitis
• Chronic UTI
• Epidydimal
• Diverticula
• Urethrocutaneous fistula
• Peri urethral abscess.
• Urethral carcinoma
• Vesical stones from stasis
• Ascending pyelonephritis.
• Renal failure
22. Circumcision
.Is the surgical removal of some or all of the foreskin •
• Indications : young boy
• Social
• Religion
• Therapeutic:
• Phimosis
• Infection: balanitis ,balanoposthitis ,posthitis
• Xeroderma balanitis obliterans
• Paraphimosis tight phrenulum
• UTI
• Adults
• Inability to retract foresking
• Tight frenulum
• Balanitis
• Before radiotherapy
23. Timing varies •
• Technique
• Plastibel
• Open as in adult
• Complications
• Bleeding
• Infection
• Meatal ulcer
• Meatal stenosis
• Pain
• Psychological trauma
• Lose of glans sensitivity
• An ulcerated meatus in the circumcised meatus is a frequent
sumptom .
• The ammonical diaper is the cause of this lesion.
• Benefits
24. Foreskin 50% at 1 year retractable
90% at 3 years
99% at 17 years
Whitish ring of indurated skin.
25. Phimosis
• The foreskin can not be fully retracted over the glans penis .
• Normal separation after 3 years
• Non-retractability
• Pathology :acquired
•
• .Balanitis xertica obliterans
• Scarring
• Balanitis
• Repeated catheterization
• Foreceful retraction
• Untreated diabetic
• Presentation
• Pain during urination.
• Obvious ballooning of foresking with urination.
27. Paraphimosis
• The foreskin becomes trapped behind the glans penis
and can not be reduced .
• Treated as medical emergency if
• -persists for several hours
• -signs of lack of blood flow.
• It can result in gangrene.
• Caused by
• -during penile exam
• -penile cleaning
• -urethral catheterization
• -Cystoscopy
29. Ulceration of the urethral meatus
• Is quite common in circumcised boys.
• Delayed up to 2 years from circumcision.
• Lack of protective prepuce
• Friction
• Ammonical dermatitis
• Frenular artery ligation
• Ulcer form a scab
• Process cause fibrosis
• Acquired pin hole meatus
• follow up hypospedias repair .
• phimosis
• sparing or dribbling
• chronic retention
• renal impairment
30. treatment
• medical
• local measures to soften the scab
and alkalinization of urine .
• Meatotomy
31. STD
Gonorrheal urethritis
• Gonorrhea is a STD
• Caused by gram Neisseria gonnorhea
• Gram negative kidney shaped diploccoi
• Infect the anterior urethra of men.
• Cervix in women
• Presentaion within 2 to 10 days
• Urethral discomfort
• Dysuria scalding
• Urethral discharge
• May be slight discharge and white to yellow
• Investigations :urethral smear gram staining
• .
33. Treatment
• Antibiotics
Ciprofloxacin
Pencillin
• Contact For control
34. Women
• ASymptomatic
• Increased vaginal discharge
• Painful urination
• Vaginal bleeding between periods
• Abdominal pain
• Pelvic pain
• Complications
• Infertility
• Women pelvic inflammatory diesease
• Increase risk of HIV
35. Non specific urethritis
Non gonoccocal urethritis
• Diagnosed by exclusion
• Chlamydia trachomatis
• Ureaplasma urealytica
• 50% unknown cause
• Clinical features
•
• Dysuria :
• a few days to 3 months discharge
• Epididymitis
• Rx
• Doxycycline
36. Reiter's disease
• Sexually acquired reactive urethritis
• Subacute urethritis 4-6 weeks clean
discharge.
• Cnojuctivitis 50%
• 10 days to 2 weeks arthritis
• Keratoderma blennorhagic
• Nodulr
• Vesicular
• Pusturlar
• In the Sole of foot
• Prognosis
37. • Arthiritis
• Anterior uveitis
• Treatment
• Topical steroids and mydiatrics for the
eye
• Antibiotics and systemic steroids
•
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