62
I URETHRAL STRICTURE
Urethral stricture: the management of chronic complications
Tropical Doctor, Apri1I975
urine. The detrusor no longer empties the bladder completely and the residual urine which results leads to frequency of micturition and an increasing risk of infection. Bladder sensation is diminished and muscle is replaced by fibrous tissue until eventually the stage is reached when there is incontinence of urine due to N. W. Harrison, MD, FRCS "retention with overflow". Senior Urological Registrar, St Peter's Hospitals In chronic retention the bladder is greatly distended and the Institute of Urology, London but as there is no pain, decompression is not required with the same urgency as in the acute situation. It is more important, initially, to direct one's attention to TROPICAL DOCTOR, 1975,5,62-65 the state of renal function, remembering that. as the In general, it is only patients with acute stricture detrusor has been failing the ureters may have complications who are admitted to hospital. The become obstructed leading to hydronephrosis and management of these acute problems was considered destruction of renal tissue. Thus clinical evidence of in the last issue of Tropical Doctor (January 1975, renal failure should be sought and blood urea and p. 25).In this article the more insidious and intractable haemoglobinestimations obtained. A raised blood urea is an indication for urinary chronic stricture complications will be discussed (Table I). The majority of patients with strictures diversion and this is readily achieved by suprapubic are managed in out-patient departments and dispens- puncture (see previous article). Relief of a chronic aries, and it is there that the majority of the chronic obstruction is always followed by a period of excess problems will be found. water and sodium loss due to the osmotic effect of urea and to failure of tubular reabsorptive function. This obligatory polyuria may amount to severallitres Table I. Chronic stricture complications per day and it is essential to measure the urine output Retention of urine Incontinence carefully, and to give intravenous fluid if necessary. Abdominal swelling Failure to appreciate this may result in a patient slipping into acute renal failure in spite of an apObstructive nephropathy Renal failure parently adequate fluid intake. A pulse and blood Decompression diuresis pressure chart is a most useful guide to the adequacy of fluid replacement. Residual urine Diverticula The extent to which both bladder and kidneys will Detrusor failure recover their function after relief of obstruction canBladder neck stenosis not be predicted. The bladder may not regain its Fistulae and Non-specificinfection contractility and thus continue to empty inadequately, chronic sepsis Specificinfection if at all, even after the stricture has been satisfactorily Elephantiasis dilated. A period of continuous bladder drainage to maintain an empty bladder for six weeks may be False passages followedby successfulvoiding. An episode of acute retention may be superimposed Stones Bladder on a chronically failing detrusor and the severity of Urethra the acute symptoms will be related to the extent add Carcinoma Bladder duration of the chronic pathologicalchanges. Urethra In any painless retention remember to consider the possibility of a neuropathic cause (e.g. spinal TB or CHRONIC RETENTION OF URINE tumour) and to look for neurological signs, especially A urethral stricture produces an increase in the out- in the sacral dermatomes. flow resistance to micturition which leads to compensatory hypertrophy of the detrusor muscle. For a . RESIDUAL URINE time a satisfactory urine flow may be maintained After successful dilatation of a stricture a catheter without harmful effects, but sooner or later further should be passed and the residual urine checked. A changes occur: through the thickened bundles of persistently high residue may be found in as many as muscle the bladder wall herniates producing saccula- a third of patients. The cause is either detrusor tion and later diverticula which may retain a residue of failure or obstruction at the bladder neck, or a
Tropical Doctor, April .H)75 combination of both. Management of the former has already been referred to. Bladder neck stenosis probably occurs secondarily to chronic infection, but the presence of a stricture does not preclude the possibility of benign (or malignant) prostatic hypertrophy as the cause of outflow obstruction. A bladder neck contracture may be felt as a prominent lip with a straight metal bougie and radiological investigations are helpful (see Bewes 1973). Treatment requires bladder neck resection or prostatectomy by the transvesical route. Transurethral resection is the ideal approach to bladder neck surgery but requires both a resectoscope and the skill to use it, and a urethral calibre sufficient to accommodate it. EXTERNAL FISTULAE
Urethral fistulae may be the sequel to inadequately treated extravasation or periurethral abscess. Many
URETHRAL STRICTURE
I 63
patients, however, give no history of any acute episode and appear to develop fistulous openings in a slow and insidious manner. Multiple fistulae may involve the perineum, scrotum, penis, perianal region, and inner aspects of the thighs (Fig. I). Their full extent is best demonstrated radiologically. Treatment by diversion of urine, a prolonged course of antibiotics, and dilation of the stricture may be successful in fistulae of recent origin. As there is usually no retention, diversion by suprapubic cystostomy is necessary. Chronic fistulae with epithelialized tracks present very difficult problems. In theory, excision of all the tracks together with urinary diversion should allow healing, but in practice the results of such treatment, which may require many weeksin hospital, are often disappointing. Tuberculosis and urethral malignancy are unusual causes of fistulae failing to close and should be excluded by bacteriological and histological examination. Chronic fistulae and periurethral sepsis may lead to gross elephantiasis of the scrotum and penis (Fig. 2). The tissues are hard and irregular and do not pit. Excision of the chronically oedematous tissue, even if extensive, is likely to be rewarding as the underlying structures, such as the penile shaft, are not affected and can be covered with split skin grafts ifnecessary. FALSEPASSAGES
A false passage is a forced passage. It results from a failure to appreciate the art of bouginage or the virtue of avoiding instrumentation when the urethra is acutely inflamed. Damage is also more likely to be inflicted if dilation is carried out under general anaesthesia, when the fact that the bladder has been reached through a false passage may not be appreciated. It is best to avoid the use of general anaesthesia for urethral bouginage. Once a false passage has been created a bougie may pass quite easily through it, yet urine does not, and the patient's symptoms are not improved. There is an increased risk of bleeding, extravasation, and abscess formation. False passages can be demonstrated radiologically (Bewes 1973). The simplest management is to pass a bougie through the correct route under the direct vision ofa urethroscope; this requires experience in endoscopic techniques. STONES
Fig. I. Multiple chronically infected andepithelialized fistulae involving thepenis, scrotum, perineum, and thighs.
Stones are very likely to form in infected and stagnant urine, and infection will persist until stones are removed. Urethral stones may form in the dilated portion proximal to a stricture. Removal of bladder
64 I URETHRAL
STRICTURE
Tropical Doctor, April J975 The diagnosis of a bladder tumour is often delayed because haematuria is likely to be attributed to the stricture or its management. A further difficulty is that cystoscopy cannot be performed until the stricture has been dilated sufficiently to accommodate thc instrument, at least 18 French gauge, depending on the cystoscopes available. A tumour may show up on a cystogram as a filling-defect and the' bladder should always be examined for tumours at open cystostomy. If a tumour is confined to the bladder, partial or total cystectomy is the only treatment available. Total cystectomy introduces the problem of permanent urinary diversion either by ileal conduit or ureterosigmoidostomy. The latter method which avoids the need for appliances is probably most suited to the tropics. Unfortunately, in many patients the tumour has already invaded outside the bladder wall at the time of diagnosis and may even appear through a cystostomy track or urethral fistula. Such tumours are inoperable and attempts at palliation by means of a ureterocolic diversion are to be condemned; they only serve to increase and prolong the patient's misery by preventing ureteric obstruction and allowing the local tumour growth to continue. IMPASSABLE AND UNSTABLE STRICTURES
Fig. 2. Chronic sepsis leading togross elephantiasis of thepenis. stones by suprapubic cystostomy or urethral stones by urethrotomy must be accompanied by appropriate treatment of the stricture and the infection which are the underlying causes. Prolonged suprapubic catheterization is often associated with troublesome stone formation. Regular catheter changes, a high fluid intake, and an acid urine should help to reduce the incidence. The urine may be acidified by ascorbic acid 500 mg, 2-4 times a day, or ammonium chloride 8-12 g a day. CARCINOMA
In Uganda tumours of the bladder and urethra are more common in patients with strictures. Squamous cell carcinoma is the predominant histological variety followed by adenocarcinoma. The persistent residual urine associated with a stricture would result in more prolonged exposure of the bladder mucosa to any carcinogen in the urine. Chronic infection may be another aetiologicalfactor.
Having discussed the management of the local complications of urethral strictures there remains the problem of the impassable and the unstable stricture. A stricture which defies the passage of the smallest bougie may yet allow the passage of urine, if only very slowly. Should urinary retention develop, diversion by suprapubic puncture can be performed, but the problem of the impassable stricture remains. An unstable stricture is one which can be dilated but contracts down so rapidly that even with frequent dilatations an adequate calibre is never reached. These difficult strictures should be investigated further by radiological techniques (Bewes 1973) in order to establish the location and extent of the stricture, or strictures, and the pressure of false passages, fistulae, or bladder neck stenosis. The only satisfactory answer to these problems, and the only way to cure a stricture, is to reconstruct the strictured urethra by urethroplasty techniques. Urethroplasty operations are demanding in time and skill and nearly always involve a two-stage procedure and close supervision over many months. It is unrealistic to expect such operations to be available to many patients in the tropics for some years. The only satisfactory way to learn urethroplasty techniques is by apprenticeship to someone with a
Tropical Doctor, April I975 special interest and experience in this reconstructive work. Where the facilities for urethroplasty are not available alternative solutions are permanent suprapubic catheterization, permanent external perineal urethrotomy, external urethrotomy with closure followedby regular dilatation, or internal urethrotomy with a urethrotome, also followed by regular dilatation. Of these, a permanent suprapubic catheter is the simplest solution, but the long-term problems of infections, stone formation, and possible malignancy are real drawbacks. External urethrotomy with closure, considered unsuitable for use in acute retention (see previous article) is perhaps the best compromise for resistant stricture problems, and must be followedby regular dilatations. GONORRHOEA
In this and a previous article the management of the main complications of stricture has been considered and is summarized in Fig. 3. For countries with a high stricture rate the implications in terms ot medical care are considerable. The major aetiological factor in the majority of strictures is gonococcal urethritis. In Uganda the incidence of gonorrhoea in young adult males has been estimated at 15% per year with a ratio to stricture complications of about 50 to 1 (Griffiths 1963). There is thus much scope for reducing the incidence of urethral stricture by better health education and more adequate treatment of gonorrhoea. From a surgical point of view, the better the management of the uncomplicated stricture the lower the incidence of complications. When complications do arise a safe general rule of management is: "If in doubt, divert". Diversion resolves the immediate problem and allows time for
URETHRAL STRICTURE
I 65
A SCHEME FOR THE MANAGEME}lT OF STRICTURE COMPUCATIONS
REGULAR URETRRAL DILATATION FOR IJFE
URETHROTOMY
II
:PERMANENT~ \ IURETHROPLASTY I
SUPRAPUBIC CATHETER
I
J_ Cure
Fig. 3. A schemefor themanagement of stricture complications.
further investigation and a careful decision on the best course of management. ACKNOWLEDGMENT
I am grateful to Mr P. C. Bewes, Mr W. J. Carswell, and Mr H. M. Obonyo for their help in the preparation of the two articles on stricture complications. REFERENCES
Bewes, P. C. (1973). Urethral stricture. Tropical Doctor, 3, 77-81. Griffiths, H. B. (1963). Gonorrhoea and Fertility in Uganda. Eugenics Review, 55,103-108.
I URETHRAL STRICTURE
Urethral stricture: the management of chronic complications
Tropical Doctor, Apri1I975
urine. The detrusor no longer empties the bladder completely and the residual urine which results leads to frequency of micturition and an increasing risk of infection. Bladder sensation is diminished and muscle is replaced by fibrous tissue until eventually the stage is reached when there is incontinence of urine due to N. W. Harrison, MD, FRCS "retention with overflow". Senior Urological Registrar, St Peter's Hospitals In chronic retention the bladder is greatly distended and the Institute of Urology, London but as there is no pain, decompression is not required with the same urgency as in the acute situation. It is more important, initially, to direct one's attention to TROPICAL DOCTOR, 1975,5,62-65 the state of renal function, remembering that. as the In general, it is only patients with acute stricture detrusor has been failing the ureters may have complications who are admitted to hospital. The become obstructed leading to hydronephrosis and management of these acute problems was considered destruction of renal tissue. Thus clinical evidence of in the last issue of Tropical Doctor (January 1975, renal failure should be sought and blood urea and p. 25).In this article the more insidious and intractable haemoglobinestimations obtained. A raised blood urea is an indication for urinary chronic stricture complications will be discussed (Table I). The majority of patients with strictures diversion and this is readily achieved by suprapubic are managed in out-patient departments and dispens- puncture (see previous article). Relief of a chronic aries, and it is there that the majority of the chronic obstruction is always followed by a period of excess problems will be found. water and sodium loss due to the osmotic effect of urea and to failure of tubular reabsorptive function. This obligatory polyuria may amount to severallitres Table I. Chronic stricture complications per day and it is essential to measure the urine output Retention of urine Incontinence carefully, and to give intravenous fluid if necessary. Abdominal swelling Failure to appreciate this may result in a patient slipping into acute renal failure in spite of an apObstructive nephropathy Renal failure parently adequate fluid intake. A pulse and blood Decompression diuresis pressure chart is a most useful guide to the adequacy of fluid replacement. Residual urine Diverticula The extent to which both bladder and kidneys will Detrusor failure recover their function after relief of obstruction canBladder neck stenosis not be predicted. The bladder may not regain its Fistulae and Non-specificinfection contractility and thus continue to empty inadequately, chronic sepsis Specificinfection if at all, even after the stricture has been satisfactorily Elephantiasis dilated. A period of continuous bladder drainage to maintain an empty bladder for six weeks may be False passages followedby successfulvoiding. An episode of acute retention may be superimposed Stones Bladder on a chronically failing detrusor and the severity of Urethra the acute symptoms will be related to the extent add Carcinoma Bladder duration of the chronic pathologicalchanges. Urethra In any painless retention remember to consider the possibility of a neuropathic cause (e.g. spinal TB or CHRONIC RETENTION OF URINE tumour) and to look for neurological signs, especially A urethral stricture produces an increase in the out- in the sacral dermatomes. flow resistance to micturition which leads to compensatory hypertrophy of the detrusor muscle. For a . RESIDUAL URINE time a satisfactory urine flow may be maintained After successful dilatation of a stricture a catheter without harmful effects, but sooner or later further should be passed and the residual urine checked. A changes occur: through the thickened bundles of persistently high residue may be found in as many as muscle the bladder wall herniates producing saccula- a third of patients. The cause is either detrusor tion and later diverticula which may retain a residue of failure or obstruction at the bladder neck, or a
Tropical Doctor, April .H)75 combination of both. Management of the former has already been referred to. Bladder neck stenosis probably occurs secondarily to chronic infection, but the presence of a stricture does not preclude the possibility of benign (or malignant) prostatic hypertrophy as the cause of outflow obstruction. A bladder neck contracture may be felt as a prominent lip with a straight metal bougie and radiological investigations are helpful (see Bewes 1973). Treatment requires bladder neck resection or prostatectomy by the transvesical route. Transurethral resection is the ideal approach to bladder neck surgery but requires both a resectoscope and the skill to use it, and a urethral calibre sufficient to accommodate it. EXTERNAL FISTULAE
Urethral fistulae may be the sequel to inadequately treated extravasation or periurethral abscess. Many
URETHRAL STRICTURE
I 63
patients, however, give no history of any acute episode and appear to develop fistulous openings in a slow and insidious manner. Multiple fistulae may involve the perineum, scrotum, penis, perianal region, and inner aspects of the thighs (Fig. I). Their full extent is best demonstrated radiologically. Treatment by diversion of urine, a prolonged course of antibiotics, and dilation of the stricture may be successful in fistulae of recent origin. As there is usually no retention, diversion by suprapubic cystostomy is necessary. Chronic fistulae with epithelialized tracks present very difficult problems. In theory, excision of all the tracks together with urinary diversion should allow healing, but in practice the results of such treatment, which may require many weeksin hospital, are often disappointing. Tuberculosis and urethral malignancy are unusual causes of fistulae failing to close and should be excluded by bacteriological and histological examination. Chronic fistulae and periurethral sepsis may lead to gross elephantiasis of the scrotum and penis (Fig. 2). The tissues are hard and irregular and do not pit. Excision of the chronically oedematous tissue, even if extensive, is likely to be rewarding as the underlying structures, such as the penile shaft, are not affected and can be covered with split skin grafts ifnecessary. FALSEPASSAGES
A false passage is a forced passage. It results from a failure to appreciate the art of bouginage or the virtue of avoiding instrumentation when the urethra is acutely inflamed. Damage is also more likely to be inflicted if dilation is carried out under general anaesthesia, when the fact that the bladder has been reached through a false passage may not be appreciated. It is best to avoid the use of general anaesthesia for urethral bouginage. Once a false passage has been created a bougie may pass quite easily through it, yet urine does not, and the patient's symptoms are not improved. There is an increased risk of bleeding, extravasation, and abscess formation. False passages can be demonstrated radiologically (Bewes 1973). The simplest management is to pass a bougie through the correct route under the direct vision ofa urethroscope; this requires experience in endoscopic techniques. STONES
Fig. I. Multiple chronically infected andepithelialized fistulae involving thepenis, scrotum, perineum, and thighs.
Stones are very likely to form in infected and stagnant urine, and infection will persist until stones are removed. Urethral stones may form in the dilated portion proximal to a stricture. Removal of bladder
64 I URETHRAL
STRICTURE
Tropical Doctor, April J975 The diagnosis of a bladder tumour is often delayed because haematuria is likely to be attributed to the stricture or its management. A further difficulty is that cystoscopy cannot be performed until the stricture has been dilated sufficiently to accommodate thc instrument, at least 18 French gauge, depending on the cystoscopes available. A tumour may show up on a cystogram as a filling-defect and the' bladder should always be examined for tumours at open cystostomy. If a tumour is confined to the bladder, partial or total cystectomy is the only treatment available. Total cystectomy introduces the problem of permanent urinary diversion either by ileal conduit or ureterosigmoidostomy. The latter method which avoids the need for appliances is probably most suited to the tropics. Unfortunately, in many patients the tumour has already invaded outside the bladder wall at the time of diagnosis and may even appear through a cystostomy track or urethral fistula. Such tumours are inoperable and attempts at palliation by means of a ureterocolic diversion are to be condemned; they only serve to increase and prolong the patient's misery by preventing ureteric obstruction and allowing the local tumour growth to continue. IMPASSABLE AND UNSTABLE STRICTURES
Fig. 2. Chronic sepsis leading togross elephantiasis of thepenis. stones by suprapubic cystostomy or urethral stones by urethrotomy must be accompanied by appropriate treatment of the stricture and the infection which are the underlying causes. Prolonged suprapubic catheterization is often associated with troublesome stone formation. Regular catheter changes, a high fluid intake, and an acid urine should help to reduce the incidence. The urine may be acidified by ascorbic acid 500 mg, 2-4 times a day, or ammonium chloride 8-12 g a day. CARCINOMA
In Uganda tumours of the bladder and urethra are more common in patients with strictures. Squamous cell carcinoma is the predominant histological variety followed by adenocarcinoma. The persistent residual urine associated with a stricture would result in more prolonged exposure of the bladder mucosa to any carcinogen in the urine. Chronic infection may be another aetiologicalfactor.
Having discussed the management of the local complications of urethral strictures there remains the problem of the impassable and the unstable stricture. A stricture which defies the passage of the smallest bougie may yet allow the passage of urine, if only very slowly. Should urinary retention develop, diversion by suprapubic puncture can be performed, but the problem of the impassable stricture remains. An unstable stricture is one which can be dilated but contracts down so rapidly that even with frequent dilatations an adequate calibre is never reached. These difficult strictures should be investigated further by radiological techniques (Bewes 1973) in order to establish the location and extent of the stricture, or strictures, and the pressure of false passages, fistulae, or bladder neck stenosis. The only satisfactory answer to these problems, and the only way to cure a stricture, is to reconstruct the strictured urethra by urethroplasty techniques. Urethroplasty operations are demanding in time and skill and nearly always involve a two-stage procedure and close supervision over many months. It is unrealistic to expect such operations to be available to many patients in the tropics for some years. The only satisfactory way to learn urethroplasty techniques is by apprenticeship to someone with a
Tropical Doctor, April I975 special interest and experience in this reconstructive work. Where the facilities for urethroplasty are not available alternative solutions are permanent suprapubic catheterization, permanent external perineal urethrotomy, external urethrotomy with closure followedby regular dilatation, or internal urethrotomy with a urethrotome, also followed by regular dilatation. Of these, a permanent suprapubic catheter is the simplest solution, but the long-term problems of infections, stone formation, and possible malignancy are real drawbacks. External urethrotomy with closure, considered unsuitable for use in acute retention (see previous article) is perhaps the best compromise for resistant stricture problems, and must be followedby regular dilatations. GONORRHOEA
In this and a previous article the management of the main complications of stricture has been considered and is summarized in Fig. 3. For countries with a high stricture rate the implications in terms ot medical care are considerable. The major aetiological factor in the majority of strictures is gonococcal urethritis. In Uganda the incidence of gonorrhoea in young adult males has been estimated at 15% per year with a ratio to stricture complications of about 50 to 1 (Griffiths 1963). There is thus much scope for reducing the incidence of urethral stricture by better health education and more adequate treatment of gonorrhoea. From a surgical point of view, the better the management of the uncomplicated stricture the lower the incidence of complications. When complications do arise a safe general rule of management is: "If in doubt, divert". Diversion resolves the immediate problem and allows time for
URETHRAL STRICTURE
I 65
A SCHEME FOR THE MANAGEME}lT OF STRICTURE COMPUCATIONS
REGULAR URETRRAL DILATATION FOR IJFE
URETHROTOMY
II
:PERMANENT~ \ IURETHROPLASTY I
SUPRAPUBIC CATHETER
I
J_ Cure
Fig. 3. A schemefor themanagement of stricture complications.
further investigation and a careful decision on the best course of management. ACKNOWLEDGMENT
I am grateful to Mr P. C. Bewes, Mr W. J. Carswell, and Mr H. M. Obonyo for their help in the preparation of the two articles on stricture complications. REFERENCES
Bewes, P. C. (1973). Urethral stricture. Tropical Doctor, 3, 77-81. Griffiths, H. B. (1963). Gonorrhoea and Fertility in Uganda. Eugenics Review, 55,103-108.
