Editing Urethral stricture

{{Short description|Narrowing of the urethra}}
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| synonyms      = Urethral narrowing, urethral stricture disease
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| caption       = [[Urethra]] is tube at center.
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A '''urethral stricture''' is a narrowing of the [[urethra]], the tube connected to the [[Urinary bladder|bladder]] that allows [[urination]]. The narrowing reduces the flow of [[urine]] and makes it more difficult or even painful to empty the bladder.<ref name=":0" />

Urethral stricture is caused by injury, instrumentation, infection, and certain non-infectious forms of [[urethritis]]. The condition is more common in men due to their longer urethra.<ref name=":0">{{Cite web |title=Urethral Stricture Disease: Symptoms, Diagnosis & Treatment |url=https://www.urologyhealth.org/urology-a-z/u/urethral-stricture-disease |access-date=2022-09-09 |website=Urology Care Foundation}}</ref>

== Signs and symptoms ==

The hallmark sign of urethral stricture is a weak urinary stream. Other symptoms include:<ref name="Urethral stricture: etiology, inves">{{cite journal |vauthors= Tritschler S, Roosen A, Füllhase C, Stief CG, Rübben H |date=2013 |title=Urethral stricture: etiology, investigation and treatments |journal= Dtsch Ärztebl Int|volume=110 |issue=13 |pages=220–226 |doi=10.3238/arztebl.2013.0220 |pmid=23596502 |pmc=3627163 }}</ref>
* Splaying of the urinary stream
* Urinary frequency
* Urinary urgency
* Straining to urinate
* [[Dysuria|Pain during urination]]
* [[Urinary tract infection]]
* [[Prostatitis]]
* Inability to completely empty the bladder.

Some people with severe urethral strictures are completely unable to urinate. This is referred to as acute [[urinary retention]], and is a [[medical emergency]]. [[Hydronephrosis]] and [[kidney failure]] may also occur.<ref>{{cite web |url=https://www.lecturio.com/concepts/hydronephrosis/| title=Hydronephrosis|website=The Lecturio Medical Concept Library |access-date= 25 July 2021}}</ref><ref>{{cite web|title=Kidney Failure|url=https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure|website=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=25 July 2021}}</ref>

=== Complications ===
{{div col|colwidth=18em}}
* [[Urinary retention]]
* [[Prostatitis]]
* Bladder dysfunction
* Urethral [[diverticulum]]
* Periurethral abscess
* [[Fournier's gangrene]]
* [[Urethral]] [[fistula]]
* Bilateral [[hydronephrosis]]
* [[Urinary infections]]
* Urinary [[calculus (medicine)|calculus]]
{{div col end}}

== Causes ==

Urethral strictures most commonly result from injury, urethral instrumentation, infection, non-infectious inflammatory conditions of the urethra, and after prior [[hypospadias]] surgery. Less common causes include congenital urethral strictures and those resulting from malignancy.<ref name="Urethral stricture: etiology, inves"/>

Urethral strictures after blunt trauma can generally be divided into two sub-types;
* Pelvic fracture-associated urethral disruption occurs in as many as 15% of severe pelvic fractures.<ref>{{cite journal|last1=Figler |first1=B. D.|last2=Hoffler|first2=C. E.|last3=Reisman|first3=W.|last4=Carney|first4=K. J.|last5=Moore |first5=T. |last6=Feliciano |first6=D.|last7=Master|first7=V.|title=Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries|journal=Injury|date=2012 |volume=43|issue=81|pages=242–249|doi=10.1016/j.injury.2012.03.031|pmid=22592152}}</ref> These injuries are typically managed with suprapubic tube placement and delayed urethroplasty 3 months later. Early endoscopic realignment may be used in select cases instead of a suprapubic tube, but these patients should be monitored closely as vast majority of them will require urethroplasty.<ref>{{cite web|url=https://www.auanet.org/education/guidelines/urotrauma.cfm|title=American Urological Association - Urotrauma|website=www.auanet.org|access-date=21 April 2018}}</ref>
* Blunt trauma to the perineum compresses the bulbar urethra against the pubic symphysis, causing a "crush" injury. These patients are typically treated with suprapubic tube and delayed urethroplasty.

Other specific causes of urethral stricture include:
* Instrumentation (e.g., after [[transurethral resection of prostate]], [[transurethral resection of bladder tumor]], or endoscopic kidney surgery)
* Infection (typically with [[gonorrhea]])
* [[Lichen sclerosus]]<ref name=lichenrecon1>{{cite journal|last1=Palminteri|first1=E.|last2=Brandes|first2=S. B.|last3=Djordjevic |first3=M.|title=Urethral reconstruction in lichen sclerosus|journal=Curr Opin Urol|date=2012|volume=22|issue=6|pages=478–483|doi=10.1097/MOU.0b013e328358191c|pmid=22965317|s2cid=6900460}}</ref>
* Surgery to address hypospadias can result in a delayed urethral stricture, even decades after the original surgery.

== Diagnosis ==
Among ways to diagnose this condition is:
[[File:Urethra stricture.jpg|thumb|right|Urethrography showing urethral stricture in man (labeled ''Verengung'' which translates to "Narrowing").]]
* [[Cystoscopy]]<ref name="pmid28685197">{{cite journal |vauthors=Strittmatter F, Beck V, Stief CG, Tritschler S |title=[Urethral stricture : From diagnostics to appropriate treatment] |language=German |journal=Urologe A |volume=56 |issue=8 |pages=1047–1057 |date=August 2017 |pmid=28685197 |doi=10.1007/s00120-017-0443-z |url=}}</ref>
* [[Urethrography]]<ref>{{Cite journal|vauthors=El-Ghar MA, Osman Y, Elbaz E, Refiae H, El-Diasty T |title=MR urethrogram versus combined retrograde urethrogram and sonourethrography in diagnosis of urethral stricture |journal=Eur J Radiol |volume= 74|issue= 3|pages= e193–e198|date=July 2009 |pmid=19608363 |doi=10.1016/j.ejrad.2009.06.008 }}</ref><ref>{{Cite journal|last1=Maciejewski|first1=Conrad|last2=Rourke|first2=Keith|date=2015-12-02|title=Imaging of urethral stricture disease|url=http://tau.amegroups.com/article/view/5675|journal=Translational Andrology and Urology|language=en|volume=4|issue=1|pages=2–9|doi=10.3978/j.issn.2223-4683.2015.02.03|pmid=26816803|pmc=4708283|issn=2223-4691}}</ref>

== Treatment ==
Initial treatment usually involves urethral dilation (widening the tube) or [[urethrotomy]], where the stricture is cut away with a [[Cystoscopy|cystoscope]].

=== Dilation and urethrotomy ===

Urethral dilation and other [[Endoscopy|endoscopic]] approaches such as [[urethrotomy|direct vision internal urethrotomy (DVIU)]], laser urethrotomy, and self intermittent dilation are the most commonly used treatments for urethral stricture. However, these approaches are associated with low success rates<ref>Santucci R and Eisenberg L: Urethrotomy has a much lower success rate than previously reported. J Urol 2010; 183: 1859.</ref> and may worsen the stricture, making future attempts to surgically repair the urethra more difficult.<ref>{{cite journal | url=https://www.auajournals.org/doi/10.1016/j.juro.2011.12.074 | doi=10.1016/j.juro.2011.12.074 | title=Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated with Increased Stricture Complexity and Prolonged Disease Duration | journal=Journal of Urology | date=May 2012 | volume=187 | issue=5 | pages=1691–1695 | last1=Hudak | first1=Steven J. | last2=Atkinson | first2=Timothy H. | last3=Morey | first3=Allen F. | pmid=22425115 | url-access=subscription }}</ref>

A Cochrane review found that performing intermittent self-dilatation may confer a reduced risk of recurrent urethral stricture after endoscopic treatment, but the [[Scientific evidence|evidence]] is weak.<ref>{{cite journal|last1=Jackson|first1=MJ|last2=Veeratterapillay |first2=R |last3=Harding |first3=CK|last4=Dorkin|first4=TJ|title=Intermittent self-dilatation for urethral stricture disease in males.|journal=The Cochrane Database of Systematic Reviews|date=19 December 2014|volume=2014|issue=12|pages=CD010258|pmid=25523166|doi=10.1002/14651858.CD010258.pub2|pmc=10880810}}</ref>

=== Urethroplasty ===

[[Urethroplasty]] refers to any open reconstruction of the urethra. Success rates range from 85% to 95% and depend on a variety of clinical factors, such as stricture as the cause, length, location, and caliber.<ref name="S">Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol. 2002 Apr;167(4):1715-9.</ref><ref name="F">Figler BD, Malaeb BS, Dy GW, Voelzke BB, [[Hunter Wessells|Wessells H.]] Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft. Urology. 2013 Nov;82(5):1166-70.</ref><ref name="Barbagli">Barbagli G1, Sansalone S, Romano G, Lazzeri M. Bulbar urethroplasty: transecting vs. nontransecting techniques. Curr Opin Urol. 2012 Nov;22(6):474-7.</ref><ref name="Bello">Bello JO. Impact of preoperative patient characteristics on posturethroplasty recurrence: the significance of stricture length and prior treatments. Niger J Surg. 2016; 22(2):86-89</ref> Urethroplasty can be performed safely on men of all ages.<ref>Santucci RA, McAninch JW, Mario LA et al. (July 2004). "Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications". J Urol. 172 (1): 201–3.</ref>

In the [[posterior urethra]], anastomotic urethroplasty (with or without preservation of bulbar arteries) is typically performed after removing scar tissue.{{citation needed|date=April 2021}}

In the [[bulbar urethra]],<ref name="S" /><ref name="F" /><ref name="Barbagli" /> the most common types of urethroplasty are anastomotic (with or without preservation of corpus spongiosum and bulbar arteries) and substitution with [[buccal mucosa graft]], full-thickness [[skin graft]], or split thickness skin graft. These are nearly always done in a single setting (or stage).{{citation needed|date=April 2021}}

In the [[penile urethra]], anastomotic urethroplasties are rare because they can lead to chordee (penile curvature due to a shortened urethra). Instead, most penile urethroplasties are substitution procedures utilizing buccal mucosa graft, full-thickness skin graft, or split-thickness skin graft. These can be done in one or more settings, depending on stricture location, severity, cause and patient or surgeon preference.

=== Urethral stent ===
[[File:3D Medical Animation Urethral Stunt.jpg|alt=3D Medical Animation still shot of Urethral Stent|thumb|254x254px|3D medical animation still shot of urethral stent]]
A permanent urethral stent<ref>{{cite web|url=http://www.americanmedicalsystems.com/prof_male_detail_objectname_prof_urolume_ureth_stricture.html|archive-url=https://web.archive.org/web/20060313034647/http://www.americanmedicalsystems.com/prof_male_detail_objectname_prof_urolume_ureth_stricture.html|url-status=dead|archive-date=13 March 2006|title=Urolume Endoprosthesis|website=americanmedicalsystems.com|access-date=21 April 2018}}</ref> was approved for use in men with bulbar urethral strictures in 1996, but was recently{{When|date=July 2021}} removed from the market.{{Citation needed|date=July 2021}}

A temporary thermoexpandable urethral stent (Memotherm) is available in Europe but is not currently approved for use in the United States.

=== Emergency treatment ===

When in acute urinary retention, treatment of the urethral stricture or diversion is an emergency. Options include:
* Urethral dilatation and catheter placement. This can be performed in the [[Emergency Department]], a practitioner's office or an operating room. The advantage of this approach is that the urethra may remain patent for a period of time after the dilation, though long-term success rates are low.
* Insertion of a [[suprapubic catheter]] with catheter drainage system.  This procedure is performed in an Operating Room, Emergency Department or practitioner's office. The advantage of this approach is that it does not disrupt the scar and interfere with future definitive surgery.

=== Ongoing care ===

Following urethroplasty, patients should be monitored for a minimum of 1 year, since the vast majority of recurrences occur within 1 year.

Because of the high rate of recurrence following dilation and other endoscopic approaches, the provider must maintain a high index of suspicion for recurrence when the patient presents with obstructive voiding symptoms or urinary tract infection.

==Research==

=== Urethrotomy vs. urethroplasty ===
Comparing the two surgical procedures, a UK trial found that both urethrotomy and urethroplasty are effective in treating urethral narrowing in the bulbar region. At the same time the more invasive urethroplasty had longer-lasting benefit and was associated with fewer re-interventions.<ref>{{Cite journal |date=2020-12-18 |title=Men with urethral narrowing can be offered a choice of effective surgery |url=https://evidence.nihr.ac.uk/alert/men-urethral-narrowing-effective-surgery-choice/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/alert_43436|s2cid=241410809 |url-access=subscription }}</ref><ref>{{Cite journal |last1=Goulao |first1=Beatriz |last2=Carnell |first2=Sonya |last3=Shen |first3=Jing |last4=MacLennan |first4=Graeme |last5=Norrie |first5=John |last6=Cook |first6=Jonathan |last7=McColl |first7=Elaine |last8=Breckons |first8=Matt |last9=Vale |first9=Luke |last10=Whybrow |first10=Paul |last11=Rapley |first11=Tim |last12=Forbes |first12=Rebecca |last13=Currer |first13=Stephanie |last14=Forrest |first14=Mark |last15=Wilkinson |first15=Jennifer |date=13 September 2020 |title=Surgical Treatment for Recurrent Bulbar Urethral Stricture: A Randomised Open-label Superiority Trial of Open Urethroplasty Versus Endoscopic Urethrotomy (the OPEN Trial) |url=https://linkinghub.elsevier.com/retrieve/pii/S0302283820304309 |journal=European Urology |language=en |volume=78 |issue=4 |pages=572–580 |doi=10.1016/j.eururo.2020.06.003|pmid=32636099 |s2cid=220412303 |hdl=2164/16774 |hdl-access=free }}</ref> The results were integrated into the new UK guidelines on the treatment urethral narrowing by [[British Association of Urological Surgeons]].<ref>{{Cite journal |last1=Bugeja |first1=Simon |last2=Payne |first2=Stephen R. |last3=Eardley |first3=Ian |last4=Mundy |first4=Anthony R. |date=18 June 2020 |title=The standard for the management of male urethral strictures in the UK: a consensus document |url=http://journals.sagepub.com/doi/10.1177/2051415820933504 |journal=Journal of Clinical Urology |language=en |volume=14 |issue=1 |pages=10–20 |doi=10.1177/2051415820933504 |s2cid=225765110 |issn=2051-4158|url-access=subscription }}</ref>

=== Bioengineering ===
The use of bioengineered urethral tissue is promising, but still in the early stages. The Wake Forest Institute of Regenerative Medicine has pioneered the first bioengineered human urethra and in 2006 implanted urethral tissue grown on bioabsorbable scaffolding (approximating the size and shape of the affected areas) in five young (human) males who had congenital defects, physical trauma, or an unspecified disorder necessitating urethral reconstruction. As of March 2011, all five recipients report the transplants have functioned well.<ref>{{cite news| url=https://healthland.time.com/2011/03/08/scientistis-grow-a-new-urethra-and-possibly-many-other-human-organs-in-the-lab/ | magazine=Time | title=Scientists Grow New Body Parts in the Lab |author=Alice Park | date=8 March 2011}}</ref>

=== Cell therapy approach through endoscopy ===

Buccal mucosal tissue harvested under local anesthesia after culturing in the lab when applied as cells through endoscopy after urethrotomy in a pilot study (BEES HAUS Procedure) has yielded encouraging results.<ref>{{cite journal |last1=Vaddi |first1=Suryaprakash |last2=Vijayabaskar |first2=Reddy |last3=Abraham |first3=Samuel JK |date=22 November 2018 |title=Buccal epithelium Expanded and Encapsulated in Scaffold-Hybrid Approach to Urethral Stricture (BEES-HAUS) procedure: A novel cell therapy-based pilot study |journal=International Journal of Urology |volume=26 |issue=2 |pages=253–257 |doi=10.1111/iju.13852 |pmc=7379713 |pmid=30468021 |doi-access=free}}</ref> This procedure has subsequently been standardised for in vitro cell culture,<ref>{{cite journal |last1=Katoh |first1=S |title=A 3D Polymer Scaffold Platform for Enhanced in vitro Culture of Human & Rabbit Buccal Epithelial Cells for Cell Therapies |journal=Tokai J Exp Clin Med. |date=2021 |volume=46 |issue=1 |pages=1–6 |pmid=33835468 |url=http://mj-med-u-tokai.com/pdf/460101.pdf}}</ref> then in animal models of urethral stricture for both morphological engraftment of the buccal cells onto the site of the urethral injury <ref>{{cite journal |last1=Horiguchi |first1=Akio |title=Successful engraftment of epithelial cells derived from autologous rabbit buccal mucosal tissue, encapsulated in a polymer scaffold in a rabbit model of a urethral stricture, transplanted using the transurethral approach |journal=Regenerative Therapy |date=2021 |volume=18 |pages=127–132 |doi=10.1016/j.reth.2021.05.004 |pmid=34189194 |pmc=8203727 |url=https://doi.org/10.1016/j.reth.2021.05.004}}</ref> and also immunohistochemically by negative and positive markers confirming that the transplanted cells are the ones that got engrafted covering the wounded surface of the urethra, leading to possible prevention of recurrence of the stricture.<ref>{{cite journal |last1=Horiguchi |first1=Akio |title=Engraftment of Transplanted Buccal Epithelial Cells onto the Urethrotomy Site, Proven Immunohistochemically in Rabbit Model; a Feat to Prevent Urethral Stricture Recurrence |journal=Stem Cell Rev. Rep. |date=2023 |volume=19 |pages=275–278 |doi=10.1007/s12015-022-10466-1 |pmid=36306011 |url=https://doi.org/10.1007/s12015-022-10466-1|pmc=9823073 }}</ref> Clinically, this procedure has been started as an application recently in Japan as per the regenerative medicine law of Japan.<ref>{{cite news |title=India-Japan Technology Transfer: GN Corporation Pioneers BEES-HAUS Cell Therapy in Japan |url=https://cijtoday.com/india-japan-technology-bees-haus-therapy-in-japan/ |publisher=CIJ Today}}</ref>

== References ==
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== External links ==
{{Medical resources
|  DiseasesDB      = 13562
|  ICD10           = {{ICD10|N|35||n|30}}
|  ICD9            = {{ICD9|598}}
|  ICDO            =
|  OMIM            =
|  MedlinePlus     = 001271
|  eMedicineSubj   = med
|  eMedicineTopic  = 3075
}}

{{Urinary tract disease}}
{{Authority control}}

[[Category:Urethra disorders]]
[[Category:Male genital disorders]]