URETHRAL DISEASE

By
Professor Assistant
Dr. Duraid Alhadithi
MALE URETHRA

 The male urethra has a length of 17.5 to 20 cm and consists of

anterior and posterior portions.
 The posterior urethra is divided into the prostatic and
membranous urethras. The prostatic urethra is 3.5 cm long and
extends from the internal sphincter at the bladder neck and
terminates at the distal end of The verumontanum.
 The membranous urethra is 1 to 1.5-cm long and extends from
the distal end of the verumontanum to the external sphincter at
the urogenital diaphragm. It is the narrowest portion of the
urethra.
 The anterior urethra is divided into the bulbar, and penile, or
pendulous, portions. The bulbar urethra extends from the
external sphincter to the penoscrotal junction, where there is
slight angulation of the urethra by the suspensory ligament of
the penis. The proximal bulbous urethra is dilated and has a
conical shape at the bulbomembranous junction
FEMALE URETHRA

 The female urethra is 4 cm long and extends from the bladder

neck obliquely in an anterior and inferior direction to the
external orifice situated between the labia minora.

 The urethra is widest at its proximal aspect and tapers distally.

Skene glands are groups of periurethral glands found distally
and empty through two small ducts to either side of the
external meatus.
URETHRAL STRICTURE
DISEASE
 The term urethral stricture refers to anterior urethral disease, or
a scarring process involving the spongy erectile tissue of the
corpus spongiosum (spongiofibrosis).

 In contrast, posterior urethral “strictures” are not included in

the common definition of urethral stricture.

 Posterior urethral stricture is an obliterative process in the

posterior urethra that has resulted in fibrosis and is generally
the effect of distraction in that area caused by either trauma or
radical prostatectomy.
Etiology OF URETHRAL
stricture
 Any process that injures the urethral epithelium or the
underlying corpus spongiosum to the point that healing results
in a scar can cause an anterior urethral stricture.
 Today, most urethral strictures are the result of trauma (usually
straddle trauma). This trauma to the urethra often goes
unrecognized until the patient presents with voiding symptoms
resulting from the obstruction of the stricture or scar.
 inflammatory strictures associated with gonorrhea were the
most commonly seen in the past and are less common now.
 congenital stricture is an entity that is difficult to understand.
Diagnosis and Evaluation

 Patients who have urethral strictures most often present with

obstructive voiding symptoms or urinary tract infections
such as prostatitis and epididymitis. Some patients also present
with urinary retention.
 it is important to determine the location, length, depth, and
density of the stricture (spongiofibrosis).
 The length and location of the stricture can be determined with
radiography, urethroscopy, and ultrasonography.
 The depth and density of the scar in the spongy tissue can be
deduced from the physical examination, the appearance of the
urethra in contrast-enhanced studies, and the amount of
elasticity noted on urethroscopy.
 The depth and density of fibrosis are difficult to determine
objectively.
 Ultrasound examination clearly can augment contrast-
enhanced studies and is accurate in determining the length of
narrow-caliber annularity .
obstructive voiding symptoms

 Abdominal pain.
 Continuous feeling of a full bladder.
 Frequent urination (frequency).
 Inability to urinate (acute urinary retention)
 Pain during urination (dysuria)
 Problems starting urination (urinary hesitancy)
 Slow urine flow.
 Urinary tract infection.
Treatment

 treatment options should be discussed with the patient, with

care taken to emphasize the anticipated outcome with regard to
potential cure.
➢ Dilation : The goal of this treatment, a concept that is
frequently forgotten, is to stretch the scar without producing
more scarring.
 If bleeding occurs during dilation, the stricture has been torn
rather than stretched, possibly further injuring the involved
area.
 urethral balloon-dilating catheters
➢ Internal Urethrotomy : Internal urethrotomy refers to any
procedure that opens the stricture by incising it transurethrally.
The urethrotomy procedure involves incision through the scar
to healthy tissue to allow the scar to expand (release of scar
contracture) and the lumen to heal enlarged
 The most common complication of internal urethrotomy is
recurrence of stricture. Less commonly noted complications
of internal urethrotomy include bleeding (almost always
associated with erections immediately after the procedure) and
extravasation of irrigation fluid into the perispongiosal
tissues.
 Urethral stents (removable or permanently implantable)
are another modality used in opposing the forces of wound
contraction after internal urethrotomy or dilation.
➢ Lasers : carbon dioxide, argon, KTP, Nd : YAG, holmium :
YAG, and excimer lasers.
➢ The ideal laser for use in the treatment of urethral stricture
disease is one that totally vaporizes tissue, exhibits negligible
peripheral tissue destruction, is not absorbed by water, and is
easily propagated along a fiber.
➢ Open Reconstruction : Excision and Reanastomosis. It has
now been demonstrated with certainty that the most
dependable technique of anterior urethral reconstruction is the
complete excision of the area of fibrosis, with a primary
reanastomosis of the normal ends of the anterior urethra.
➢ Grafts that have been successfully used for primary urethral
reconstruction are the full-thickness skin graft, the bladder
epithelial graft, the oral mucosal graft and the rectal
mucosal graft. Oral mucosal grafts as mentioned can be taken
from the cheek (buccal), the lip (labial), and the undersurface
of the tongue (lingual).Split-thickness skin grafts have been
used for staged anterior urethral reconstruction.
PELVIC FRACTURE URETHRAL
INJURIES
 Pelvic fracture urethral injuries are the result of blunt pelvic
trauma and accompany about 10% of pelvic fracture injuries.
 Although it is possible to totally disrupt the urethra with a
straddle injury, these injuries most commonly involve only the
bulbous urethra.
 Distraction injuries are for all intents unique to the
membranous urethra.
 Many injuries appear not to totally distract the entire
circumference of the urethra. Instead, a strip of epithelium is
left intact. In these patients, the placement of an aligning
catheter may allow the urethra to heal virtually unscarred or
with an easily managed stenosis.
Evaluation

 As with the repair of any stricture or stenosis, it is important to

define the precise anatomy of the pelvic fracture injury before
treatment is undertaken.
 this includes the depth, density, length, and location. In pelvic
fracture urethral distraction defects, the depth and density of
fibrosis are predictable.
 Although the location of the distraction injury has been
demonstrated to be an important factor in continence after
reconstruction, this information should be a factor only in
counseling of patients before the reconstruction and not in the
treatment approach. The length of the defect is an important
consideration and must be determined as precisely as possible.
Peyronie’s Disease

 Peyronie’s disease is a disorder in which scar tissue, called a

plaque, The plaque builds up inside the tissues of a thick,
elastic membrane called the tunica albuginea.
 The most common area for the plaque is on the top or bottom
of the penis. As the plaque builds up, the penis will curve or
bend, which can cause painful erections.
 Curves in the penis can make sexual intercourse painful,
difficult, or impossible.
 Peyronie’s disease begins with inflammation, or swelling,
which can become a hard scar.
 In most patients, reassurance is sufficient and a necessity.
 Most of the patients with Peyronie’s disease do not require
surgery.
 Peyronie’s disease was associated with Dupuytren disease.
 30% to 40% of men with Peyronie’s disease will also have
Dupuytren disease.
 Peyronie’s disease is also reported to occur in patients after
external trauma to the penis.
 Most patients with Peyronie’s disease demonstrate lesions
dorsally.
SYMPTOMS

 The presenting symptoms of Peyronie’s disease include, in

many patients, penile pain with erection; penile deformity,
both flaccid and erect; shortening with and without an
erection; plaque or indurated areas in the penis; and, in
many patients, erectile dysfunction.
 On physical examination, virtually all patients have either a
well-defined plaque or an area of induration that is palpable.
The plaque is usually on the dorsal surface of the penis.
 Spontaneous improvement in pain virtually always occurs as
the inflammation resolves.
Evaluation

 All patients must be evaluated with a medical history as well as a

detailed psychosexual history.
 Approximately one third of the patients will develop dystrophic
calcification in the plaque that can be demonstrated by
ultrasonography or plain radiography.
 The place for MRI in the evaluation of Peyronie’s plaque has not
been defined, nor has the place for vascular testing been clearly
defined. However, most investigators now would agree that in
patients who are to be operated on, vascular testing to stratify the
vascular parameters of erectile function is a necessity.
 Once all of the data have been assembled, individualization with
regard to the patient’s requirements, findings, and assessment is
imperative.
MANAGEMENT

 Medical Management:
➢ vitamin E , a tocopherol, is an antioxidant, 200 mg three times a
day for a 3-month course.
➢ tamoxifen, it is used at a dosage of 20 mg twice daily.
➢ colchicine was The patients were in the early phase of disease and
received colchicine at a dose of 0.6 mg three times a day. In that
study, diminished plaque size and improved penile curvature were
reported in approximately 50% of the patients.
➢ acetyl-L-carnitine, 1 g twice daily for 3 months .
➢ Intralesional injection of corticosteroids.
➢ The calcium antagonist verapamil intralesional injection.
➢ interferons as intralesional therapy.
Surgical Management

 For a patient to be a surgical candidate his disease must be stable

and mature.
 the signs of disease stability include resolution of pain and
stabilization of curvature or other deformity.
 Most investigators arbitrarily impose a 12- to 18-month period
from onset of disease.
 Indications for surgery include deformity that precludes
intercourse and/or erectile dysfunction that precludes intercourse.
 plication or corporoplasty techniques seem to preserve the
patient’s erectile function more effectively; however, excellent
results can be achieved with incision and grafting techniques.
 The use of a penile prosthesis for all Peyronie’s disease patients is
condemned.