Late Adults

URETHRAL STRICTURE

By Dr. E.E. Sowho

Stricture in medical sense means narrowing of a tubular passage in the human body usually resulting from damage or injury. The urethra on the other hand is the tubular passage through which urine flows from its reservoir in the body (urinary bladder) to the outside. The urethra is much longer in men than in women. In men, most of the urethra is lodged within the penis where it also serves as the passage for semen (sperm) during sexual intercourse. This dual role as well as the longer length of the male urethra predisposes men to urethral stricture (narrowing of the urethra) – a problem which is very rare in women.

When the urethra is narrowed, urine can no longer flow freely through the passage to the outside in the affected person. Urethral stricture is one of the two causes of obstruction to the flow of urine in men, the other being an enlargement of prostrate gland (the male organ sitting below the urinary bladder). While prostratic enlargement is confined to men above the age of 50 years, urethral stricture occurs mainly in young men- below the age of 50 years.

 

CAUSES

  1. Some children are born with urethral stricture although this is a rare condition.
  2. The narrowing when located at the tip of the penis may be caused by badly performed circumcision. Infection of a fresh circumcision wound may also lead to ulceration and subsequent narrowing at the tip of the penis.
  3. Various types of injury to the urethra may cause stricture. When a man falls astride a man-hole and sustains injury to the tissues near the scrotum or fractures the bone of the waist (fractured pelvis) following a major road traffic accident, the urethra may be injured.
  4. The use of certain instruments such as catheters or blunt metallic instrument in the course of medical treatment of a sick patient may cause damage to the urethra and result in stricture unless appropriate care is taken by the doctor in charge.
  5. The most important cause of urethral stricture in the developing countries however is GONORRHOEA. Unless treated early and with appropriate drugs, this infection damages the urethra and stricture may result some years after the infection has apparently cleared.

 

SYMPTOMS AND SIGNS

If a man under the age of 50 years has to strain before he can pass his urine, then the probability that he has a urethral stricture is very high. Apart from straining, the urinary stream may be split into two or more parts and it may be interrupted before the end of urination. For a while, after the patient has finished passing urine, he may discover that drops of urine continue to come out from the penis (terminal dribbling) leading to wetting of his pants.

Those with severe urethral stricture may suddenly discover that they are not able to pass urine despite an intense urge to do so (Acute retention). This very painful condition demands emergency hospital treatment. The retention may develop gradually over many weeks or months. The urinary bladder will be full of urine all the time in such patients and urine may escape from the tip of the penis without the patient being able to hold it. (chronic retention with over-flow).

When a doctor is consulted, he may be able to feel the portion of the urethra affected by stricture as a thickening along the penis. Special tests are needed to confirm the diagnosis. An X-ray of the urethra taken after injecting a special fluid into the urethra (urethrogram) will show the length and degree of the stricture.

COMPLICATIONS

  1. Infection is a common complication in patients with urethral stricture. Infections of the urinary passages itself can spread to and damage the kidneys or predispose to formation of solid concentrations (stones) along the urinary tract. Infection of the tissues around the urethra may lead to boils in the scrotal region.
  2. The obstruction to the outflow of urine caused by the stricture can cause a “back pressure” effect on the urinary bladder and the tubes linking it with the kidneys (ureters).  This “back pressure” effect causes the ureters to dilate and may destroy the kidneys when it is allowed to persist. This is one of the ways in which kidney failure can occur and it rapidly results in death.
  3. The straining to pass urine in stricture patients may cause hernia and piles.
  4. Infertility may occur in stricture patient (inability to make a woman pregnant). This is because the passage for the sperm is commonly blocked by the same infection causing the stricture. The sperm from those affected contains no spermatozoa hence their inability to make a woman pregnant.

 

TREATMENT:

There are two main ways a patient with stricture can be treated. Many stricture patients can be satisfactorily treated with regular (intermittent) dilation of the narrowed urethral passage. The procedure is painful hence it is better to have some form of anaesthesia (local or regional) before it is done.  This form of treatment can cause bleeding, creation of false urethral passage, and sometimes a dangerous form of infection of the patient’s blood stream called septicaemia but these are not common. Unfortunately, it is not all strictures that can be dilated. When this happens a temporary passage is often required in lower abdomen to allow urine flow out directly from the urinary bladder, through a rubber tube. Subsequently such a patient may require an operation to create a new urethral passage which is similar to the natural one. This operation is usually done in two (sometimes more) stages before it is completed.

 

PREVENTION

Africans are said to be more prone to forming hard scars and strictures, therefore the best thing is to prevent urethral stricture by observing the following rules:-

  1. Circumcision must be properly done and infection must not be allowed in the fresh wound.
  2. Medical treatment must be sort promptly when urethral injury occurs.
  3. Avoid sexual contact with people who are likely to have gonorrhoea – prostitutes and women with multiple sex partners.
  4. Use condom if you must engage in casual sexual intercourse.
  5. Consult a doctor early for appropriate treatment when you have gonorrhea. Gonorrhoea in this environment has become resistant to most of the drugs in the market; therefore do not waste time by buying drugs from chemist shops or native doctors. Delay in treatment increases the chance of developing urethral stricture.
  6. A man who discovers that he has gonorrhoea must also take his wife for treatment otherwise cure may be difficult to achieve as he is likely to be reinfected. Of course, either the man or his wife could have been the first to acquire the infection before transfer to the partner; so the question of who is right or wrong should not arise.

In conclusion, urethral stricture in most cases is a late complication of badly treated or untreated gonorrhoea and as the saying goes “prevention is better than cure”. However, when it occurs, cure is an achievable goal.