The urethra is the tube that carries urine from the urinary bladder, where it is stored, to the outside.
In the male it is a much longer duct and it crosses the prostate gland, with a curved morphology. In women it is a shorter and more accessible duct.
Obstructive problems of the urethra, called urethral strictures, are very often confused with obstructive growth of the prostate, a condition much more frequent in relation to the natural aging of men. However, the correct differentiation of the two processes is vital because the treatment is totally different.
The abnormal positioning of the end of the urethra, usually hypospadias, the meatus or place where urine exits to the outside, is a common congenital anomaly in the newborn child that must also be surgically corrected.
What is urethral stricture?
It is a narrowing of the urethral canal that causes difficulty in urinating or, at least, in completely emptying the bladder, which in the long term will cause urinary tract infections, incontinence or leakage, a loose and short stream, a feeling of urgency and increased frequency of urination.
As time goes by, the situation may worsen and lead to the destruction of the bladder muscle after years of working under high pressure, which may cause inability to urinate (chronic urinary retention), urine ascending to the ureters or kidneys from the bladder and irreversible renal failure, even if the patient feels perfectly well and urinates comfortably.
Causes of urethral strictures
The cause of urethral stricture can be congenital (from birth), traumatic, infectious, due to manipulation of the lower urinary tract (catheters, transurethral surgery…), inflammatory and even unknown.
Xerotic Balanitis Obliterans (BXO), a condition of probable autoimmune cause and that at the beginning is confused with phimosis or narrowing of the foreskin and that ends up narrowing the entire urethra, deserves special mention.
Urethral strictures are not exclusive to men, contrary to what some doctors believe due to their different anatomy, and this causes many women to go undiagnosed and untreated.
What treatment does urethral stricture require?
Urethral stricture is always treated surgically. In selected cases of congenital cause, short length and without fibrosis, an endoscopic urethrotomy can be attempted, which is minimally invasive and easy to perform but with a success rate of at most 40% in these favorable cases.
In other cases, the treatment is open surgery. Depending on the cause, its location and appearance, one can choose to perform exeresis of the narrow urethral segment and a termino-terminal anastomosis (cutting the diseased area and rejoining the ends), not recommended if the length is greater than 1-1.5 cm to avoid incurvation of the penis in erection, or opt for augmentation or substitution urethroplasty with skin flaps or free grafts.
Unless it is possible to perform a termino-terminal urethroplasty, we usually opt for buccal mucosa grafts (from inside the patient’s mouth), with excellent tolerance, the patient is eating the next day, and a very good viability of the mucosa in the urethral bed.
In the event that replacement of the diseased urethra is required (for example, in a BXO), we perform surgery in two stages: first we remove the diseased urethra and place the buccal mucosa graft in the site, and after 4-6 months the patient is operated on again to close the new urethra and give it a tubular conformation.
The patient’s recovery is usually rapid and the hospital stay does not usually last more than 2 or 3 days, although the bladder catheter is maintained, depending on the technique used, for up to three weeks.
Subsequently, it may be necessary to perform outpatient urethral calibrations for a period of time to check that the urethra does not narrow again. We do not recommend urethral dilatations as definitive treatment for male urethral strictures, but those performed after surgery can help the healing process and prevent restenosis; they are only performed in selected cases, hence the importance, once again, of individualizing the treatment.
In female urethral strictures, initial dilatations can be attempted and, depending on the result, surgical intervention can be considered in case of recurrence.
In terms of results, the success rate is variable depending on the characteristics of the stricture, but is close to 85-90%.
What is hypospadias?
As mentioned above, it is an abnormal position of the end of the urethra in the penis, visible in up to 5 out of every 1,000 males at birth. In this case the urethral meatus is located below the glans penis, the shaft of the penis or even more proximal, accompanied by a “downward” incurvation of the penis.
Generally, it is not accompanied by urethral stricture so the child can urinate without difficulty, but early surgical correction is advised (between 3 and 18 months of age) to avoid the psychological problems associated with an abnormal looking penis.
There are many surgical techniques to correct the position of the urethral meatus and penile incurvation, depending on the severity of the process.
Final Conclusions
The first thing to do is to make an accurate diagnosis of symptoms that can be confused with a prostate condition in men or a problem of recurrent urinary tract infections or painful bladder in women.
The choice of the most appropriate surgical technique for each patient is fundamental, as well as rigorously informing both the disease and the technique to be used and its repercussions. Urethral surgery is technically demanding and requires years of practice to be performed with guarantees.