How to treat urethral stenosis

Urethral stenosis is most likely caused by urethral obstruction due to urinary tract infection, or it may be caused by abnormal renal function, so patients should check the cause of the disease before receiving treatment. Generally, urethral stenosis can cause pain during urination, and redness and swelling of the genitals. I hope that patients can receive timely treatment for this condition.

Disease treatment

Treatment principles

1. Actively treat urethral and surrounding infections;

2. To restore the urethra's urination function and restore the anatomical continuity and integrity of the urethra;

3. Avoid new complications during treatment;

4. Patients with chronic renal insufficiency undergoing cystostomy;

5. If there is urethrorectal fistula, colostomy should be performed first;

Nonsurgical treatment

Non-surgical treatment mainly relies on urethral dilation. Even in cases after surgical treatment, dilation should be performed regularly to prevent re-stenosis. Urethral dilation should not be performed when there is acute inflammation of the urethra and should be performed under good anesthesia and strict aseptic conditions. Avoid using violence when expanding. If necessary, use a finger to guide in the rectum to prevent penetration into the false passage or even the rectum. The expansion must be done gradually from the smaller probe to the larger probe, and you must avoid being impatient. Too rapid expansion can easily lead to laceration of the urethral wall, followed by scar formation and aggravation of stenosis. Generally, it is best for men to expand to F24. After each urethral dilation, the urethra becomes congested and edematous. It will take about 2 to 3 days to disappear, so it is not advisable to continue expanding within 4 days. The second interval usually starts from about 1 week and gradually extends. Injecting urethral instillation solution through the urethra can prevent the recurrence of urethral stricture. It has the effect of soft expansion. Physical therapy methods such as audio and iodine ion penetration can accelerate scar softening and consolidate the effect of expansion.

Surgery

(1) Treatment of posterior urethral stenosis: The treatment of posterior urethral stenosis after urethral injury should be continued for 3 to 6 months. The following surgical methods can be selected according to the extent of the injury: 1) Internal urethrotomy (optional): Use a urethral scalpel (cold knife) or laser to cut the scar at the narrow area, expand the inner diameter of the urethra, and then place a catheter. It is suitable for patients with shorter stenosis segment (<1cm) and mild scar. If the second internal incision is not effective, other treatment methods should be used. 2) Urethral anastomosis (recommended): Make a perineal incision, remove the stricture and scar, and anastomose the two ends of the urethra. It is suitable for membranous urethral strictures with a stricture segment of less than 2 cm. Posterior urethral strictures with longer stricture segments can be treated with urethral anastomosis by separating the corpus cavernosum septum, resecting the lower edge of the pubic bone, or resecting part of the pubic bone. During the operation, the scar should be removed as much as possible and the two ends of the urethra should be sutured without tension. Suprapubic cystostomy is very useful for draining urine and finding the proximal urethra during surgery. 3) Urethral dragging (optional): It is suitable for patients who cannot undergo urethral anastomosis. After the stricture of the urethra is removed, the distal urethra is freed and dragged appropriately over the proximal stricture segment and fixed to the abdominal wall or fixed to the bladder with a traction line. The disadvantage is that it can cause penis shortening and curvature of the penis during erection.

4) Urethral replacement surgery (optional): for urethral stenosis or atresia in longer sections. The urethral defect was repaired with pedicled flap and free graft.

Ⅰ. Pedicle flap: commonly used is the penis and perineum skin. The flap needs a good blood supply; hair, stones, and diverticulum formation are complications. The long-term incidence of urethral restenosis is still high.

Ⅱ. Free grafts: Various autologous mucosa, skin, and tissue engineering materials (decellularized matrix) are suitable for long-segment urethral reconstruction.

(2) Treatment of anterior urethral stenosis: The most appropriate time to treat stenosis after urethral injury is 3 months after the injury. Short-segment anterior urethral strictures (<1 cm) involving the corpus cavernosum, especially those located in the bulbar region, can be treated with endoscopic transurethral incision or urethral dilation (recommended). For patients with dense anterior urethral strictures involving the corpus spongiosum or those who are refractory to endoscopic transurethral incision or urethral dilation, open urethroplasty is required (recommended). Because the effectiveness of repeated use of these two treatments for patients who do not respond to endoscopic transurethral incision or urethral dilation is very low and the medical economic benefits are very poor, repeated incision may also cause patients to eventually need more complex urethroplasty. For urethral strictures less than 2 cm in the bulb, scar excision and anastomosis is a more suitable treatment method (recommended), with a success rate of up to 95%. However, for penile urethra and long bulbar urethra strictures (>2cm), simple end-to-end anastomosis is not recommended because it can cause erectile dysfunction and pain. For such patients, alternative urethroplasty using a transfer flap or free graft is recommended (recommended). Urethral stenting is not recommended for patients with traumatic urethral strictures[88](not recommended). Patients with urethral stricture who fail non-surgical treatment can choose appropriate surgical treatment. There are many surgical treatment methods, and the choice depends on the doctor's experience, the patient's stenosis and medical conditions.

1.Urethra incision is suitable for cases of urethral stenosis. It is more common in patients with balanitis, partial penile amputation or after hypospadias repair. A longitudinal incision can be made on the ventral side of the external urethral opening to form a mild hypospadias. The urethral mucosa on both sides of the incision is sutured to the skin of the glans penis to stop bleeding.

2. Internal urethrotomy: If the urethral stricture is very short or even a membranous stricture, the stricture ring can be cut open with a special cold knife under direct vision of the urethra. The ureterotomy can be performed using a thin ureteral catheter as a guide. If necessary, an electric knife can be used to remove excess scar tissue. If the narrow posterior urethra is completely blocked but not long, the bladder can be cut open and a finger can be used as a guide inside the bladder to chisel through it with an electroresectoscope or urethral probe. Then a resectoscope is inserted to remove the scar and create a channel. A urinary catheter is then placed in place for a long period of time (20 days or longer) to allow for healing. Some people also advocate leaving several thin silicone tubes in the urethra for 3 months after the operation. When the patient urinates, urine is released from the gaps in the silicone tubes, which also play a role in water expansion and achieve better results. For multiple long-segment urethral strictures, if an Otis endoscopic incision can be inserted, endoscopic incision should be performed. The depth of the incision can be controlled.

3. In cases where internal incision cannot be performed for urethral stricture resection and re-anastomosis, a suitable incision should be selected to remove the stricture segment of the urethra and the surrounding scar tissue under good exposure, strictly stop bleeding, and use absorbable sutures to perform eversion suture of the two ends of the urethra under tension-free conditions. The wound should be drained thoroughly and the catheter should be retained for about 2 to 3 weeks after surgery. When retaining a urinary catheter, a silicone catheter with less irritation must be used. For posterior urethral stenosis, an abdominal suprapubic incision can be chosen. If necessary, part of the pubic symphysis can be removed to achieve good exposure. The bulbar urethra can be accessed through a transperineal arcuate or straight incision. During surgery, damage to surrounding normal tissues should be minimized to avoid more scars and impotence after the operation. In order to reduce the tension on the anastomosis, the distal urethra can be freed, even directly reaching the coronal sulcus. However, the proximal urethra should not be left free for too long. If the posterior urethral stricture resection and anastomosis are difficult, a long straight needle can be used to perform anastomosis through the abdominal perineal incision. Alternatively, the distal urethral stump can be fixed to the catheter with a gut thread and pulled into the bladder to align the two ends. The catheter can then be fixed as a stent to achieve the purpose of alignment.

4. Stricture urethrotomy is suitable for penile urethral stenosis or long urethral stenosis that is difficult to repair in one stage. The stricture is opened or removed and a stoma is made at the distal and proximal ends of the urethra to form a hypospadias. After 3 months, repair was performed according to the hypospadias. Urethrocutaneous fistula may often occur if a primary resection and re-anastomosis is performed for penile urethral stenosis. Posterior urethral strictures that are difficult to repair can also be cleared through the perineum and then a perineal or scrotal skin flap can be dragged into the channel and sutured to the bladder neck to form a perineal-shaped hypospadias, which can then be repaired in a secondary stage.

5. The defective urethra during urethroplasty can be repaired with the own bladder mucosa or pedicled bladder flap. Repair with pedicled flap and/or medium-thickness skin graft. 6. Urinary diversion surgery Generally, urethral stricture surgery requires a cystostomy to drain urine to make the surgery successful. Patients with failed surgery can maintain a cystostomy pending reoperation or as a permanent treatment. Urethral stricture surgery is a difficult procedure. Adequate preparation must be made before surgery, the surgical plan must be accurately designed, and regular dilation and follow-up are required to achieve good results. The common complications after surgery include recurrence of stenosis, urinary fistula formation, impotence, and urinary incontinence.

Postoperative care: A urinary catheter is left in place for 1 to 2 weeks after simple endoscopic incision. For other surgical procedures, a urinary catheter is usually left in place for 3 to 4 weeks after surgery. The time to remove the cystostomy is determined based on urination conditions. Encourage patients to drink plenty of water and use antibiotics appropriately.