Urethral Stricture

The term, urethral stricture, means that there is an abnormal narrowing affecting any part of the urethra. The urethra is that part of the urinary system that is responsible for taking urine out of the bladder to the outside. In females, this structure is found in a position just above the vagina, while in males, the urethra passes through the penis. When any part of this structure is affected by the abnormal narrowing described above, there will be an area of scar formation called fibrosis at the site of an injury or inflammation such that the tube is unable to expand and allow urine to flow out without hindrance. When any part of the urethra is not able to expand or distend with the passage of urine, discomfort is observed and there may be pain as the urine is passed. If it results from a recent injury, the sensation may be a painful one. This results from the fact that the area of fibrosis contracts and narrows that part of the urethra such that in order to pass urine when pressed, an extra effort needs to be made to force the urine through that narrowed part of the tube. This extra effort is often achieved by contracting the muscles of the abdominal wall so that more pressure can be generated to push out the urine. Urethral stricture is the most common cause of the retention of urine in sub-Saharan Africa. It is, therefore, a huge disease burden across all age groups and affects both males and females.

The causes of this condition vary. Some people are born with the condition in which case they are said to be victims of a congenital malformation. Most of the cases seen in the hospital, though, are due to various other causes, which we shall be discussing in the following paragraphs. The common issue that a child can be born with that will present as a urethral stricture will occur near the tip of the meatus, where it becomes a narrow opening that is described as a pinhole opening. This kind of stricture is tight, of course, barely visible to the ordinary person and consistent with a situation in which the child will spend a long time to fully empty a bladder full of urine, which is the common complaint the parents will describe.

The second of these features is a stricture that forms anywhere else in the urethra other than the meatus. The meatus is the very end of the urethra and is the external opening we usually see when we inspect the tip of the penis or the vagina. Urethral stricture can develop when that structure heals from any form of disruption due to the above conditions. These conditions lead to scar formation that ultimately contracts. Contraction like this causes narrowing and shortening of the urethra.

Other causes of this problem are attributable to various types of trauma. These may be injuries sustained from external forces and due to internal reasons. External causes of such injuries include blows delivered to the urethra during falls and while riding. Such external injuries tend to be common among workmen and drunks, who can fall astride manholes on roads or the sides of open drains as it’s far more likely in many of our towns and cities. Such injuries may not be obvious immediately until the affected person attempts to urinate and there is the appearance of blood at the tip of the penis.

Two weeks ago, we discussed the passage of hot implements into the male urethra by unskilled hands acting in an attempt to treat “woman’s disease”. The use of such instruments, which are often searing hot, is liable to cause intense burning of the urethra followed by healing with the formation of scar tissue and fibrosis. Such foreign body usage and the presence in some situations of a stone in the meatus can lead to the formation of urethral strictures. The presence of such a stone is known as urethral calculus. Finally, in women especially, the practice of douching causes a chemical variant of such urethral injuries that leads to narrowing. Mechanically, the pressure of a baby’s head during labour can cause damage to either the urethra or the rectum, with the former causing a stricture.

Other common causes of this condition occur after surgical procedures conducted within this tube such as in trans-urethral surgical procedures that will include the resection of an enlarged prostate through a scope. This ought to be discussed with the patient before the operation so that they are aware that complications like these can result. This is also true in situations involving any surgical repair of the vagina for a variety of reasons. These reasons will include repair following serious injuries such as in road traffic accidents, bedroom trauma, penetrating injuries and gunshot wounds. The effects are usually evident following operations performed for the repair of damage sustained by the vagina. Among the inflammatory reasons for urethral stricture are unique kinds of problems some of which we have already discussed. One of these causes is gonorrhoea either in the acute phase of the infection or in the chronic phase. The subsequent recovery from either phase often leaves scar tissue behind that narrows the urethra and perhaps shortens it as well. This is broadly called “woman’s disease” among locals, meaning that this is not a condition that was ever strange to local folks. Tuberculosis and bladder flukes, known as schistosomiasis, also cause such problems.

The diagnosis of this condition usually starts with taking the history of the patient. This is followed by a physical examination. In some cases, especially in males, the area of stricture can be felt through gentle examination. Further examination can be performed using an instrument under sterile conditions like a urethral catheter or a metal rod called a bougie. Either one will be arrested at the site of the obstruction. This can be followed by doing an ultrasound scan of the abdomen, which may show damage to the bladder, ureters and even the kidneys if the problem has persisted for a long time.

Also, there may be a large residual volume of urine even after normally passing urine. So that, within a short while, the bladder is full again and a fresh urge develops to urinate. Therefore, one common symptom of this condition is frequent urination. With specific urethra sonography, in which the scan can look through the urethra, the extent of the damage can be seen. The urine can also be obtained for culture and analysis so that the degree of associated urine infection can be determined. Lastly, a specialised x-ray examination involving the use of contrast called retrograde urethrogram will specifically diagnose the site and extent of the stricture. Any associated infection must be treated with appropriate medications.

Specific treatment also varies depending on what kind of instruments are available, the level of trained manpower in that hospital and the kind of presentation the patient exhibits, whether it is acute or chronic. In patients who are in urinary retention, as we described on this page about three weeks ago, it is important to relieve their obstruction to bring an end to their misery. Sometimes, this is successful in relieving the obstruction and urine can then flow through the pipe in a temporary measure. Sometimes, due to poverty or the fear of an operation, many men will use these devices for a long time and make do with changing the catheters at intervals. When this is unsuccessful, an emergency opening can be created into the bladder through the lower part of the abdomen and a tube placed through that opening. This allows urine to flow unhindered and bypasses the damaged urethra. Sometimes, the urethra can be dilated at intervals using bougies, which are designed to overcome the obstruction and allow urine to flow. These strictures can be single and short or single and long or multiple. Each type presents a different sort of challenge to manage it but the most reliable and definitive treatment of this condition is an open reconstruction of the urethra under anaesthesia.

Questions and answers

Dear doctor, a woman with three kids got the dreaded HIV/AIDS and the husband just divorced her. Some people are very dangerous indeed. What do you say to that, doctor? 080638 ****

Well, it is difficult to judge whether the woman is the dangerous party based on your comment or it is the man. Is the husband free of the disease and if not, did he transfer it to her or vice versa? You can be sure that there are many cases like this one across the country and the world. But official attitudes to this disease varies in different jurisdictions. One has seen women with HIV/AIDS threaten hospital staff to not disclose their condition to their spouses and vice versa. Without the guarantee of state protection, the hospitals sometimes keep quiet even though this ought to be a notifiable condition. There lies the real danger, and it cuts across all genders. There are lots of cases like this and it causes huge social repercussions in the end with lots of regret.

Dear doctor, please I have a medication in my chest cupboard that I bought in the United States with a lot of money to treat my chest condition. It cost me the equivalence of N75,000 and it expired last month. Do you think it is safe for me to use it at least through this month? That will afford me the ability to get some more. 080232****

Thank you for this question. An expiry date is a useful guide to the consumption of medications. If they are properly kept, they can be used up to three, six or even 12 months after the expiry date. If they are poorly stored, they can degrade significantly despite a valid expiry date. You can safely use this drug that you kept in your chest cupboard for your chest condition, although we do not know the name.

Dear doctor, your write-up on March 19 on the inability to pass urine was top-notch as usual. Thanks for the excellent public health education. In your article, you mentioned urethral stricture almost in passing. Could you kindly do a full explanation on it — the symptoms, its diagnosis, immediate/short term, non-surgical resolution, and or treatment available in Nigeria? I am 67 years old, male, and after reading a bit about it after your article was published, I got a little worried that some of the symptoms we attribute to prostatic enlargement may actually be from this stricture. We will appreciate it if you can, as usual, bring full enlightenment to this ailment on your page. Thank you and congratulations on 10 years of doing this wonderful public health education. Also, it seems your Twitter account has not been active since mid-2022. 080231****

Thank you very much for your comments, sir, and your support through the years. It’s been an enchanting ride. However, your questions/comments are always guaranteed to provoke a full-page article; it is by no means exhaustive, but this week, you do have many of your answers. Definitely, when a man presents with many of the features of urinary obstruction such as we have been talking about now for several weeks, an enlargement of the prostate is an alternative diagnosis to consider. Following that, it can always be confirmed or disregarded. As for the Twitter handle, most questions posted there are direct messages that I also respond to directly. It is active, but I do not regularly tweet.

Dear doctor, thank you so much for your essay of last week where you talked about borderline personality disorder. It was just as if I was reading a running commentary about my sister-in-law. She is 34 years old with two children for my elder brother. When people discuss something that makes them laugh, she is annoyed by it. When the issue should cause annoyance, she is very angry. And when we are sitting like a family to watch, let’s say a programme like Big Brother, she stays away, will not participate in discussions about it and finds the flimsiest excuses to complain. We used to think that she is just different and maybe a little spoilt, but now, I can appreciate that she may be mentally ill. What should we do about this? Thank you.               080231****

Thank you very much for your comments and questions. They are a special breed of people who are never wrong in their own eyes. They do not see what they do to others but are extremely sensitive to real or imagined slights from people around them. As far as they are concerned, they represent the very best of human behaviour. It is a difficult situation to have to deal with and I sympathise with your family.  First, you have to persuade her to understand that she has a health problem which is very, very difficult. Then you should take her to see a clinical psychologist. From that point, it will be known whether what she requires is psychological help alone or a psychiatric evaluation.

Dear doctor, thank you for all the health education you have been providing. May the Lord bless you and your family. I would like to know the pre-marital medical tests to be done by intending couples (man and woman).

While the tests we will share with you here are not necessarily exhaustive, they are the usual, more common tests that would often be recommended for an intending couple to undertake. They are as follows:

1)     Blood grouping to determine compatibility status

2)     Genotype, which is just as important as the above for the wellbeing of your offspring

3)     Venereal disease status such as syphilis and gonorrhoea

4)     HIV/AIDS status

5)     Hepatitis status, especially for Hepatitis B and C.

Dear doctor, please my left finger, the one for the wedding ring, has been giving me severe pain as if an object dropped on it. I have used some pain relievers but I have seen no changes. At times, if I want to fold my hand, it will shock me seriously. Please what do you think I can do? I may not feel it at times, but when I feel it, it is very painful. Please help.

If you have such severe pain that also shocks you some of the time, it is concerning. You said the pain is as if an object dropped on it which indicates that there is no such injury and there is no indication either of a swelling. A lot of times, this sort of injury will be from a damage to a nerve which is most probably what you are dealing with. Such an injury will arise from the back of the elbow joint where the nerve is in physical contact with the bone. As a result, you should see a physician for examination who may also ask you to see a neurologist depending on what their findings are. That way, you can get the necessary treatment.

Dear doctor, so diabetes damages kidneys? Actually, does that make a patient to go through dialysis? Is it only kidneys that are damaged by diabetes?  080655****

Good evening to you, sir. When diabetes is poorly managed such that the control of the blood sugar level is poor, kidneys can suffer sustained damage over time. However, other organs can be in similar peril such as the blood vessels, the eyes, the brain, the skin and the heart. The immune system is also impaired very much.

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