It was a retrospective and descriptive study conducted in the urology division of Yalgado Ouedraogo University Teaching Hospital from October 2009 to September 2014. Sixty three (63) male patients with anterior urethral stricture disease were included. All the patients have their diagnosis confirmed by voiding retrograde cystourethrogram (VCUG) or during surgical intervention. Anterior urethral stricture constitutes 41.1% of all urethral stricture. Hospital prevalence was 4.2%. Patient average age was 50.5 years. Dysuria and urinary retention were the major complaints representing respectively 66.7% and 33.3%. The infectious cause of urethral stricture was 71.1% of cases, followed by iatrogenic and traumatic causes with respectively 17.4% and 11.1% of cases. Voiding retrograde urethrocystogram (VCUG) was the only diagnostic procedure. Single urethral stenosis of the anterior urethra was about 88.8% while multiple stenosis constituted about 11.2%. Bulbar urethral stricture was the major location for the stenosis. Urine analysis was performed on 82.5% patients and ruled out urinary infections in 69.2% of cases with identification and isolation of Escherichia Coli in 77.7%. Majority of patients (61.9%) had open surgery of which 39.7% had end to end resection and anastomosis. Dilatation constituted 33.3% of treatment of the stricture of the anterior urethra. No endoscopic treatment was registered. At the removal of the catheter, all were successful but with time, the success rate was 87% at 6 months, 89.7% at 12 months, 85.2% at 18 months 63.1% at 24 months.
Urethral stricture is a permanent reduction of the lumen of urethra, or even the complete obliteration of its canal, which reduces the urinary flow from the bladder to the exterior whatever the level and the etiology of the stricture. Anterior and posterior urethra’s strictures are distinguished. The anterior part of urethra goes from the end of the membranous portion to the urethral meatus. It can be subdivided into bulbar and penile urethra. The symptomatology of urethral stricture is univocal and represented by dysuria or urinary bladder retention. Infectious aetiologies are decreasing in developed countries compared to traumatic and iatrogenic aetiologies [
It was a retrospective and descriptive study in the urology division of Yalgado Ouedraogo University Teaching Hospital from October 2009 to September 2014. This study included all patients with anterior urethra stricture only confirmed by retrograde urethrography/voiding cystouretrography (VCUG) or during the surgery with a complete medical record. The patients who have not complete medical records and VCUG were excluded to this study. Epidemiological, clinical and managements parameters are studied.
In the period of study, 153 patients present urethral stricture, from whom 63 have presented anterior urethral one. The strictures of the anterior urethra accounted for 41.1% of all urethral strictures. The hospital prevalence of these strictures among hospitalizations (1507 patients) in the urology department was 4.2%.
The mean age of the patients was 50.5 years with 3 and 81 years extremes.
Patients consulted on average after about 6 months. Dysuria and urine retention were the main reasons for consultation with respectively 66.7% and 33.3% of cases as presented on
Forty-two (66.6%) had a history of urinary tract infection.
Reasons of consultation | Frequency * (n) | Percentage * (%) |
---|---|---|
Dysuria | 42 | 66.7 |
Urinary bladder retention | 21 | 33.3 |
Urinary Burns | 15 | 23.8 |
Urinary frequency | 6 | 9.5 |
Blood at the meatus | 2 | 3.2 |
Urethral Fistulas | 2 | 3.2 |
*Some patients have presented one or more reasons of consultation.
Medical/Surgical history | Frequency (n) | Percentage (%) |
---|---|---|
Lower Urinary Tract Infection | 44 | 66.6 |
Schistosomiasis | 12 | 19 |
Urethral trauma | 9 | 14.2 |
Primary urethral repair | 8 | 12.7 |
Suprapubic cystostomy | 5 | 7.9 |
Urethral dilatation | 3 | 4.8 |
Hypospadias repair | 1 | 1.6 |
On the physical examination, 20 patients had physical signs which are distributed as follows in
Clinical signs | Frequency (n) | Percentage (%) |
---|---|---|
Hypogastric tenderness | 10 | 15.87 |
Urethral discharge | 8 | 12.7 |
Urethral and perineum sclerosis | 2 | 3.2 |
Complications | Frequency (n) | Percentages (%) |
---|---|---|
Suppurative peri-urethritis | 8 | 12.7 |
Orchiepididymitis | 6 | 9.7 |
Urethral Fistulas | 5 | 7.9 |
Prostatitis | 1 | 1.6 |
Bacteria | Frequency (n) | Percentage % |
---|---|---|
E. coli | 28 | 77.7% |
Klebsiella sp | 9 | 25% |
Pseudomonas aeruginosa | 2 | 5.5% |
Enterobacter cloacae | 1 | 2.7% |
Neisseria gonorrhea | 1 | 2.7% |
Staphylococcus saprophyticus | 1 | 2.7% |
The etiology of the anterior urethral stricture was infectious in 71.4% of cases, followed by iatrogenic and traumatic ones with respectively 17.5% and 11.1%. The urine analysis performed in 82.5% patients showed a urinary tract infection in 69.2% of cases and isolated E. coli in 77.7% of the cases, shown in
VCUG was performed in all patients. Stricture of the anterior urethra was unique in the majority of cases (88.8%) and multiple in 11.2% of cases. The bulbar seat was their favorite location. The length of strictures averaged 2.05 ± 0.7 cm.
・ Urethral stricture location
There were 29 cases of bulbar localization on the 63 (46.4%) and 25 (41.6%) of the penile sites.
・ The number of stricture
Strictures of the anterior urethra in our series were unique in 88.8% (n = 56)
Stricture location | Frequency (n) | Percentage (%) |
---|---|---|
Bulbar | 29 | 46.4 |
1/3 proximal penile urethra | 17 | 26.8 |
1/3 distal penile urethra | 6 | 9.5 |
Junction bulbar and penile urethra | 5 | 7.7 |
1/3 middle penile urethra | 2 | 3.2 |
Meatal | 2 | 3.2 |
Pan anterior urethral | 2 | 3.2 |
Total | 63 | 100 |
of cases and multiples in 11.2% (7 cases).
・ The length of the stricture
The length of the urethral stricture was less than 1cm in 23 cases. In the slices of 1 - 2 cm and more than 2 cm we noticed the same number of cases 16. The distribution of anterior urethral stricture cases according to their length has been shown in
Surgical procedure | Frequency (n) | Percentage% |
---|---|---|
Urethroplasties | 39 | 61.9% |
End to end anastomosis | 25 | 39.7% |
Mikalowsky repair technique | 6 | 9.5% |
Pediculated penile flap | 3 | 4.7% |
Bengt Johansen technique | 2 | 3.2% |
Meatotomy | 2 | 3.2% |
Scrotal flap | 1 | 1.6% |
Urethral Dilatation | 23 | 36.5% |
Definitive urinary diverting | 1 | 1.6% |
Total | 63 | 100% |
In emergency 25 patients underwent a suprapubic urinary derivation. 23 by cystostomy and 2 by suprapubic cystocatheterism.
After the emergency management, thirty-nine patients (61.9%) had prior received urethroplasty and 23 patients (36.5%) an instrumental treatment by dilatation.
The majority of patients (61.9%) had open surgery. 39.7% of them were urethrectomy and termino-terminal anastomosis. The instrumental dilatation was about 33.3% of the treatment of stricture of the anterior urethra. No endoscopic treatment had been recorded. After the urinary catheter removal we recorded a total success but over the time the rates were: 87% success at 6 months; 89.7% success at 12 months; 85.2% success at 18 months, 63.1% success at 24 months, 58.3% success at 36 months and 33.3% success at 48 months.
During the study period, the hospital prevalence of the anterior urethral stricture was 4.2% in the department. Retrospective study by Guiriansoro Z [
In Europe, Lumen N et al. [
In our study, dysuria and acute urinary retention were the most frequent reasons for consultation with respectively 66.7% and 33.3% of cases. In the literature, the first reason for consultation of the urethral stricture was dysuria [
Urinary tract infections were the medical history developed by the majority of patients, around 66.6% of cases. Infections were followed by traumatic urethral catheterism which accounted for 14.2% of the medical history. Mattiche H [
Bulbar localization was the most frequent in our study. We found 29 cases (46.4%) of bulbar strictures, 25 cases (39.5%) of penile strictures, 2 cases (3.2%) of meatus localization and 7 (10.9%) were multiple localizations on the anterior urethra. In West Africa, Akpo et al. [
We have identified 3 groups of etiology in our study: infectious, iatrogenic and traumatic. Our study showed a predominance of infectious etiologies (71.4%) followed by iatrogenic causes (17.5%). Traumatic etiology accounted for 11.1%. In our regions, the main etiologies of strictures of the anterior urethra are infectious. In Gabon Falandry [
However, Fleury [
The infectious origins are decreasing in African studies but remain one of the common causes of urethral stricture despite the existence and availability of antibiotics and the different means of sexual transmitted infections prevention.
The iatrogenic etiology accounted for 17.5% of the anterior urethral stricture etiologies in our study. In developed countries, urethral strictures are more likely to be of iatrogenic origin and could be explained by the fact that urologic endoscopy is a common practice in their context. Fleury [
Trauma to the anterior urethra represents about 10% of urogenital trauma. Compared to the lesions of the posterior urethra, these traumas rarely occur in a vital or polytraumatic context and are rarely associated with pelvic fractures. The majority in these cases involve blunt trauma, often affecting young people who are sexual active. From these results, it appears that traumatic etiology was not the main cause in the occurrence of anterior urethral stricture.
The penile urethra stricture corresponds to a phenomenon of fibrosis of the corpus spongiosum whose morphological and functional fate is difficult to predict. The surgical treatment of such lesions is difficult and calls for the general principles of wound healing. Reconstruction of the urethra in its penile portion appears easier than the treatment of proximal strictures or strictures of the bulbar urethra because it is more accessible. In our regions, open surgery is the most commonly used treatment of urethral strictures. The most common method used after urethroplasty in our study was urethral dilatation. Thirty-three percent of the patients had benefited of instrumental dilatation. These results showed a relative decrease in the rate of patients treated only with instrumental dilatation but this rate remains high because our patients treated with urethroplasty may have an ulterior instrumental dilation. We have not noticed either incidents or accidents and none deaths recorded in the immediate or postoperative period. However, at an average follow-up of 12.51 months, 9% of the patients did not have a good result. Ibrahim Ag et al. [
This difference could be explained by the diversity of follow-up delays. The short follow-up time of the patients was related to the non-respect of the appointments after leaving hospital by a large number of patients. All the patients whose strictures were 1 cm at most have obtained good results after 6 months of follow-up versus 85.7% for anterior urethral stricture with [1-2 cm] and 66.6% for those > 2 cm. However, our results remain superior to those of Guirassy et al. [
Anterior urethral stricture is relatively a frequent affection in our urology division. The stricture of the anterior urethra is a pathology of all ages but it’s more frequent in young’s. The most evocative sign is dysuria but urine retention and the complications such as urethral fistulas can constitute the reason for first consultation. The diagnosis remains based on the VCUG and other exploration techniques as uroflowmetry which is not available and is an important element in the postoperative follow-up. The VCUG allowed in all cases to locate the seat, the number of stenosis and to appreciate the length of the stenosis. Aetiologies are dominated by infectious causes with a high predominance of E. coli. Diagnosis at complications stage, poor exercise conditions and the inaccessibility of diagnostic and therapeutic means often make the management difficult. The therapeutic methods are multiple and the therapeutic choice depends on the location, the number and the length of the stricture. The treatment of anterior urethral stricture remains surgical in our context. The better management of urinary tract infections and urethral trauma should be reduced significatively the burden of urethral stricture in our setting.
There is no conflict of interest.
Yameogo, C.A., Ouattara, A., Kaboré, F.A., Ky, B.D., Bougayiri, A., Traoré, O. and Kambou, T. (2017) Male Anterior Urethral Stricture: Epidemiological Profile and Management at Ouagadougou University Teaching Hospital (Burkina-Faso). Open Journal of Urology, 7, 196-206. https://doi.org/10.4236/oju.2017.711023