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LITERATURE
2.1.
spongiosum, which contains the urethra, whose diameter is 8-9 mm. these corpora
capped distally by the glans. Each corpus is enclosed in a fascial sheath (tunica
albuginea) and all are surrounded by a thick fibrous envelope known as Bucks
fascia. A covering of skin, devoid of fat, is loosely applied about these bodies. The
prepuce forms a hood over the glans.
Beneath the skin of the penis (and scrotum) and extending from the base
of the glans to the urogenital diaphragm is Colles fascia, which is continous with
Scarpas fascia of the lower abdominal wall.
The proximal ends of the corpora cavernosa are attached to the pelvic
bones just anterior to the ischial tuberosities. Occupying a depression of their
ventral surface in the midline is the corpus spongiosum, which is connected
proximally to the undersurface of the urogenital diaphragm, through which
emerges the membranous urethra. This portion of the corpus spongiosum is
surrounded by the bulbouspongiousus muscle. Its distal end expands to form the
glans penis. The suspensory ligament of the penis arises from the linea alba and
pubic symphysis and inserts into the fascial covering of the corpora cavernosa1.
The adult male urethra approximately 23-25 cm long. The urethra may be
further subdivided into five segments :
a. Posterior urethra
The posterior urethra begins as the prostatic urethra at the level of the bladder
neck and extends as a channel through the prostate, anterior to midline.
Prostatic urethra
The prostatic urethra ends distal to the verumontanum, which is a 0.5 cm
long protuberance found on the ventral wall of the urethra. The paired
ejaculatory ducts empty into the prostatics urethra at the level of the
verumontanum. There is internal urethral sphincter. The prostate it self is
closely adherent to the posterior aspect of the anterior pubic arch at the
stroma5.
b. Anterior urethra
The anterior urethra is urethra which is cover by corpus spongiosum3.
Bulbous urethra
The bulbous urethra commences proximally at the level of the inferior
aspect of the urogenital diaphragm, where it pierces and courses through
the corpus spongiosum. The urethral remains eccentrically dorsally
positioned in the corpus spongiosum throughout the bulbous urethra.
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Pendulous urethra
The pendulous urethra is closely adherent to the corporal bodies dorsally.
Fossa navicularis
Fossa navicularis is the distal most portion of the anterior urethra which is
surrounded by the spongy tissue of the glans penis5.
2.2.
Physiology
The bladder neck interconnects the bladder with the posterior urethra
below which is contains the internal urethral sphincter. The internal urethral
sphincter keeps urine out of the bladder neck and also out of the posterior urethra
which leads off from the bladder neck immediately. But its main function is to
prevent
retrograde
ejaculation
at
sexual
diaphragm contains the external urethral sphincter that is under the control of will.
It is this sphincter that is opened when there is the need to micturate.
Urethra is used for both reproductive and urinary functions. It
passes semen from its prostatic part into the spongy part. When ejaculation is to
take place in the male, semen is released from the seminal vesicle or from the tail
of epididymis into the prostatic urethra in the first phase of ejaculation. The
second phase is controlled by the bulbospongiosus muscle which assists the penile
urethra to release forcibly its contained semen to the outside, and in reproductive
capacity.
2.3.
Injuries Of Urethra
Urethral injuries are uncommon and occur most often in men, usually associated
with pelvic fracture or straddle type falls. They are rare in women because female
urethra have shorter length and its greater mobility in relation to the pubic arch1,5.
2.3.1. Injuries to the posterior urethra
a.
Etiology
Blunt trauma causes the vast majority of injuries to the posterior urethra is
pelvic fracture. Some causes of pelvic fracture are motor-vehicle accident or
b.
c.
Signs
Blood at urethral meatus
Suprapubic tenderness
The presence of pelvic fracture
Symptoms
Lower abdominal pain
Inability to urinate
History of crushing injury to the
pelvis
d.
Classification
Classification of blunt posterior urethral injuries was described by Colapinto &
McCallum 1977. This classification uses radiographic findings to sort blunt
urethral injuries by type5 :
Type I
Rupture of the puboprostatic ligaments and surrounding periprostatic
the perineum.
Type IV
Bladder neck injury with extension into the urethra
Type V
Pure anterior urethral injury
Symptoms
Blood at urethral meatus
History of fall or history
of
instrumentation
hematoma/butterfly Local pain into the perineum
hematoma
Rectal examination :
A normal prostate
d. Classification
The classification system for anterior urethral injuries was described by
McAninch and Armenakas. This classification is based upon radiographic findings
:
Contusion
Clinical features suggest urethral injury, but retrograde urethrography is
normal.
Incomplete disruption
Urethrography demonstrates extravasation, but urethral continuity is partially
maintained. Contrast is seen filling the proximal urethra or bladder.
Complete disruption
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Urethral Stricture
The term urethral stricture refers to anterior urethral disease, or a scarring
process involving the spongy erectile tissue of the corpus spongiosum. Urethral
strictures are fibrotic narrowing composed of dense collagen and fibroblasts
which usually extends through the tissue of the corpus spongiosum and into
adjacent tissue. In contrast, posterior urethral strictures is an obliterative process
in the posterior urethra that has resulted in fibrosis and is generally the effect of
distraction in that area caused by either trauma or radical prostatectomy.
2.4.1. Epidemiology
Urethral stricture incidence increase gradually with increasing age, and
most often in men. In non industrialized countries, urethral stricture is more
commonly infectious or inflammatory in origin.
2.4.2. Etiology
Etiology of urethral stricture divided into congenital urethral stricture and
acquired urethral stricture. Congenital urethral stricture is uncommon in infant
boys. Urethral strictures can result from inflammatory, ischemic, or traumatic
processes. Most acquired strictures are due to infection or trauma. Although
gonococcal urethritis is seldom a cause of stricture today, infection remain a major
cause particularly infection from long-term use of indwelling urethral catheters.
Large catheters and instruments are more likely than small ones to cause ischemia
and internal trauma. External trauma, for example, pelvic fracture can partially or
completely sever the membranous urethra. Straddle injuries can produce bulbar
strictures.
2.4.3. Patofisiology
In general, a urethral stricture is a fibrotic process with varying degrees of
spongiofibrosis that results in poorly compliant tissue and decreased urethral
lumen caliber. The normal urethra is a lined mostly by squamous epithelium.
Beneath the basement membrane there is connective tissue layer of spongiosum
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rich in vascular sinusoids and smooth muscle. The connective tissue composed of
mainly fibroblast and an extracellular matrix that contain collagen, proteoglycans,
elastic fibers and glycoproteins.
The most dramatic histologic changes of urethral strictures occur in the
connective tissue. Strictures are the consequence of epithelial damage and
spongiofibrosis. After trauma, the epithelium became ulcerated and covered with
stratified columnar cells. The stricture itself was noted to be rich in myofibroblast
and giant multinucleated cells. Both were felt to be related to stricture formation
and collagen production. An increase in collagen result in fibrosis.
Based on level narrowing of urethral lumen, urethral stricture divide into 3 type :
Mild
: If the occlusion is less than 1/3 diameters of urethral lumen
Moderate : If the occlusion between 1/2 to 1/3 diameters of urethral lumen
Severe
: If the occlusion is more than 1/2 diameters of urethral lumen
2.4.4. Classification of urethral stricture
Note :
A. Mucosal fold
B. Iris constriction
C. Full-thickness involvement with minimal fibrosis in the spongy tissue
D. Full-thickness spongiofibrosis
E. Inflamation and fibrosis involving tissue outside the corpus
spongiosum
F. Complex stricture complicated by a fistula. This can proceed to the
formation of an abscess, or the fistula may open to the skin or the
rectum.
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(or
both)
will
demonstrate the location and the extent of the stricture. Sonography has
also been a useful method of evaluating the urethral stricture. Urethral
fistula and diverticula are sometimes noted. Vesical stones, trabeculations,
or diverticula may also be seen.
d. Instrumental Examination
Urethroscopy allows visualization of the stricture. Small caliber
strictures prevent passage of the instrument through the area. Direct
visualization and sonourethrography aid in determining the extent,
location, and degree of scarring. Additional areas of scar formation
adjacent to the stricture may be detected by urethroscopy.
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repeated if the stricture recurs and (3) it is very safe, with few
complications.
c. Internal Urethrotomy
Internal urethrotomy is any procedure that opens the stricture by
incising it transurethrally. This procedure involves incision through the
scar to healthy tissue to allow the scar expand (release of scar contracture)
and the lumen to heal enlarged. Internal urethrotomy separate the scarred
epithelium so that the healing occurs by secondary intention. In healing in
the secondary intention, epithelialization progreses from the wound edges.
As it progress from the wound edge, epithelialization slows. In an effort to
aid epithelialization, nature invokes the forces of wound contraction.
Wound contraction closes the wound defect and limits the size of the area
that require epithelialization. If epithelialization progresses completely
before wound contraction significantly narrows the lumen, the internal
urethrotomy may be a success. If wound contraction significantly narrow
the lumen before completion of epithelialization, the stricture has reccured.
Predictor success is the extent of luminal narrowing, the narrower the
percent of narrowing, the worse the outcome.
Complication of internal urethtotomy are recurrence of stricture,
bleeding, extravasation of irrigation fluid into the perispongiosal tissues,
fistula between the corpus spongiosum and the corpora cavernosa.
The data shows the strictures at the bulbous urethra that are less
than 1,5cm in length and not associated with dense, deep spongiofibrosis
can be managed with internal urethrotomy.
d. Surgical reconstruction
If urethrotomy under direct vision fails, open surgical repair should
be performed. Short strictures (<2cm) of the anterior urethra should be
completely excised and primary anastomosis done. If possible, the
segment to be excised should extend 1 cm beyond each end of the stricture
to allow for removal of any existing spongiofibrosis and improve
postoperative healing.
Strictures >2cm in length can be manage by patch graft
urethroplasty. The urethra is incised in the midline for the full length of the
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strictures plus an additional 0.5 cm proximal and distal to its end. A fullthickness skin graft obtained preferably from the penile skin or buccal
mucosa and all subcutaneous tissue is carefully removed.the graft is then
tailored to cover the defect and meticulously sutured into place.
Strictures involving the membranous urethra ordinarily result from
external trauma and present problems in reconstruction. Most can be
corrected by a perineal approach with excision of the urethral rupture
defect and direct anastomosis of the bulbar urethra to the prostatic urethra.
2.4.8. Prognosis
A stricture should not be considered cured until it has been observed for
at least 1 year after therapy, since it may recur at any time during the period.
Urinary flow rate measurements and urethrograms are helpful to determine the
extent of residual obstruction.
2.4.9. Complication
Complication include of chronic prostatitis, cystitis, chronic urinary
infection, diverticula, utherocutaneus fistulas, periurethral abscesses, and urethral
carcinoma. Vesical calculi may develop from chronic urinary stasis and infection.
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