CHAPTER II

LITERATURE

2.1.

Anatomy of Male Urethra

The penis is composed of two corpora cavernosa and the corpus

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.

Figure 1. Fascial planes of the lower genitourinary tract

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.

Figure 2. Segments of male urethra

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

level of the paired puboprostatic ligaments.

Membranous urethra
The membranous urethra is approximately 1 to 1.5 cm long, extending
between the prostatic apex and the proximal corpus spongiosum. There is
external urethral sphincter. The membranous urethra is the only segment of
the urethra that is unprotected by surrounding spongy tissue or prostatic

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.
10

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.

The lining membrane of male urethral consist of two membrane, such as :

a. Submucous membrane
The urethral submucosa contain connective and elastic tissue, smooth muscle
and the numerous glands of Littre, whose ducts connect with urethral lumen.
b. Mucous membrane
The urethral mucosa that transverse the glans penis is formed of squamous
epithelium. Proximal to this, the mucosa is transitional in type.
2.1.1. Vascular Supply
The penis and urethra are supplied by the internal pudendal arteries. Each
arteries divides into a deep artery of the penis, a dorsal artery of the penis and the
bulbourethral artery. These branches supply the corpus spongiosum, the glans
penis and the uretha1. Corpus spongiosum receives blood from the common penile
artery. The corpus spongiosum has a dual blood supply such as proximal blood
supply and a retrograde blood supply through the dorsal arteries as they arborize
in the glans penis2.
The superficial dorsal vein lies external to Bucks fascia. The deep dosal
vein is placed beneath the dorsal arteries. These veins connect with the pudendal
plexus which drains into the internal pudendal vein1.
The lymphatics from the deep urethra drain into the internal iliac
(hypogastric) and common iliac lymph nodes1.
2.1.2. Innervation
Most of the afferent fibers from the bladder and urethra course in the pelvic
splanchnic nerves. Pain fibers from the urethra course in the pelvic splanchnic and
pudendal nerves.
11

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

intercourse. The urogenital

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.

falls from the height and pelvic crush injuries5.

Mechanism of injury
Injury to the posterior urethra occurs when a shearing force is applied at the
prostatomembranous junction in blunt pelvic trauma. The prostatic urethra is
fixed in position because of the attachments of the puboprostatic ligaments.
Displacement of the bony pelvis from a fracture type injury thus leads to

c.

either tearing or stretching of the membranous urethra.

Signs and symptoms1
12

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

Perineal or suprapubic tenderness

Rectal examination :
- Large pelvic hematoma
- Prostate displaced superiorly
Urethrogram :
Shows the site of extravasation at the
prostatomembranous junction

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

hematoma stretch the membranous urethra without rupture.

Type II
Partial or complete rupture of the membranous urethra above the urogenital
diaphragm or perineal membrane. On urethrography, contrast material is seen

extravasating above the perineal membrane into the pelvis.

Type III
Partial or complete rupture of the membranous urethra with disruption of the
urogenital diaphragm. Contrast extravasates both into the pelvis and out into

the perineum.
Type IV
Bladder neck injury with extension into the urethra
Type V
Pure anterior urethral injury

2.3.2. Injuries to the anterior urethra

a. Etiology
Blunt injuries to the bulbous urethra are typically caused by straddle type
injuries (eg, motor vehicle accidents; bycycle accidents; falling astride onto a
fence, railing or saddle) or kicks to the perineum5. Straddle injury may cause
13

laceration or contusion of the urethra. Self instrumentation may cause partial

disruption1.
b. Mechanism of injury
The force contacting the perineum crushes the bulbous urethra up against the
inferior edge of pubic symphisis, leading to contusion or urethral laceration1,5.

Figure 3. Mechanism injury to the bulbous urethra

c. Signs and symptoms1

Signs
The perineum is very tender
A mass may be found
Perineal

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
14

Urethrography demonstrates extravasation with absent filling of the proximal

urethra or bladder. Urethral continuity is disrupted.
2.4.

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
15

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

Figure 4. Anatomy of anterior 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.
16

2.4.5. Clinical Finding

a. Symptoms and Signs
As the urethral lumen gradually strictures down, obstructive
voiding symptoms worsen and in an insidious pattern. Typical symptoms
include weak urinary stream, straining to void, hesitancy, incomplete
emptying, urinary retention, post-void dribbling and urinary tract
infections. Other fairly common symptoms can include urinary frequency,
urgency, nocturia, dysuria, or occasionally suprapubic pain.
Others symptoms are blood in the semen, bloody dark urine,
discharge from the urethra, pain in the lower abdomen, and pelvic pain.
Indurations in the area of the stricture may be palpable.
b. Laboratory Findings
If urethral strictures is suspected, urinary flow rates should be
determined. The patient is instructed to accumulate urine until the bladder
is full and then begin voiding. After the patients repeats this procedure 810 times over several days in a relaxed atmosphere. The mean peak flow
can be calculated. With strictures creating significant problems, the flow
rate will be less than 10 mL/s (normal 20 mL/s).
Urine culture may be indicated. The midstream specimen is usually
bacteria free, with some pyuria (8-20 WBC per high power field) in a
carefully obtained first a liquor of urine.
c. X-Ray Findings
Urethrogram or voiding cystourethrogram

(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.

17

2.4.6. Differential Diagnosis

Neurogenic bladder, bladder stone, bladder neck stenosis, urethral
stricture, urethral stone, urethral tumor, benign prostatic hyperplasia, prostate
carcinoma, prostatitis, meatal stenosis, phimosis, and paraphimosis.
2.4.7. Treatment
a. Dilation
Dilation of urethral strictures is not usually curative, but it fractures
the scar tissue of the stricture and temporarily enlarges the lumen. As
healing occurs, the scar tissue reforms. Dilatation may initially required
because of the severe symptoms of chronic retention of urine. The urethra
should be liberally lubricated with a water-soluble medium before
instrumentation. A filiform is passed down the urethra and gently
manipulated through the narrow area in the bladder. A follower can then be
attached and the area gradually dilated to approximately 22F. A 16 F
silicone catheter can then be inserted. If difficulty arises in passing the
filliform under the direct vision.
An alternative method of urethral dilatation employs Van Buren
Sounds. First, a 22F sound should be passed down to stricture site and
gentle pressure applied. If this fails, a 20F sound should be used. Smaller
sounds should be used with care, because they can easily perforate the
urethral wall and produce false passages. Bleeding and pain are major
problems caused by dilatation.
b. Urethrotomy under endoscopic direct vision
Lysis of urethral strictures can be accomplished using a sharp knife
attached to an endoscope. The endoscope provides direct vision of the
stricture during cutting. A filiform should be passed through the stricture
and used as a guide during lysis. The stricture is usually incised
circumferentially with the multiple incisions. A 22f should pass with ease.
A catheter is left in place for a short time to prevent bleeding and pain.
Result of this procedure have been satisfactory in short term follow up in
70-80% of patient, but long term success rates are much lower. The
procedure has several advantages : (1) minimal anesthesia is required- in
some cases, only topical anesthesia combined with sedation; (2) it is easily
18

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
19

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.

20