Laporan Kasus

Striktur Uretra

Oleh:
Jim Christover Niq, S.Ked
04054821517072

Pembimbing:
dr. H. Marta Hendry, SpU

BAGIAN ILMU BEDAH

RUMAH SAKIT Dr. MOH. HOESIN PALEMBANG
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
2015

HALAMAN PENGESAHAN

Presentasi Kasus yang Berjudul:

Striktur Uretra
Oleh
Jim Christover Niq, S.Ked
04054821517072
Telah diterima sebagai salah satu syarat dalam mengikuti Kepaniteraan Klinik Senior
(KKS) di bagian Ilmu Bedah Rumah Sakit Dr. Moh. Hoesin Palembang Fakultas
Kedokteran Universitas Sriwijaya periode 24 Agustus-30 Oktober 2015.

Palembang, Oktober 2015

Pembimbing,

dr. H. Marta Hendry, SpU

CASE REPORT

Urethral Stricture
Jim Christover Niq1, Marta Hendry2
1

Clinical Senior Clerkship, School of Medicine, Medical Faculty of Sriwijaya

University, Dr. Mohammad Hoesin General Hospital, Palembang
2
Department of Urology, School of Medicine, Medical Faculty of Sriwijaya
University, Dr. Mohammad Hoesin General Hospital, Palembang
Background: Urethral stricture is a narrowing of the urethra caused by
scarring, which functionally has the effect of obstructing the lower urinary
tract. This scar is due to fibrosis to the lumen of urethra and to a more severe
level the fibrosis will occur at corpus spongiosum. Urethral stricture is a
relatively common disease in men with an associated prevalence of 229-627
per 100,000 males, who are typically older men. Stricture incidence increases
gradually with increasing age, particularly for those older than 55.
Clinical Presentation: A male, 53 years old, came to emergency room General
Hospital DR. Mohammad Hoesin Palembang with the chief complain of
unable to urinate since 1 day ago. From physical examination, general
examination was normal. On suprapubic region, from inspection, bulging (+),
cystostomy (+), palpable pain (+). From the rectal touche, there is no enlargement
of prostate. Laboratorory test within normal limits. Urethrogram of this patient
show narrowing in urethral pars bulbosa
Discussion: Urinary retention is one of chief complain that caused by some
diseases. The symptoms of urinary retention are inability to urinate, pain or
discomfort in lower abdomen, bloating of the lower abdomen . In this case,
urinary retention is caused by urethral stricture pars bulbosa that can be seen in
urethrogram.
Conclusion: Urethral stricture is one of the disease that can caused the urinary
retention. Diagnosis should be considered in male patient that unable to urinate
especially if there is a history of urethritis, trauma, or prostate surgery.
Keywords: Urethral stricture, urinary retention.

Background

Obstruction in the urinary system, is a medical emergency because it can cause death
to the patient. Obstructions can occur in the upper urinary tract and lower urinary
tract. Obstruction of the upper urinary tract includes the kidneys and ureter with
clinical manifestations in the form of colic pain or anuria. While the lower urinary
tract obstruction in the bladder and urethra causing urinary retention.1
Urinary retention is the inability to secrete urine, so that the urine collected in the
vesica urinaria exceeded the maximum limit. One reason is due to narrowing of the
lumen of the urethra because of fibrosis in the walls, called urethral stricture. This
disease is a curative treatment with surgery, but not as rare as some surgical
techniques can cause high disease recurrence for patients. Thus the proper and
adequate treatment is necessary to avoid the risk of recurrence of urethral stricture
disease.1
Urethra is a tube that connects the vesica urinaria to the urinary meatus for removal
of fluids from the body. Urethra is divided into 2 parts, urethra pars posterior and
urethra pars anterior. Urethra is equipped with the internal urethral sphincter, which
is located on the border of the bladder and urethra, and external urethral sphincter,
which is located on the border of the urethra pars anterior and posterior. In female,
urethral length is about 3 to 5 cm long while in adult male, urethral length is about
23-25 cm.
Urethra pars posterior in male is divided into 2 parts which is urethra pars prostatica
(part of urethra that surrounded by prostate) and urethra pars membranacea. Urethra
pars anterior in male is part of urethra that wrapped by corpus spongiosum of penis.
Urethra anterior is consist of pars bulbosa, pars pendularis, fossa navicularis, and
external urethral meatus.
Urethral stricture is a narrowing of the urethra caused by scarring, which
functionally has the effect of obstructing the lower urinary tract. This scar is due to
fibrosis to the lumen of urethra and to a more severe level the fibrosis will occur at

corpus spongiosum. Urethral stricture is a relatively common disease in men with an

associated prevalence of 229-627 per 100,000 males, who are typically older men.
Stricture incidence increases gradually with increasing age, particularly for those
older than 55.2
Everything that injure the urethra can cause urethral stricture. Urethral stricture can
be divided into two based on the cause of stricture, which is congenital and acquired.
Most acquired stricture are due to infection and trauma. Historically, infection
urethritis was the leading cause of urethral strictures. However, with patient
education and improved diagnosis and treatment methods of sexually transmitted
diseases, infectious urethritis is now responsible for only a small proportion of cases.
Trauma represents a very significant etiology of urethral stricture disease. The
frequency of urethral damage based on location are: posterior urethral more than
95% associated with pelvic fractures. While the anterior urethral damage to the groin
up to the bulb of the urethra, caused by iatrogenic such as medical instruments, and
can also be caused by a foreign object. Urethral stricture bulbosa prevalent in men,
due to the injury of the perineum in a straddle position. Other mechanisms of
traumatic injury include pelvic fracture-related urethral injury (PFUI) and iatrogenic
injury secondary to instrumentation like catheter. Urethral stricture also can be
caused by lichen sclerosis, radical prostatectomy, and transurethral which are not
careful done.3
Urethra structure consists of a layer of mucosal and submucosal layer. Mucosal
lining of the urethra is a continuation of the mucosa bladder, ureter and kidney. The
mucosal consists of columnar epithelium, except in the area near the external orifice,
the epithelium is squamous and layered. On the sub mucosa consists of a layer of
vascular erectile. In the event of injury to the urethra, there will be healing
epimorfosis way, meaning that the damaged tissue is replaced by another network
(connective tissue) that is not the same as the original. This leads to loss of
connective tissue elasticity and narrowing urethral lumen, resulting in urethral
stricture.4

Based on the stage of narrowing of the lumen, urethra stricture divided into three
stage which is mild, moderate and severe. The mild stage is <1/3 diameter occlusion
of the lumen, the moderate is <1/3-1/2 diameter of the lumen, and the severe is >1/2
diameter of the lumen. In the severe level, sometimes palpable hard tissue in the
corpus spongiosum known as spongiofibrosis.5
The main symptoms of urethral stricture are those of obstructed and irritated
micturition, with increased urination time and a feeling of incomplete bladder
emptying, combined with increased micturition frequency and urgency. Chronic
urethral discharge can be found and likely to be associated with chronic prostatitis.
Urethrocutaneous fistulas may be present and bladder may be palpable if there is
chronic urinary retention.5
Diagnosis of urethral stricture can be made by anamnesis to knowing the risk factor,
history of illnesses on patient, and symptoms on patients. The additional examination
such as uroflowmetry and urethrogram also very helpful. Uroflowmetry records the urine
stream (measured as volume per unit of time) and the overall urination time. Urinary
flow rates can be calculated by divided urine volume with urination time. Normal
urinary flow rate in adult men is 20 ml/s and urinary flow rate less than 10 ml/s
indicate obstruction. Urethrogram is made to see the location of stricture, grade of
urethral narrowing, and length of stricture. Other primary diagnostic procedures
required are ultrasonography to determine any urinary retention and ultrasound
examination of the upper urinary tract to rule out hydronephrosis.5
Complications of urethral stricture are trabeculasi, sacculasi and diverticel, urine
residu, vesico-ureter reflux, urinary tract infection, kidney failure, urine infiltrat,
abcess and fistula.6
Urethral stricture can not be eliminated with any kind of drugs. Patients who present
with urinary retention, a suprapubic sistostomi promptly carried out to remove the
urine, if found periurethral abscess, using incision and antibiotics. Treatment of

urethral stricture has many options and varied depending on the length and location
of the stricture, as well as the stage of narrowing of the lumen of the urethra.6
Treatments of urethral stricture are dilation, internal urethrotomi, and external
urethrotomi. Dilation of stricture is not usually curative and only temporarily
enlarges the lumen. Dilation may initially be required because of severe symptom of
chronic urinary retention. Internal urethrotomi is done by cutting scar in urethra with
Otis or Sachse. External urethrotomi is open surgical repair with excision of fibrosis
and then anastomosis will be made between healthy urethra.6
Ways to prevent the occurence of urethral stricture is by avoiding trauma to the
urethra and pelvis, measures transurethral with caution, as the catheter, avoid direct
contact with patients infected with sexually transmitted diseases such as gonorrhea,
with the faithful to one partner and using condoms. Early treatment of urethral
strictures can avoid complications such as infection and kidney failure.2
Urethral stricture may be recur at any time and patient should not be considered
cured until it has been observed for at least 1 year after therapy without sign of
recurrence. Urinary flow rate measurement and urethrogram are helpful to determine
the extent of residual obstruction. To prevent recurrence of stricture, sometimes
patient must do periodic dilatation and clean intermittent catheterization.2
Urethral stricture often recurs, so patients must often undergo regular examinations
by a doctor. The disease is said to be cured if after observation for one year showed
no signs of recurrence.2
Clinical Presentation
A male, 53 years old, came to emergency room General Hospital DR. Mohammad
Hoesin Palembang with the chief complain of unable to urinate since 1 day ago.
Previously, the patient complained difficult while urinating (+), lessened force and
size of the stream of urine (+), terminal dribbling of urine after going to toilet to pass
the urine (+) and then, after a long time, patient complained unable to urinate at all.

Since 2 months before admission, patient complained of difficult while urinating

(+), hesitancy in starting urination (+), terminal dribbling (+), urinating
discontinously (+), lessened force and size of the stream of urine (+), frequent of
urination (+), more than 8x/day,

dissatisfaction after urinate (+), dysuria (+),

nocturia (-), urgency while urinating (-), bloody urine (-). Back pain (-), fever (-),
stone found while urinating (-), pyuria (-).
From the history of past illness, Riwayat trauma pelvis 20 tahun yang lalu, riwayat
pemasangan kateter 20 tahun yang lalu dan ga masuk, cystostomy on September
2015. He has no history of diabetes melitus and CVD, and no history of same
diseases in his family.
From physical examination, general examination was normal. On local examination,
abdomen and CVA region was within normal limit, no bulging and pain on CVA
region. On suprapubic region, from inspection, bulging (-), cystostomy (+), tenderness
(+). From the rectal touche, there is no enlargement of prostate.
Laboratory examination show normal hemoglobin (14,8), normal leukocyte
(7700/mm3), and normal BSS (118 mg/dL). From the clinical chemical such as
ureum (39 mg/dl) and creatinin (0,9 mg/dl) is normal. Urethrogram of this patient
show narrowing in urethral pars bulbosa (figure 1, figure 2).

Figure 1.

Figure 2
This patient was diagnosed with urethral stricture. The treatment for this disease is
pro cystostomy and Sachse surgery. Prognosis for this patient, quo ad vitam is dubia
ad bonam and quo ad functionam is dubia ad bonam.
Disscussion
In this case, A male, 53 years old, came to emergency room General Hospital DR.
Mohammad Hoesin Palembang with the chief complain of unable to urinate since 1
day ago. Urinary retention can be caused by some diseases like benign prostatic
hyperplasia (BPH), uretthrolitiasis, neurogenic bladder, cancer in bladder or urethra,
and urethral stricture. The symptoms of urinary retention are inability to urinate, pain
or discomfort in lower abdomen, and bloating of the lower abdomen.
Based on autoanamnesis, the symptoms of this patient commonly found in lower
urinary tract (LUTS). LUTS based on its mechanism is divided into symptoms
during storage, voiding, and post-micturition complaints. Complaints during storage
once was known as the irritating symptoms like urgency, polakisuria, or frequency,
nocturia, and dysuria. Voiding complaints formerly known as obstructive symptoms
like hesitancy (straining during micturition), weakened urinary stream, terminal
dribbling urine and intermittensi. Post-micturition complaints include dissatisfaction
after micturition, and still feels there is residual urine after micturition. The
symptoms of this patient commonly found in obstructive lower urinary tract
symptoms that can be come from vesica or urethra. The possible causes are urethral
stricture, BPH, urethrolitiasis and urethral cancers. From the history of past illness,

there is a history of trauma (straddle injury) and medical instrumentation of the

urethra.
Based on physical examination, in this patient show normal general examination. In
suprapubic region, there is bulging (-), cystostomy (+), and tenderness (+), in which
show there is urine retention. On regio genitalia externa, there is no bloody
discharge. From rectal touche, anal sfingter tonus good, no tenderness, there is no
palpable enlargement of prostate, consistensy soft, flat on the surfaces, and there is
no nodules. It is seen that there is no enlargement of the prostate in this patient at this
time, so the differential diagnosis of BPH can be removed.
From the laboratory test, the levels of hemoglobin, hematocrit, leukocytes and
diff.count within normal limits as well as clinical chemistry urea and creatinine
within normal limits. Therefore, it can be concluded that there are no signs of
infection, anemia, and normal kidney function. But, based on the urethrogram, we
found urethral stricture at the pars bulbosa.
So, from the anamnesis of present complaints, history of the past illness, physical
examination and several additional examination of these patients, we can diagnosed
with urinary retention ec urethral stricture pars bulbosa. The disease is more
common in men, because mens urethra longer than women so its more prone to
have an injury. Possible causes in this case is the result of external trauma (straddle
injury) and iatrogenic (post TURP). Management that can be given to patients with
urinary retention are treated with suprapubic cystostomy and then cut the fibrosis
part of the urethra through internal uretrotomy. Early treatment of urethral strictures
can avoid complications such as infection and kidney failure. Follow-up gradually on
this patient is recommended because urethral stricture more likely to be recurrence.
During each follow-up, it is necessary to check the flow of the urine immediately by
a doctor or by uroflowmetry and patients are encouraged to conduct periodic
catheterization or Clean Intermittent Catheterization (CIC) to prevent the recurrence
of strictures. The disease is said to be cured if during one year of observation, no

symptoms of recurrence, so this patient's prognosis quo ad vitam is dubia ad bonam

and quo ad functionam is dubia ad bonam.
Conclussion
Urethral stricture is a narrowing of the lumen urethra because of fibrosis. Most
patients complain with urine retention. The main causes of urethral stricture are
urethral manipulation and trauma. Thus, the diagnosis should be considered in males
who complain unable to urinate, with a history of blunt trauma to the pelvis, straddle
injury, urethra manipulation and urinary tract infections. The most important
examination is the laboratory to determine the presence of infection and kidney
damage, as well as radiological like urethrogram to locate, length, and determine the
degree of narrowing of the urethral stricture. The goal is to get an accurate diagnosis
and know the possible causes. It is important to determine the best treatment for
patients with urethral strictures.
Refferences
1. Scott M. Gilbert, M.D., Department of Urology, Columbia-Presbyterian Medical Center,
New York. Urethral Stricture. http: // www. medlineplus. com/ medicalencyclopedia. html

2. Andrich Daniela E,Anthony R Mundy. Urethral Stricture Surgery:the state of the

art. In

:Kirby Roger S,Michael P OLearly. In ;Hot Topics in Urology. London :

Elsevier Limited;2004. Chapter 19, p. 239-252.

3. Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol
2007;177:1667-74.
4. Tanagho EA and McAninch JW. Smiths General Urology 17 th Edition. New York:

McGraw Hill.
5.

AR

Mundy.

Management

of

urethral

stricture.

Post

Grad

Medical

Journals.2006;82:489-493/www. postgradmedj.com/
6. Purnomo BB. 2007. Dasar-Dasar Urologi. Edisi Kedua. Jakarta: CV. Sagung Seto.