Postgonococcal urethral strictures

Gonorrhoea is common everywhere, but for quite unknown reasons, strictures are much more common in some communities than in others. In Uganda in 1963, for example, the attack rate for young adult males was estimated to be about 15% per year, with one patient in 50 getting a stricture. If yours is a ''high stricture area', like Uganda, treating them will be your most common urological task, so that you will need to hold a regular ''bougie clinic'. You will also see a few strictures which are the late results of schistosomiasis, trauma (68.7), prostatectomy (unusual), tuberculosis (rare), or of an operation on the urinary tract. Whatever its cause, you should, if possible, refer a patient with a stricture for a urethrogram, urethroscopy, and the release of his stricture with an optical urethrotome. If this is impossible, you will have to bougie him yourself, and if this fails, to treat him as in Section 23.9.

Strictures can be of any length from 5 mm to 10 cm. The commonest sites for gonococcal ones are: (1) the bulbous urethra, (2) at the junction of the penis and scrotum, and (3) in the glans penis[md]in this order. Gonococcal strictures are the result of fibrosis in the corpus spongiosum. Meatal strictures are described in Section 23.28.

A urethral stricture increases the resistance to micturition, which causes the detrusor muscle of the bladder to hypertrophy. This may produce an adequate flow for a time, but as time passes, sacculations and diverticula form in the bladder, it no longer empties completely, and the high residual urine it contains leads to frequency of micturition, and infection. Sensation from it is diminished, as its wall is increasingly replaced by fibrous tissue. Finally, the patient develops ''retention with overflow', and becomes incontinent. Bilateral hydronephroses form, and his blood urea rises; this completes the picture of secondary renal failure (obstructive uropathy).

Besides: (1) acute painful retention, and (2) chronic painless retention with overflow incontinence, the many other complications of a stricture include: (3) False passages. (4) Periurethral abscesses causing: (a) extravasation of urine, with gross distension of his penis and scrotum (sometimes leading to gangrene), and (b) external fistulae. (5) Infection of his urinary tract. (6) Infection of his seminal vesicles, epididymes, and testes. (7) Chronic non-specific infection ending in elephantiasis. (8) Obstructive uropathy ending in renal failure. (9) Bladder neck stenosis, and detrusor failure. These are common and may explain why bouginage and external urethroplasty often fail. (11) The results of straining, such as hernias or prolapse of his rectum. (12) Stones in his urethra and bladder. (13) Carcinoma of his urethra or bladder. (14) Infertility and impotence.

Acute and ''acute on chronic' retention are the common presentations, but a stricture may present as any of the many complications listed above. Prostatic obstruction is the main differential diagnosis (23.18). Chronic retention distends the bladder greatly, but is painless, so that decompression is not needed so urgently as it is in acute retention.

If he has a stricture and you cannot refer him, you will first have to calibrate it (find out how big it is), and then you will have to dilate it gently with bougies. There are two phases: (1) Initial bouginage, preferably with plastic bougies, to stretch it. (2) Maintenance bouginage with metal sounds to keep it stretched. Strictures are never cured, so maintenance bouginage must continue for the rest of his life. Bougie him every week or so to begin with, and then at gradually increasing intervals, until you are dilating him only once every 6 or 12 months. Even if the stenosis of his urethra is relieved, his bladder may fail to empty because its detrusor muscle has failed as the result of long-standing obstruction.

The key to success is to start bouginage early, before passing urine becomes really difficult. The more difficult it is, the more difficult will it be for you to pass a bougie. Passing one may be so unpleasant that he will not return again until he is desperate, by which time bouginage may be almost impossible. The only way to prevent this vicious circle is to start early, when his urine flow is only starting to fall off. He will probably find that the calibre of his stream deteriorates, before its pressure falls. Encourage him with the thought that strictures can be controlled, even by dilatation, especially if they are well treated and complications are avoided. Persuade him that, unless he returns regularly, his problems will be much greater.

Watch his kidneys and measure his blood urea. If you are in doubt as to how to manage the complications of a stricture, the rule to remember is ''If in doubt divert'' the urine stream with suprapubic drainage.

START BOUGINAGE EARLY DILATE THE PATIENT FOR LIFE Fig. 23-8 PASSING A METAL SOUND. A, put the tip of the sound into the patient's urethra, point downwards. B, and C, as the sound drops gently down his urethra, rotate its handle. D, there is always a little resistance as the tip of the sound meets his external sphincter: wait for the sphincter to relax. E, the sphincter relaxes as the handle falls, and the tip of the sound rises up into his bladder. After Blandy J, ''Operative Urology', Figs. 14.21 to 14.23. Blackwell Scientific Publications, with kind permission.

STRICTURES This is the patient in Section 23.5 with retention of urine, in whom you have been unable to pass a catheter, and who you think has a stricture.

DIAGNOSTIC BOUGINAGE. If he has been on suprapubic drainage and you last attempted to pass a catheter some days ago, try again now. The oedema round his obstruction may have subsided, and you may succeed. Using careful aseptic precautions, try to pass a 14 Ch soft rubber blunt-nosed Jacques catheter.

If this passes easily into his bladder, he has not got a stricture.

If it is held up, note exactly where it is held up, and start with smaller bougies.

INITIAL AND MAINTENANCE BOUGINAGE [s7]FOR THERAPY CONTRAINDICATIONS. Don't drain an acutely inflamed stricture. The causes of inflammation include acute retention, periurethral or prostatic abscesses, and extravasation of urine. If he has any of these, drain him suprapubically until the inflammation has settled down in about 4 weeks, then dilate him. Some surgeons do this as early as 10 to 14 days.

EQUIPMENT. Soft plastic ''Neoplex' bougies sizes 1 Ch to 20 Ch. Powell's straight metal sounds 13/17 to 18/22 Ch. Lister's curved metal sounds 9/14 to 18/23 Ch. KY jelly. Ideally lignocaine jelly 2% in tubes. A penile clamp. A ureteric catheter is sometimes useful in a passable stricture. Sterilize all instruments except plastic ones by boiling. Keep plastic ones in a large tray of antiseptic solution (2.5).

ANAESTHESIA. Minimizing the pain of his first bouginage is important, because if it is too painful, he may not reattend. (1) General anaesthesia (best). (2) Lignocaine gel supplemented with intravenous thiopentone while taking the proper precautions (A 12.1). Clean his meatus with an antiseptic, not spirit. Use a syringe without a needle, to inject some 2% lignocaine jelly into his anterior urethra. Massage it well back into his perineum. With old attenders anaesthesia may unnecessary.

ANTIBIOTICS. Fever and rigors are common after dilatation, so give him give him a broad spectrum antibiotic at bouginage or, better, just before it such as: (1) gentamicin 120 mg. Or, (2) trimethoprim 200 mg. Or, (3) amoxycillin 250 mg with clavulanic acid 125 mg (''Augmentin', expensive). Also, instil 5 ml of chlorhexidine 0.05% in glycerine into his urethra 10 minutes before you dilate his stricture. These measures will not prevent all bougie reactions, but they should prevent septicaemia.

TO PASS A PLASTIC BOUGIE lay him down and hold his penis straight up. This will convert its natural ''S' shape into a ''J'.

To calibrate his stricture, ask him to breathe deeply (to relax his external sphincter). Then pass a well- lubricated 15 Ch plastic bougie down his urethra. If you cannot pass it, try a smaller one. If this does not pass, try a still smaller one.

Dilation. Now you know how wide his stricture is, you can start to dilate it.

CAUTION ! (1) If possible start with a medium-sized bougie (15 Ch) first, because it is less likely to make a false passage than a small one. (2) Don't overstretch his urethra. If a bougie is gripped[md]stop! (3) Pass each bougie only just beyond the stricture. When a stricture grips a bougie there is a loss of touch, which makes passing it safely through his prostatic urethra difficult, so that you can easily damage his prostate, and cause severe bleeding.

The first time you try, you may only be able to dilate his stricture a little. Try to dilate him 2 Ch at each visit, for example from 4 Ch to 6 Ch. Next week you may be able to dilate him to 8 Ch. But if you have not hurt him, he will find that his stream improves. Don't dilate his stricture more than 2 Ch, or at the very most 6 Ch, at any one time, because you may tear it and cause more fibrosis.

See him again each week until he reaches 20 to 22 Ch. Some surgeons are content with 15 Ch, which is adequate for normal voiding. Then lengthen the intervals at which you see him, until he is attending only once in 3 to 6 months.

PASSING METAL SOUNDS. Use plastic bougies until his stricture is stable, preferably at 20 to 22 Ch, then use metal sounds. Don't use them before his stricture is 12 Ch, because you can easily damage his urethra with smaller sounds, and make a false passage. Straight sounds are safer than curved ones, because they give you a safer ''feel' and lack leverage. You can use them for nearly all strictures, except those in the bladder neck. Usually, you only need to pass a curved sound to make a final check of his whole urethra. Pass them in the same way as bougies, but remember they are much more dangerous.

Look carefully at his notes to see what size of sound was used before. Use a straight one for the anterior urethra, and a curved one elsewhere. Hold his penis upright, and let the sound fall into his urethra by its own weight, as in Fig. 23-8. Don't push! If it meets with resistance, guide it very gently on its way. When you feel the resistance of his perineal membrane, depress it between his thighs, and it will slip into his bladder (the ''tour de maitre', or ''touch of the master').

You will know when a sound is in his bladder by: (1) The ease with which it passes through his perineal membrane into his bladder. (2) The fact that it is exactly in the midline. (3) The ease with which you can rotate the handle of a curved sound. This test does not apply to a straight one.

Eventually, try not to dilate him at intervals of less than 3 weeks, because it takes this time for any local reaction to subside. If his stricture needs dilating more often than this, it is unstable, so consider surgery.

CAUTION ! The signs of a false passage are: (1) Pain. (2) The sound deviates from the midline. (3) You cannot turn the handle of a curved sound freely. (4) He bleeds as you withdraw it. (5) Later, a perineal haematoma develops.

When you have successfuly dilated his stricture, pass a catheter and check his residual urine by passing a catheter after micturition and seeing how much urine remains in his bladder. You will find that the residual urine will be persistently high in about a third of patients; if so, see below.

NYLON FILIFORM BOUGIES are useful if you have failed to pass a sound. You will need several of these, as in Fig. 23-9. Pass the first one, until it is held up by the stricture, either in a fold or a false passage. Continue with more filiform bougies, until with luck, one gets through. Then remove the bougies that have failed to get through, and screw on flexible ''followers' of increasing size. The filiform bougie will curl up in his bladder as you advance it. This is a useful method, even if you have no followers.

MAINTENANCE BOUGINAGE. Make sure that he knows that he may need dilatation once a fortnight for 3 months, then once a month for 6 months, then every 3 months for a year, then every year ever afterwards. Remind him to come a week after his birthday! If possible, teach him self-dilatation with the bougie in C, Fig. 23-9.

CAUTION ! Adjust maintenance bouginage to his needs. Progressive extension of the interval is not always possible, and you may have to stabilize him with more frequent dilatations.

INDICATIONS FOR SURGERY. (1) His stricture is persistently impassable. (2) He needs bouginage at frequent intervals, with many failures. (3) He has an established false passage. When this happens, a curved metal sound passes easily through his false passage, but he still has chronic retention, and urethrography shows the false passage. (4) He has bladder- neck stenosis. (5) He cannot attend regularly, for example, he may not be able to afford transport.

Fig. 23-9 TWO BOUGIES. A, several long thin filiform bougies have been inserted into this patient's urethra looking for a passage through his stricture. Most have been held up at the stricture, or in false passages. In doing so, they have made it easier for the successful bougie to pass through the tiny hole, which is all that remains of his urethra. This bougie is now going to be screwed on to its follower. B, a close up of the stricture. C, a locally made straight metal bougie that you can give to a patient with a stricture in his penile urethra, so that he can dilate himself. A brass disc has been brazed to a metal rod with a smooth round end. D, a simple way to measure patency of his stricture. How far can he urinate? ''X' is a measure of its patency.