Stricture and obliteration of the urethra

Narrowing of the urethra is divided into congenital and acquired. With acquired narrowing persistent changes of the lumen of the canal caused by the development of scar tissue. Etiological factor purchased strictures can be an inflammation or injury.
Inflammation of the urethra stricture is a result of the transferred gonorrhea, urethritis, tuberculosis or syphilis of the urethra. Gonorrheal urethritis now quickly cured with antibiotics, and education strictor occurs only as an exception. As stricture after gonorrheal urethritis develops slowly and clinically manifested in 10-15 years or more, are now found gonorrheal stricture mainly in individuals who had gonorrhoea until sulfanilamidami and antibiotics.
Anatomically gonorrheal stricture differ from traumatic fact that they are multiple and hit the front of the urethra. The form of their ring-shaped or cylindrical.
Traumatic stricture develop rapidly in the coming weeks after the injury. They are single and are in the form of heavy in bulbous or back of the urethra. The complete rupture of the urethra occurs Bamyan (obliteration) of the urethral lumen.
Due to the difficulty of urine outflow urethra behind stricture is expanding. Expansion contributes to the stagnation of urine, the accession of infection and the development of the inflammatory process with the involvement of glands Littre and gaps blinking, with the formation of granulation and purulent-inflammatory infiltration underlying tissues. All this can lead to ulceration, abscess formation and eliminate the canal. Through a defect in the wall of urine enters surrounding the urethra tissue. Urinary infiltration leads to the development phlegmon and the formation of urinary fistulas.
A growing obstacle to the emptying of the bladder initially causes hypertrophy of the muscular wall of the bladder, and then atony her. The amount of residual urine is gradually increasing. Atony bladder is accompanied by expansion of the ureter and renal pelvis up to the formation of Hydrometereology.
Urine flow becomes thin, urination difficult. Patient with difficulty and not completely empty the bladder. After the act of the bladder from the urethra is allocated a few drops of urine, lingering behind stricture. In far comes strictures of urethra semen during sexual intercourse is not allocated at all (aspermia), and retrograde flows into the bladder.
Residual urine is increased frequency of urination, a feeling of incomplete emptying of the bladder. Swelling of the mucosa in the area of narrowing (for example, after erections) or weakening of the detrusor (intoxication) can cause acute urinary retention. Long-existing atony bladder can go to a paradoxical incontinence (ischuria paradoxa).
Stricture of the urethra can be detected by introduced into the urethra capitate elastic Buga. First imposed thicker bugi and determine the localization of stricture. Following this, enter consistently bugi descending caliber, until one of them will take place in a bubble. Caliber last burza gives an idea about the diameter of the stricture.
The most reliable diagnostic method is urethrography. When filling the urethral lumen solution sergazina can get the image to the narrowed areas, to determine their location, extent, and caliber, the expansion of the canal behind stricture, urinary leakages, fistulas (Fig. 131).

urethrogram when gonorrheal stricture
Fig. A. Urethrogram when gonorrheal stricture.

urethrogram with traumatic urethral stricture
Fig. 1316. Urethrogram with traumatic urethral stricture.

Treatment. Conservative treatment is systematic birovni - the introduction into the urethra metal Buga consistently increasing caliber. Systematic bairovna affects scars not only mechanically. Bugi cause blood, which promotes softening scars. If you cannot spend metal bougie, trying to hold in the urethra bundle of thin elastic Buga. After injection into the channel sterile vaseline oil injected simultaneously 3-4 filiform elastic bougie in the form of a bundle to stricture. When you try in turn promote each of them is often possible to spend one filiform bougie through narrowed place. Filiform bougie left in the urethra at the 24 or 48 hours. Urine during urination is allocated by him. Bougie expands the lumen of the urethra and in the subsequent possible to conduct the tools larger diameter. Bairovna facilitated by the use of tapered, Pugovkina of Buga Rothera. You can also use bugi Lefort conductors (Fig. 132). Previously in the urethra being thin elastic bougie Explorer, which at the outer end has cutting for screwing metal bougie. Thus, metal bougie, bolted to the Explorer, follow him, without causing unnecessary trauma of the urethra.
Bairovna held 2-3 times a week. Repeated courses are appointed individually for each patient depending on the speed of relapse stricture.
When a dense scarring that can not be stretching bogami resort to surgical interventions.
Internal dissection of the urethra (the internal urethrotomy) is done in cases where through narrowed the place manages to hold filiform elastic bougie (Explorer). To him screwed uretritom and after it is carried out through the urethra (Fig. 133). Through the chute urethrotomy on long thin arm entered triangular knife with cut and blunt tip that cuts through all occurrences scars without damaging the mucosa in the normal areas. Dissection can be produced by the anterior and lateral walls of the urethra; a cut on the back wall is undesirable because of the risk of damage to the seed of tubercle. After dissection scars in the urethra introduce 2-3 nights a permanent catheter.
When obstruction perineal Department urethra Explorer is used outside urethrotomy. In the urethra to the site of narrowing enter bougie, who assistant captures strictly on the midline of the body. Then on the crotch produce curved, bulging addressed to the scrotum section. After dissection of the skin, subcutaneous tissue and aponeurosis exposed bulbous part of the urethra. The scar area urethra on its bottom surface excised, via the outer opening of the urethra into the bladder impose permanent rubber catheter, which is the formation of a missing part of the urethra. Over the catheter sutured periuretralnuu tissue, muscles and skin. If you find stricture of considerable length, it is better to make a complete excision of scar section (operation Century A. Vishnevsky) with the introduction of the urethra constant of a rubber catheter for 2-3 weeks, which is formed by connective tissue tube defect replacement of the urethra.
Both internal and external urethrotomy require subsequent permanent dilations, because in these methods of treatment scars are formed again.
Best results are urethral resection (ideal resection by B. N. Koltsovo). Naked perineal Department of the urethra, excised scar stretch, unmodified peripheral and Central parting her mobilize and sew the end to end (Fig. 134). Urine from the bladder divert through suprapubic fistula, which contributes to the primary anastomosis healing.
This operation applies with traumatic strictures bolotnogo or hanging Department of the urethra.
Stricture membranous and prostatic portion of the urethra inaccessible to operate under the control of the eyes. In such cases, resort to intussusception of the urethra by P. D. Solovovo or tonalitatii her P. M. Bronstein.
Operation P. D. Solovova consists in the following. After cystectomy or extending the previously imposed suprapubic fistula enter through the bladder into the back of the urethra bougie or metal catheter to stricture or land obliteration. Then an incision of the skin and subcutaneous tissue on the perineum. Allocate peripheral Department of the urethra to the place of narrowing or obliteration and cross the urethra in the transverse direction. The scars in the area of stricture may be trimmed so that the finger entered from the bladder through the urethra, pass freely into the wound on the perineum. The bill retrograde held catheter put on short rubber tube. Through the wall of the Central end cut off the urethra spend 3-4 long silk ligature, the ends of which stitch rubber tube, and then the metal catheter together with the tube is extracted through Podmoskovye fistula. Thus, the Central end of the urethra inaguiruetsa educated in the tunnel. Ligatures stretched and fixed to the skin of the anterior abdominal wall (Fig. 135). In the bubble enter the drainage tube. After 10-12 days the urethra grows to surrounding tissues, ligatures are cut and delete them.
If the length of the stricture (or obliteration) membranous or prostatic of the urethra does not exceed 1 to 1.5 cm applies tonalitatea by R. M. Bronstein. It also requires the prior opening of the bladder. From its cavity in the rear part of the urethra introduced on 1 -1,5 cm tip of the index finger of the left hand, and to meet him through the outer opening of the urethra impose metal bougie, at the end of which drilled a small hole. When the end of bougie comes to narrowing entered in the urethra, the finger feels it through scarring of the urethra. Based on this feeling, was forcibly carried through the scar tissue in the direction introduced into the urethra finger. When the end of bougie penetrates the bladder, he put on a rubber catheter and fix it seam carried out through the hole in the end of bougie. Then bougie extract retrograde, cut off from the catheter, and the last remains in the lumen of the canal for 2-3 weeks. By removing the catheter begin systematic birovni.