Introduction

Urethral stricture disease is caused by any process that injures the urethral epithelium or the underlying spongiosum leading to healing by scar formation. The scar causes obliteration of the urethral lumen which leads to poor stream of urine or subsequent cessation of urine flow. The resultant scar can be of various depths, densities and lengths, replacing portions of the corpora spongiosum with loss of urothelium and subsequent circular contraction of the lumen. Strictures are documented in ancient literature from the Greek and Egyptian period and are a common sequel of sexually transmitted Illness (STI). This results in a chronic inflammatory process (1). Earlier studies indicated sexually transmitted diseases to be still common in the age group 15 to 50 years in developing countries (2).This trend is reported to have changed with gonorrhea ,the historical cause of urethral stricture having been replaced by urethral instrumentation and external trauma as the most common cause of the disease(1,2). However there are still some incidences of urethral stricture disease especially in men with a history of chlamydia or gonorrhea (3, 4, 5, 6,). As trauma becomes the leading role of urethral stricture disease in other centers we postulated that at Moi Teaching and Referral Hospital (MTRH), inflammatory cause is the leading cause of urethral stricture disease.

 

Methods

We conducted a retrospective study covering a period of five (5) years, from 1st January 2003 to 31st December 2007 at MTRH, the second largest public tertiary institution in Kenya. Data on all cases of urethral stricture disease seen at the hospital during the period of study was collected. The parameters studied included age, sex, and aetiology of the urethral stricture.

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Results

 

We sampled 143 files out of which only 112 had adequate information. All patients except one were male. The mean age of the patients with urethral stricture disease was 42.7 years (SD 20.8) years with a range of 3 months to 86 years. In 50.9% of cases urethral strictures were due to urethritis, 47.3% due to trauma while1.8% were due to rare causes like urethral diverticulum and urethral carcinoma (Table 1). In cases due to trauma the causes were distributed almost equally between iatrogenic (28%) and accidental trauma (25%) (Table 2). Urethral stricture disease in the female patient occurred as a complication of vesiicole vaginal fistula (VVF) repair.

Urethral stricture due to accidental trauma occurred on average among younger patients (mean 27.7 +/-14.3 years) while strictures due to urethritis occurred in middle aged patients (mean 45.6+/- 16.3 years).

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Click to view table 1

Click to view table 2

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Urethral stricture disease due to accidental trauma occurred more in the younger age group (27.7+/-14.3 years), while urethritis caused strictures among the middle age group (47.6+/- 16.3). The association between the age and aetiology was statistically significant (ANOVA, F (3,108) =9.278, p<0.001).

 

Discussion

The  trend in he aetiology of urethral stricture disease has been noted to have changed in the developed world and in some urban centres in developing countries (2). In both situations, trauma is the leading cause having overtaken urethritis (7,8,9). Inflammatory strictures seen in the developed countries are caused by Lichen Sclerosis (LS) a form of chronic dermatitis or Balanitis Xerotica Obliterance (BXO), a variant of Lichen Sclerosis (10,11). At the Moi Teaching and Referral Hospital, urethritis remains the highest cause of urethral stricture disease, being responsible for up to 51% of all the patients in our study. The hospital, though the second national referral in Kenya, its catchment area is a rural farming population in western region of Kenya. This trend may be replicated in most rural populations in developing countries. Studies published before the 1980’s indicated that urethritis was the most common cause of urethral strictures at 40% (12). Some recent studies still show that urethritis still leads as a cause of urethral stricture disease at 63%, a rate much higher than would be expected. Sub-Saharan African countries still have a high prevalence of urogenital infections especially gonococcal urethritis, which when inadequately treated leads to urethral stricture formation (8). High prevalence of gonococcal urethritis is attributed to lack of information about STI’s among youth, early onset of sexual activity, sex with multiple partners and reluctance to use condoms. Other causes identified include prostitution, lack of adequate attention to urethral discharge, antibiotics resistance, lack of screening for Chlamydia trachomatis and incomplete diagnosis of STI’s relying mainly on the clinical diagnosis (13). Poverty may also contribute to inadequate treatment as the patients may be unable to afford a complete dosage of the prescribed antibiotics, even when accurate diagnosis has been made. Health facilities which are inadequately equipped for treatment of STI’s and counterfeit drugs can lead to missed opportunity for adequate treatment. However with the advent of HIV and AIDS, and the extent of health education curried out for over 25 years, it would have been expected that urethritis should by now have been overtaken by trauma as the leading cause of urethral stricture disease. In our study, trauma was responsible for 47% of cases. Among the traumatic causes, non-accidental trauma was attributed to in 25% of all strictures, while accidental trauma caused 22.3% of all strictures. In the developed world, the commonest causes of urethral trauma that lead to urethral stricture disease are urethral instrumentation, and external trauma (2). Iatrogenic or non-accidental urethral injuries in our centre were due to catheterization, instrumentation and prostatectomy (both open and transurethral) and following radiotherapy for carcinoma of the prostate. All these conditions lead to tissue damage which heals by scar formation and narrowing of the urethral lumen. In prolonged catheterization, urethral injury could be due to urethral inflammation or ischemia (14,15). Ischemia may also result from prolonged hypotension in the catheterized patients (16,17,18). Studies have shown that 3.2 injuries occur in every 1,000 patients catheterized (19), while 22% of all strictures are caused by accidental trauma. In a study by Mathur R, et al, trauma was the commonest cause of urethral disease in men with a mean age of 35.5 years (range 15-65 years) (2). In our study, accidental trauma occurred more among younger men (27.7±14.3 years). This is the most economically active age group which is vulnerable to trauma and urethral trauma may be part of the multiple injuries such a patient may have sustained (20,21). In general, trauma was the second cause of urethral stricture disease at 47%. Larger urban centres even in developing countries have trauma being the leading cause of urethral strictures. Mathur R, et al found trauma to be the commonest cause at 54%, Similar to Tijan KH, et al (N=60) where trauma was the undisputed cause of urethral strictures (8,9). Similar to Tijan KH, et al (N=60) where trauma was the undisputed cause of urethral strictures (8,9). It seems that trauma is a leading cause of urethral strictures in bigger cities of the developing world as it is in developed nations while urethritis leads in causing urethral stricture disease in smaller cities and rural areas. Inflammatory strictures as those caused by urethritis tend to be multifocal making difficult to treat. In our study, the mean age of men affected by urethral stricture disease as a sequel to urethritis was 45.6 years with a range of 25.3 years to 55.9 years. Duration of time from infection to the onset of symptoms may be many years apart. So far no study has conclusively determined the length of time required between infection and stricture formation. This could explain why manifestation of urethral stricture disease occurs in mid-life when history of urethritis may have occurred several years earlier.

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References

1. Attwater HL. The history of urethral strictures.Br Jurol. 1943;15:39.

2. Schyver and A.Maheus.Epidemiology sexually transmitted disease :global picture. Bull World Health Organ 1990;68(5):639-654.

3. A.R. Mundy. Management of urethral strictures. grad med J 2006;82:489-493.

4. Greenberge SH. Male reproductive tract sequel of gonococcal and non-gonococcal urethritis. Arch Androl 1979;3:317-9.

5. 0saba AO. Sexually transmitted disease in tropical Africa. A review of the present situation. Br J Vener Dis 181;57:89-94.

6. Pandhi D, Reddy BS. Watering can perineum-a forgotten complication of gonorrhea. J Euro Acad Dermatol Venereal 2002;16:89-94.

7. R, Agarwal G, Satsangi B,Khan F ,Odiya S. comprehensive analysis of aetiology on the diagnosis of Urethral strictures. In Braz J Urol 2011 May-June;37(3):362-9.

8. Tijani KH,Adesanya AA,Ogo CN. The new pattern of Urethral Stricture disease in Lagos, Niger Post. Grad Med J. 2009 June;16(2):162-5.

9. Santucci RA, Joyce GF, Wise M . Male urethral strictures disease. J Urol 2007;177;1667-1674.

10. Babagli G, Lazzeri M,Palminteri E, Turini D. Lichen Sclerosis of the male genitalia involving anterior urethra.Lancet 1999; 354:429.

11. Barbagli G, Palmenteri E, Lazzeri M,Turini D. Lichen sclerosis of the male genitalia. Contemp Urol 2001; 13:47-58.

12. De Sy WA, Oosterlinck W, Verbaeys A: Le treatment du retrecissement de L ureteric masculine. Act Urol Belg. 1981; 49:101-2.

13. Boubacar Fall, Sow Y,Mansouri I,Sarr A, Thiam A, Diao B, Fall PA, Ndoye AK, Diagne BA. Aetiology and current characteristics of male urethral stricture disease: experience from a public teaching hospital in Senegal. Int. Urol Nephrol 2011 Dec;43(4):969-74.

14. Feston AS, Morey AF, Aviles R, Gercia CR. Anterior urethral strictures: aetiology and characteristics

15. Barbagli G, Guazzoni G, Lazzeri M: Retrospective analysis of the results of 375 patients. Eur Urol. 2008; 53:828-33.

16. Abdel-Hakim A, Bernestein J, Teijura J, et al. Urethral stricture after cardiovascular surgery, a retrospective and a prospective study. Urol 1983; 130:1100-2.

17. Abdel –Hakim A, Hassouna M, Teijueira J, Elhilali M. Role of the urethral ischemia in the development of urethral strictures after cardiovascular surgery: a pre­liminary report. J Urol 1984; 131:1077-9.

18. Bamshad BR, Poon MW, Sterwart SC. Effect of car­diopulmonary bypass on urethral blood flow as measured by laser Doppler flowmetry. J Urol 1998; 131:1077-9.

19. Kashefi C, Messer K, Barden R, et al Incidence and prevention of iatrogenic urethral injuries. J urol. 2008; 178:2254-7; discussion 2257-8.

20. Masiira-Mukasa N, Ombito BR. Surgical admissions to the rift valley provincial general hospital, Kenya. East Afri Med. J. 2002 Jul; 79(7):373-8.

21. Abdulkadir AS, Adewele OA, Amogu KE, et al. Traumatic Urologic Injuries in Ile –Ife , Nigeria. J Emerg Trauma Shock.2010 Oct- Dec;3(4):311- 313