- What is Urethra (Urinary Channel)?
- What are the Causes of Urethral (Urinary Channel) Stricture?
- Symptoms of Urethral (Urinary Channel) Stricture
- Diagnosis of Urethral (Urinary Channel) Stricture
- Treatment of Urethral (Urinary Channel) Stricture
- Visuals of Urethra Stricture Surgery in Women
What is Urethra (Urinary Channel)?
Urethra (the urinary channel) is a 5-6 cm long channel that discharges urine from the bladder. Vagina is a pressed-cylinder shaped sexual intercourse organ with a length of 7.5-10 cm that is connected to the womb. Urethra is located right above the vagina (image 1: urethra) Urethra is formed of 4 layers form inside to the exterior. Its mucosa consists of a tissue reach with blood vessel network, and a longitudinal muscle tissue at the interior and a circular muscle tissue at the exterior. The interior muscle layer is the continuation of the bladder muscle. There are 2 pcs urine retaining bolds (sphincter) mechanisms in the urethra.
The thin fibers, which arrive from the bladder, joint and thicken the outlet point of the urethra, which is called distal urethra, and form a hoop. This hoop is the urine retainer external bold (external sphincter). Even this external urine retainer (sphincter) bold extends all along the urethra, its thickest place is close to the outlet hole, where urethra discharges the urine. The internal urine retainer bolt (sphincter) is located in the bladder neck where the urethra and the bladder join. You can see the internal and the external sphincter in the picture.
What are the Causes of Urethral (Urinary Channel) Stricture?
The elasticity of the urinary channel can be distorted due to vaginal childbirth, surgical procedures inside the vagina, traffic accidents, inflammations of the urinary tract, unnecessary repetitive application of catheters inside the urinary channel, and application of radiotherapy for cancer in peripheral organs. This causes the interior of the urinary channel to shrink partially or entirely. Urine flow becomes difficult and results in complaints such as think and strained urination or frequent urination. The most common cause is the unnecessary application of catheters inside the urinary channel. Another frequent cause is the shrinking and narrowing of the urinary channel as a complication of loose sling surgeries (TOT-TVT) that are performed for urinary incontinence.
Symptoms of Urethral (Urinary Channel) Stricture
Stricture prevents urine exit from the interior of the channel and therefore causes uncomfortable urine discharge. The patients can only urinate after waiting. She urinates thin and frequently. She feels pain while urinating. There is an urge to urinate. The patient can never urinate in case of advanced strictures (retention). This causes serious inflammation of the urinary tract.
Diagnosis of Urethral (Urinary Channel) Stricture
Evaluating the patient’s complaints and her previous surgeries are important for diagnosis. Observing the urinary channel by telescopic tools (ureterocystoscopy) is efficient in understanding the location & length of the stricture and the disorders it caused in the bladder. Imaging the interior of the urinary channel with medicated material (urethrography) is important for diagnosis. In addition, measuring the amount of urine that remains in the bladder provides vital information about the stricture. By ultrasonography performed from inside or outside the vagina, we can obtain information on the stricture in the urinary channel. There is no urine left in the bladder after normal urination. Urinary catheters with 9 separate calibrations between numbers 6-24 are used in the urinary (discharge) system for different purposes. (6-8-10-12-14-18-20-22-24) One can talk about stricture in the urinary channel if the number 14 catheter cannot be inserted to the female urinary channel. If catheter is applied to the urinary channel without anesthesia, the patient involuntarily squeezes her urinary channel for self-protection. It may not allow the passage of number 14 catheter even no stricture exists in the urinary channel. This may give a false stricture impression. Experienced hands don’t make this mistake. And catheterizing the patient under local anesthesia will remove this possibility of wrong diagnosis.
Treatment of Urethral (Urinary Channel) Stricture
Urethral dilatation in women is passing the place of stricture by forcing it with metal or plastic catheters. It can be applied as a first treatment. It is painful. It should be performed under general anesthesia. It has a short-term success. It should be repeated. One should know that this procedure will increase and deepen the stricture in the patient’s urinary channel.
Surgery for Urethral Stricture
Incising the stricture with endoscopic cold knife; using a light source, the physician personally sees the stricture and cuts it longitudinally with a small knife that is attached to the end of the telescopic tool. Incision made in 2 directions at 3 and 9 o’clock. One should know that this procedure can damage the urine retaining mechanisms we call sphincters (bold) and therefore cause urinary incontinence. Experienced centers successfully perform this procedure.
The open surgery performed in women for urethral stricture is called urethroplasty. It yields conclusive results. It should only be performed at experienced centers and by experienced physicians. It is a sensitive procedure. The procedure is easier if the stricture is right on the outlet of the urinary channel. The stricture zone is incised and removed all around. Two edges previously incised are re-sutured to each other. It poses no problems as it is far from the urine retainer mechanisms.
In longer strictures that are higher in the urethra, this joining and rejoining is not made. Instead, we incise the stricture longitudinally and place a graft (patch) in the middle. Grafting removes urethral stricture, the urethra reaches its normal width and conclusive results are obtained. Grafts are taken from either the vagina or the small vaginal flips adjacent to the vagina. Using the graft taken from the interior mouth mucosa is a more ideal option. Contrary to general belief, the grafts taken from the mouth pose no problem and this is the most ideal tissue in terms of self-repair. This method requires technical accuracy. The patient can feed from the mouth the next day. No scars are left and no pain occurs. It renews itself within one-two days. When needed, tissue can be taken from the same location after a few months. Repairs that use free patch (graft) are technically difficult but have high success rate. In all cases, we use free grafts and mainly those taken from the mouth mucosa. We achieve full success.
Free grafts are applied using 2 methods, which are above and under the urinary channel. By a small incision, we reach the stricture zone, the location and length of which were established prior to operation, cut the stricture longitudinally and place mouth mucosa therein. We apply catheter to the patient and wait for 10-15 days so that tissue union occurs. The patient resumes normal urination function. Also, dorsal (from the north) and ventral (from the south) techniques have advantages and disadvantages. One should avoid major incisions and tissue removal from the vagina in order not to disrupt sexual function.
Whether from dorsal or ventral, our technique gives the urinary channel its normal width by a graft taken from the mouth with no incisions in the vagina and no problems occur in the sexual functions of the patients. As the voluntary sphincter (voluntary urine retainer mechanism) is placed above the urinary channel with a horseshoe shape, surgeries performed over here require more accuracy. Loops (magnifying goggles) are used as necessary in order not to damage the sphincter (urine retaining mechanism). As the clitoral tissue will support the graft in the dorsal, it has a higher rate of success. But it requires a thinner dissection. One should pay attention to the neurovascular beam of the clitoris. Special magnifiers worn on the eye (loops) allow a more detailed view of the tissues. The urethral sphincter in women is similar to the sphincter in men behind the penis. For this reason, the urethra strictures in women are similar to the rear urethra strictures in men.
In sum, strictures in the urethra are repaired with reconstructive (restructuring) urology and the urinary channel resumes its normal function thereafter. The patient is entirely relieved from such complaints.