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com/article/1972482-overview#showall
Overview
The male urethra is a narrow fibromuscular tube that conducts urine and semen from the bladder and
ejaculatory ducts, respectively, to the exterior of the body (see the image below). Although the male urethra
is a single structure, it is composed of a heterogeneous series of segments: prostatic, membranous, and
spongy.

Male urethra and its segments.

Most proximally, the prostatic urethra is responsible for involuntary continence, transmission of semen into
the common genitourinary tract, and the most common site of bladder outlet obstruction in the Western
world. The membranous urethra is critical to voluntary continence and, because of its rigid attachments, is
highly susceptible to injury in pelvic trauma. The spongy urethra is surrounded by the corpus spongiosum
and forms the terminal conduit communicating with the outside of the body.
Knowledge of male urethral anatomy is essential for all health professionals because urethral
catheterization is one of the most commonly performed procedures in health care. The male urethra is
susceptible to a variety of pathologic conditions, ranging from traumatic to infectious to neoplastic.
Pathophysiologic variants of the urethra may have devastating consequences, such as renal failure and
infertility.
Gross Anatomy
The posterior male urethra forms from the urogenital sinus (see the image below). This sinus derives from
the endoderm-derived cloaca, which is separated from the anorectal canal by the growth of the urorectal
septum in the fourth week of gestation. The spongy urethra is formed after the seventh week by
tubularization of the urethral folds along the urethral groove under the influence of dihydrotestosterone. The
most distal portion of the urethra is likely formed by invagination of an epithelial tag at the distal end of the
genital tubercle.[1]

Embryologic development of pendulous urethra.

The male urethra originates at the bladder neck and terminates at the urethral meatus on the glans penis. It is
roughly 15-25 cm long in the adult and forms an "S" curve when viewed from a median sagittal plane in an
upright, flaccid position (see the image below). The male urethra is often divided into 3 segments on the
basis of its investing structures: prostatic urethra, membranous urethra, and spongy (or penile) urethra.

Male urethra and its segments.

Other systems for naming the parts of the urethra have been described. The urethra can be separated simply
into anterior and posterior urethra. The spongy urethra can be subdivided into fossa navicularis, pendulous
urethra, and bulbous (bulbar) urethra. Finally, the bladder neck, or preprostatic urethra, can be classified as a
distinct part of the urethra (see the image below).

Posterior wall of urethra.

Prostatic urethra
The prostatic urethra is the portion of the urethra that traverses the prostate. It originates in the region of the
bladder neck, courses roughly 2.5 cm inferiorly, and terminates at the membranous urethra. It lies in a
retropubic location and is bordered superiorly by the bladder and supported inferiorly by the sphincter
urethrae externus muscle and the perineal membrane (formerly called the urogenital diaphragm). It is
invested in the prostate, a glandular and fibrostromal organ that secretes seminal fluids and has clinical
relevance.
The urethra runs through the prostate eccentrically, with most of the prostatic tissue in a posterior and
inferior location. The prostatic urethra is surrounded by an inner circular layer and an outer longitudinal
layer of smooth muscle. The urethra forms an angle of roughly 45 (range, 0-90 ) at the midpoint of the
prostatic urethra. The segment proximal to this location is surrounded by the involuntary internal sphincter.
It is also the area most commonly affected by benign prostatic hyperplasia (BPH).
The posterior wall of the prostatic urethra contains the urethral crest, which is bordered laterally by prostatic
sinuses, into which the prostatic glands drain. The most prominent aspect of this crest is the seminal
colliculus, or verumontanum, where the paired ejaculatory ducts and the opening of the prostatic utricle (a
small midline paramesonephric duct remnant) meet the lumen of the urethra. The seminal colliculus has no
functional significance but is a crucial landmark in urethroscopy and transurethral surgery.
Membranous urethra
The shortest and least distensible portion of the urethra is the membranous urethra. This region spans from
the apex of the prostate to the bulb of the penis. It is invested in the external urethral sphincter muscle and
the perineal membrane.
The external sphincter is related anteriorly to the dorsal venous complex and is connected to the
puboprostatic ligaments and the suspensory ligament of the penis. The external urethral sphincter muscle
and the perineal membrane fix the urethra firmly to the ischial rami and inferior pubic rami, rendering this
portion of the urethra susceptible to disruption with pelvic fracture.
Spongy urethra
The spongy urethra is the region that spans the corpus spongiosum of the penis. It is divided into the
pendulous urethra and the bulbous (or bulbar) urethra. The pendulous urethra is invested in the corpus
spongiosum of the penis in the pendulous portion of the penis. The urethra is located concentrically within
the corpus spongiosum.
In the distal urethra lies the fossa navicularis, a small dilation of the urethra just proximal to the urethral
meatus. The meatus is a slitlike orifice with its long axis in a midline sagittal plane. The urethral meatus is
slightly ventral to the tip of the penis. The bulbous urethra is invested in the bulb of the penis, the portion of
corpus spongiosum that lies between the split corpora cavernosa in the superficial perineal space.

Bulbourethral (Cowper) glands, a male homologue of the greater vestibular (Bartholin) glands, originate in
the external urethral sphincter muscle but terminate in ducts that empty into the bulbous urethra. The spongy
urethra lies closer to the dorsum of the penis in the bulb.
Vasculature and lymphatic drainage
The prostatic urethra is supplied by the inferior vesical artery, which branches to penetrate the prostate and
the bladder neck in superolateral positions. The bulbourethral artery supplies the membranous and bulbar
urethra, whereas the pendulous urethra is supplied by the deep penile artery, a branch of the internal
pudendal artery. In general, venous drainage mirrors the arterial supply. The prostatic and membranous
urethra drain to the obturator and internal iliac nodes.
Lymphatic drainage from the spongy urethra drains to the deep and superficial inguinal nodes.[2]
Microscopic Anatomy
The male urethra is a fibromuscular tube. It has distinct longitudinal folds that protrude into its lumen and
make it readily identifiable on cross-section. The lining of the urethra varies from segment to segment but
transitions from the urothelium of the bladder to the keratinized stratified squamous epithelium of the glans.
The prostatic urethra is lined with transitional cell epithelium (urothelium). The membranous urethra is lined
with stratified columnar and pseudostratified epithelium. Also, a rich vascular submucosa exists in the
membranous urethra.
Finally, the penile urethra is enclosed by the corpus spongiosum and lined with stratified columnar and
pseudostratified epithelium with stratified squamous epithelium distally. The entire posterior urethra is lined
with a submucosa and a series of muscular sphincters. The urethra is lined on the dorsal surface by the
glands of Littre, which are concentrated more distally. Additionally, small diverticula, called lacunae of
Morgagni, and a larger lacuna magna can be found at the fossa navicularis.[3]
Pathophysiologic Variants
Although the male urethra is subject to varying length and angulation, no common natural variants in
urethral anatomy exist. Pathophysiologic variants include duplication, urethrorectal fistulae, congenital
strictures, hypospadias, epispadias, and posterior or anterior urethral valves.
Duplication
Urethral duplication is a rare anomaly that typically occurs in the sagittal plane. Incontinence and infection
are presenting symptoms; these anomalies can usually be picked up on newborn examination. A dorsal
duplication is associated with a normal urethral meatus at the tip of the glans and an epispadiac urethra and
dorsal chordee. The dorsal urethra may be blind-ended or associated with bladder exstrophy.
Ventral duplication and duplication in the same horizontal plane are other variants of urethral duplication.
Treatment is necessary if incontinence or infections are an issue. Fulguration or excision of the abnormal
urethra is the standard therapy.
Urethrorectal fistulae
Urethrorectal fistulae are rare and are usually associated with imperforate anus. The signs of this are passage
of stool and air through the meatus. Alternatively, in cases with a patent anus, urine may pass via the anus.
Management of urethrorectal fistula in the presence of an imperforate anus involves either opening the anus
and closing the fistula or fecal diversion if the distance between the blind-ended rectum and the perineum is
too far for immediate reconstruction.
Congenital strictures
Congenital urethral strictures are rare but most commonly occur at the membranous urethra and fossa
navicularis. They can be diagnosed with excretory urography, retrograde urethrography, or urethroscopy.
Treatment involves direct-vision internal urethrotomy for membranous or fossa navicularis strictures or
dilation for membranous strictures. Failure of endoscopic therapy warrants reconstruction.
Hypospadias

Hypospadias is the most common urethral anomaly in males, occurring in 1 in 300 live births. In addition to
a ventral ectopic urethral meatus, the typical physical findings include an incomplete dorsal hood
appearance to the foreskin and a ventral chordee. Between the eighth and 15 th weeks of gestation, under
influence of dihydrotestosterone, the urethral folds fuse, and the glans canalizes to form the urethra.
Failure of this fusion may occur with in utero exposure to estrogens or progestins. Hypospadias is classified
in severity according to the location of the failed fusion. Most cases of hypospadias are distal (ie, glanular or
coronal). More proximal cases (ie, penile shaft, penoscrotal, or perineal hypospadias) may necessitate
extensive and staged reconstructive efforts. The goal of treatment is to provide a functional penis that allows
the boy to void while standing and deposit semen in the vagina.
It is critical that boys with hypospadias are not circumcised in the newborn nursery; the extra foreskin may
be used for reconstruction. Penoscrotal and perineal hypospadias are evidence of feminization and may
indicate a need an evaluation for disorder of sexual differentiation.[4]
Epispadias
Epispadias is rare, occurring in 1 in 120,000 males. This pathologic variant results from failure of the genital
tubercle to migrate appropriately in the fifth week of gestation. As a result, the urethral meatus is on the
dorsum of the penis or at the penopubic junction. Proximal epispadias is often associated with incontinence
and dorsal chordee. Severe epispadias may be associated with bladder exstrophy. Cosmesis is good with
urethroplasty and correction of chordee, but continence is difficult to achieve surgically.[5]
Posterior urethral valves
Posterior urethral valves are thin membranes of mucosa in the distal prostatic urethra that cause varying
degrees of obstruction when the child voids. They occur in 1 in 8,000 to 25,000 live births and are
responsible for 10% of in utero diagnoses of obstructive uropathy. Antenatal ultrasonography is usually
helpful in identifying clinically significant cases of posterior urethral valves, revealing a constellation of
oligohydramnios, thickened bladder wall, full bladder, dilated posterior urethra, and bilateral
hydroureteronephrosis.
Management involves early drainage of the bladder, ablation of valves, and long-term management of
bladder dysfunction and renal failure. Roughly 30% of boys progress to end-stage renal disease.[6]
Anterior urethral valves
Anterior urethral valves are far less common than posterior urethral valves. Unlike posterior urethral valves,
they tend to manifest later in childhood, often with voiding symptoms or infection, and they have fewer
long-term sequelae of hydronephrosis and renal failure. Typically, an anterior urethral valve is not a true
valve but, rather, a diverticulum in the spongy urethra that balloons under the pressure of micturition; the
distal edge of this diverticulum causes obstruction of the urethral lumen.
Anterior urethral valves can be managed with transurethral ablation, but if they are associated with a large
diverticulum, open excision may be necessary.

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The Male Urethra
(Urethra Virilis)

The male urethra (Fig. 1142) extends from the internal urethral orifice in the urinary bladder to the
external urethral orifice at the end of the penis. It presents a double curve in the ordinary relaxed state
of the penis (Fig. 1137). Its length varies from 17.5 to 20 cm.; and it is divided into three portions,

the prostatic, membranous, and cavernous, the structure and relations of which are essentially
different. Except during the passage of the urine or semen, the greater part of the urethral canal is a
mere transverse cleft or slit, with its upper and under surfaces in contact; at the external orifice the slit
is vertical, in the membranous portion irregular or stellate, and in the prostatic portion somewhat
arched.
The prostatic portion (pars prostatica), the widest and most dilatable part of the canal, is about 3 cm.
long, It runs almost vertically through the prostate from its base to its apex, lying nearer its anterior
than its posterior surface; the form of the canal is spindle-shaped, being wider in the middle than at
either extremity, and narrowest below, where it joins the membranous portion. A transverse section of
the canal as it lies in the prostate is horse-shoe-shaped, with the convexity directed forward.

FIG. 1142 The male urethra laid open on its anterior (upper) surface. (See enlarged image)

Upon the posterior wall or floor is a narrow longitudinal ridge, the urethral crest (verumontanum),
formed by an elevation of the mucous membrane and its subjacent tissue. It is from 15 to 17 mm. in
length, and about 3 mm. in height, and contains, according to Kobelt, muscular and erectile tissue.
When distended, it may serve to prevent the passage of the semen backward into the bladder. On either
side of the crest is a slightly depressed fossa, the prostatic sinus, the floor of which is perforated by
numerous apertures, the orifices of the prostatic ducts from the lateral lobes of the prostate; the ducts
of the middle lobe open behind the crest. At the forepart of the urethral crest, below its summit, is a
median elevation, the colliculus seminalis, upon or within the margins of which are the orifices of the
prostatic utricle and the slit-like openings of the ejaculatory ducts. Theprostatic utricle (sinus
pocularis) forms a cul-de-sac about 6 mm. long, which runs upward and backward in the substance of
the prostate behind the middle lobe. Its walls are composed of fibrous tissue, muscular fibers, and

mucous membrane, and numerous small glands open on its inner surface. It was called by Weber
the uterus masculinus, from its being developed from the united lower ends of the atrophied Mllerian
ducts, and therefore homologous with the uterus and vagina in the female.
The membranous portion (pars membranacea) is the shortest, least dilatable, and, with the exception
of the external orifice, the narrowest part of the canal. It extends downward and forward, with a slight
anterior concavity, between the apex of the prostate and the bulb of the urethra, perforating the
urogenital diaphragm about 2.5 cm. below and behind the pubic symphysis. The hinder part of the
urethral bulb lies in apposition with the inferior fascia of the urogenital diaphragm, but its upper portion
diverges somewhat from this fascia: the anterior wall of the membranous urethra is thus prolonged for a
short distance in front of the urogenital diaphragm; it measures about 2 cm. in length, while the
posterior wall which is between the two fasci of the diaphragm is only 1.25 cm. long.

The membranous portion of the urethra is completely surrounded by the fibers of the Sphincter
urethr membranace. In front of it the deep dorsal vein of the penis enters the pelvis between the
transverse ligament of the pelvis and the arcuate pubic ligament; on either side near its termination are
the bulbourethral glands.

The cavernous portion (pars cavernosa; penile or spongy portion) is the longest part of the urethra,
and is contained in the corpus cavernosum urethr. It is about 15 cm. long, and extends from the
termination of the membranous portion to the external urethral orifice. Commencing below the inferior
fascia of the urogenital diaphragm it passes forward and upward to the front of the symphysis pubis;
and then, in the flaccid condition of the penis, it bends downward and forward. It is narrow, and of
uniform size in the body of the penis, measuring about 6 mm. in diameter; it is dilated behind, within
the bulb, and again anteriorly within the glans penis, where it forms the fossa navicularis urethr.

The external urethral orifice (orificium urethr externum; meatus urinarius) is the most contracted
part of the urethra; it is a vertical slit, about 6 mm. long, bounded on either side by two small labia.

The lining membrane of the urethra, especially on the floor of the cavernous portion, presents the
orifices of numerous mucous glands and follicles situated in the submucous tissue, and named
the urethral glands (Littr). Besides these there are a number of small pit-like recesses, or lacun, of
varying sizes. Their orifices are directed forward, so that they may easily intercept the point of a
catheter in its passage along the canal. One of these lacun, larger than the rest, is situated on the upper
surface of the fossa navicularis; it is called the lacuna magna. The bulbo-urethral glands open into the
cavernous portion about 2.5 cm. in front of the inferior fascia of the urogenital diaphragm.

Structure.The urethra is composed of mucous membrane, supported by a submucous tissue which

connects it with the various structures through which it passes.

The mucous coat forms part of the genito-urinary mucous membrane. It is continuous with the 1
mucous membrane of the bladder, ureters, and kidneys; externally, with the integument covering the 0
glans penis; and is prolonged into the ducts of the glands which open into the urethra, viz., the bulbourethral glands and the prostate; and into the ductus deferentes and vesicul seminales, through the
ejaculatory ducts. In the cavernous and membranous portions the mucous membrane is arranged in
longitudinal folds when the tube is empty. Small papill are found upon it, near the external urethral
orifice; its epithelial lining is of the columnar variety except near the external orifice, where it is
squamous and stratified.

The submucous tissue consists of a vascular erectile layer; outside this is a layer of unstriped 1
muscular fibers, arranged, in a circular direction, which separates the mucous membrane and 1
submucous tissue from the tissue of the corpus cavernosum urethr.
Congenital defects of the urethra occur occasionally. The one most frequently met with is where there 1
is a cleft on the floor of the urethra owing to an arrest of union in the middle line. This is known 2
as hypospadias, and the cleft may vary in extent. The simplest and by far the most common form is
where the deficiency is confined to the glans penis. The urethra ends at the point where the extremity of
the prepuce joins the body of the penis, in a small valve-like opening. The prepuce is also cleft on its
under surface and forms a sort of hood over the glans. There is a depression on the glans in the position
of the normal meatus. This condition produces no disability and requires no treatment. In more severe
cases the cavernous portion of the urethra is cleft throughout its entire length, and the opening of the
urethra is at the point of junction of the penis and scrotum. The under surface of the penis in the middle
line presents a furrow lined by a moist mucous membrane, on either side of which is often more or less
dense fibrous tissue stretching from the glans to the opening of the urethra, which prevents complete
erection taking place. Great discomfort is induced during micturition, and sexual connection is
impossible. The condition may be remedied by a series of plastic operations. The worst form of this
condition is where the urethra is deficient as far back as the perineum, and the scrotum is cleft. The
penis is small and bound down between the two halves of the scrotum, so as to resemble an
hypertrophied clitoris. The testes are often retained. The condition of parts, therefore, very much
resembles the external organs of generation of the female, and many children the victims of this
malformation have been brought up as girls. The halves of the scrotum, deficient of testes, resemble the
labia, the cleft between them looks like the orifice of the vagina, and the diminutive penis is taken for
an enlarged clitoris. There is no remedy for this condition.
A much more uncommon form of malformation is where there is an apparent deficiency of the upper 1
wall of the urethra; this is named epispadias. The deficiency may vary in extent; when it is complete 3
the condition is associated with extroversion of the bladder. In less extensive cases, where there is no
extroversion, there is an infundibuliform opening into the bladder. The penis is usually dwarfed and
turned upward, so that the glans lies over the opening. Congenital stricture is also occasionally met
with, and in such cases multiple strictures may be present throughout the whole length of the cavernous
portion.
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Background
Urethral strictures arise from various causes and can result in a range of manifestations, from an
asymptomatic presentation to severe discomfort secondary to urinary retention. Establishing effective
drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and
urologic technology is essential. Consultation with a urologist should be obtained for any patient presenting
to the emergency department with urinary retention secondary to urethral stricture disease.

Urethral

strictures.

Cross-sectional

diagram

of

the

penis.

Urethral strictures. Schematic of penile anatomy.

History of the Procedure
Urethral stricture disease has been cited as long ago as ancient Greek writings that reported establishing
bladder drainage with the passage of various catheters. Historically, the treatment consisted of urethral
dilation with sounds. Hamilton Russell described the first surgical procedure for repair of a urethral stricture
in 1914. In contemporary times, several surgical options are available.
Problem
Urethral strictures can result from inflammatory, ischemic, or traumatic processes. These processes lead to
scar tissue formation; scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance
to the antegrade flow of urine.
The term urethral stricture generally refers to the anterior urethra and is secondary to scarring in the spongy
erectile tissue of the corpus spongiosum.
A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and usually results
from a distraction injury secondary to trauma or surgery, such as radical prostatectomy. The focus of this
article is anterior urethral stricture disease.
Etiology
The most common causes of urethral stricture today are traumatic or iatrogenic. Less-common causes
include inflammatory or infectious, malignant, and congenital. Infectious urethral strictures are secondary
typically to gonococcalurethritis, which remains common in certain high-risk populations.
Pathophysiology
Urethral strictures occur after an injury to the urothelium or corpus spongiosum causes scar tissue to form.
A congenital stricture results from inadequate fusion of the anterior and posterior urethra, is short in length,
and is not associated with an inflammatory process. This is an extremely rare cause.
Presentation
The most common presentation includes obstructive voiding symptoms, urinary retention, or urinary tract
infections. Obstructive voiding symptoms are characterized by a decreased force of stream, incomplete

emptying of the bladder, urinary terminal dribbling, and urinary intermittency. These symptoms are
progressive in many patients.
Indications
Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding
symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when conservative
management fails.
Relevant Anatomy
The urethra is divided into anterior and posterior segments. The anterior urethra (from distal to proximal)
includes the meatus, fossa navicularis, penile or pendulous urethra, and bulbar urethra. The posterior urethra
(from distal to proximal) includes the membranous urethra and the prostatic urethra.
The urethra lies within the corpus spongiosum, beginning at the level of the bulbous urethra and extending
distally through the length of the penile urethra. The bulbar urethra begins at the root of the penis and ends at
the urogenital diaphragm. The penile urethra has a more central position within the corpus spongiosum in
contrast to the bulbous urethra, which is more dorsally positioned.
The membranous urethra involves the segment extending from the urogenital diaphragm to the
verumontanum.
The prostatic urethra extends proximally from the verumontanum to the bladder neck. The soft-tissue layers
of the penis, from external to internal, include the skin, superficial (dartos) fascia, deep (Buck) fascia, and
the tunica albuginea surrounding the corpora cavernosa and corpus spongiosum.
The superficial vascular supply to the penis comes from the external pudendal vessels, which arise from the
femoral vessels. The external pudendal vessels give rise to the superficial dorsal penile vessels that run
dorsolaterally and ventrolaterally along the penile shaft, providing a rich vascular supply to the dartos fascia
and skin. The deep penile structures receive their arterial supply from the common penile artery, which
arises from the internal pudendal artery. The common penile artery gives off several branches, including the
bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus spongiosum receives a dual blood
supply via anastomoses between dorsal and urethral artery branches in the glans.
The scrotum receives its vascular supply via branches from both the external and internal pudendal arteries.

Urethral

strictures.

Cross-sectional

diagram

of

the

penis.

Urethral strictures. Schematic of penile anatomy.

Contraindications
Urinary tract infections should be adequately treated prior to treatment.
Malignancy should be ruled out with an endoscopic biopsy.
Imaging Studies
Urethral strictures are diagnosed based on a suggestive history, findings on physical examination, and
radiographic or endoscopic techniques. The entire urethra, both proximal and distal to the strictured area,
must be evaluated endoscopically and/or radiographically prior to any surgical intervention.
Radiographic evaluation of the urethra with contrast studies is best achieved by retrograde urethrogram or
antegrade cystourethrogram if the patient has an existing suprapubic catheter. Retrograde urethrograms and
antegrade cystourethrograms are usually obtained through the radiology department, although the urologist
can perform them directly. These studies can be used to diagnose and define the extent of the urethral
stricture. Accurately documenting the extent and location of the stricture is important so that the most
effective treatment options can be offered to the patient.
The technical aspects of a retrograde urethrogram involve placing a nonlubricated 8F or 10F urethral
catheter into the fossa navicularis and inflating the balloon with 1-3 mL of sterile water until the balloon
occludes the urethral lumen. A scout film is obtained. Approximately 10 mL of iodinated contrast media is

then injected into the catheter under fluoroscopy, and images of the anterior urethra are taken. Extreme
pressure during the injection phase can lead to extravasation and should be avoided. Do not mistake the
membranous urethra for a stricture. On a retrograde urethrogram, the membranous urethra lies between the
distal end of the verumontanum and the conical tip of the bulbous urethra.

Retrograde

Urethral

obliteration of the bulbous urethra.

pan-urethral stricture disease.

urethrogram

strictures.

demonstrating

Retrograde

bulbar

urethrogram

urethral

demonstrating

stricture.

complete

Retrograde urethrogram demonstrating

Urethral strictures. Retrograde urethrogram

demonstrating patent urethra after buccal mucosa urethroplasty.

Urethral
strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary
anastomosis.
An antegrade cystourethrogram involves distending the bladder with water-soluble contrast media via a
suprapubic tube or urethral catheter. A scout film is taken before administration of contrast material. Once
the bladder is fully distended with contrast media, the suprapubic tube is clamped or the urethral catheter is
removed and the patient is asked to void. Spot films are taken before, during, and after the voiding phase.
This study can help delineate the posterior urethral anatomy.
Ultrasonography of the male urethra can be useful in evaluating urethral strictures. A transducer can be
placed longitudinally along the phallus, within the lumen of the urethra or along the perineum.
Ultrasonography can be used to evaluate the stricture length and the degree and depth of spongiofibrosis.
Several authors have described techniques that involve distension of the urethra with normal saline instilled
in a retrograde fashion prior to ultrasonography. Ultrasonography demonstrates thicker periurethral tissues at
the level of the stenosis compared to unaffected areas of the urethra. Ouattara et al (2004) showed that
urethral strictures identified on perineal sonograms were significantly longer than those identified on
retrograde urethrography and voiding cystourethrography.[1]
A study by Zhang et al evaluated patients with conventional voiding and retrograde urethrography and 64row multidetector CT (64-MDCT) urethrography and found that 64-MDCT urethrography is a useful
alternative to traditional radiographic methods for defining male urethral strictures.[2]
Diagnostic Procedures
Endoscopic evaluation can be conducted by flexible or rigid cystourethroscopy. Flexible cystourethroscopy
can be performed with little discomfort to the patient using only local anesthesia, such as 2% lidocaine jelly
intraurethrally.
Medical Therapy
There is no medical therapy to treat urethral stricture disease.
Surgical Therapy
Urethral dilation
Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to
stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial
strictures (no involvement of corpus spongiosum).
Internal urethrotomy
Internal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision
allows for release of scar tissue. Success depends on the epithelialization process finishing before wound
contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the
12 o'clock position, either with a cold knife or urethrotome or a hot knife that uses electrocautery to cut
through the scar tissue. Care must be taken not to injure the corpora cavernosa because this could lead
to erectile dysfunction.
Complications include recurrence of stricture, which is the most common complication, bleeding, or
extravasation of irrigation fluid into perispongial tissues, thus increasing the fibrotic response. The curative

success rate is reported as 20%-35%, with no increase in the success rate with a second internal urethrotomy
procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound
contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to
reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates by
maintaining patency of the urethral lumen. However, strictures typically return once the patient stops.[3]
Permanent urethral stents
Permanent urethral stents are placed endoscopically. Stents are designed to be incorporated into the wall of
the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous
urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting
or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated
in patients with dense strictures and in patients with prior substitution urethral reconstruction because it
elicits a hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo
lengthy open urethral reconstruction procedures.[4]

Urethral strictures. Photograph of a permanent urethral stent.

Open Reconstruction
Primary repair
Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis. The key
technical points that must be followed include complete excision of the area of fibrosis, tension-free
anastomosis, and widely patent anastomosis. Primary repair is typically used for stricture lengths of 1-2 cm.
With extensive mobilization of the corpus spongiosum, strictures 3-4 cm in length can be repaired using this
technique. Morey et al (2004) reported on a series of patients who underwent excision with anastomosis for
strictures up to 5 cm.[5]Younger patients have more compliant tissue, thus allowing for greater stretch and
more ambitious attempts at primary repair. The repair is left stented with a small silicone catheter in the
urethra. The bladder is drained with a suprapubic catheter.
Repairs involving tissue-transfer techniques

Technical points for free graft repair

Success depends on the blood supply of local tissues at the site of placement.
Pendulous urethral strictures may be repaired with the patient in the supine or split-legged
position. Bulbar or membranous urethral strictures are repaired with the patient in the exaggerated
lithotomy position.
The urethra is exposed through a penile or perineal incision.
The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from
the desired nonhair-bearing location. For example, bladder, buccal, or rectal mucosa are potential options.
The graft is sutured to the edges of the urethrotomy. The graft is covered by the dartos fascia of the
pendulous or bulbous urethra. Incisions are closed in 2 layers with an absorbable suture, and a Penrose
drain is placed through a separate incision in the suprapubic or perineal areas.
Full-thickness skin graft: Nonhair-bearing skin should be used. It is most successful in the area of
the bulbar urethra.
Split-thickness skin graft: The split-thickness skin graft is not preferred with a single-stage repair
because of the contraction characteristics of the graft. It is typically reserved for use in patients for whom
multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is
conducted as a 2-stage procedure.
First stage: The urethra is opened via a ventral midline incision down to the level of healthy
urethra. The scarred urethra is excised completely. The dartos fascia is mobilized bilaterally and then
closed in the midline over the scarred urethral bed. A split-thickness skin graft is harvested from a desired
nonhair-bearing location. The graft is transferred to the ventrum of the penis and sutured to the dartos-

covered urethral bed, and the proximal aspect is anastomosed in a spatulated fashion to the proximal
urethral stump. Xeroform gauze and Dacron padding are used to cover the graft and are secured with
supporting sutures. A 14F soft silicone catheter is placed into the urethra and bladder for stenting. Urine is
diverted with a suprapubic tube. The Dacron and Xeroform padding is removed after 5-6 days. The
suprapubic tube is removed after 2 weeks.
Second stage: Closure takes place in 6-9 months if the graft has succeeded. A 3-cmwide
strip of skin is marked along the ventrum of the penis, which is to be used as the neourethra. A superficial,
skin-deep incision is made along the marked lines. Care must be taken to spare the underlying dartos
fascia. The skin strip is developed using the tissue plane between the penile skin and dartos fascia. The
skin strip is fashioned into a neourethra as it is inverted using interrupted absorbable sutures. This is
followed by a watertight closure using absorbable sutures in a running fashion. A small suction drain is left
in the periurethral area, and the skin is closed. The drain is removed on postoperative day 3. A 14F soft
silicone catheter is passed through the reconstructed urethra for stenting purposes.Urinary diversion is
accomplished via a suprapubic tube for 3 weeks.
Buccal mucosal graft: This tissue is resistant to infection and trauma.
The epithelium is thick, making it easy to handle. The lamina propria is thin and highly
vascular, thus allowing for efficient imbibition and inosculation. Harvesting is easier than with other free
grafts or pedicled flaps. A 15- to 20-mm graft is harvested from the oral mucosa. Larger grafts can be
harvested depending on the length of the stricture. Most surgeons prefer to close the buccal harvest site
primarily. Care is taken to avoid the opening of the duct originating from the parotid gland. The duct for
this salivary gland is also known as Stensen duct.
The graft is sutured to the edge of the urethra. A Penrose drain is left in the incision bed for
24 hours to allow drainage. A 16F urethral catheter is left for 7 days. Suprapubic urinary drainage is
continued for 2 weeks. The suprapubic tube is removed in 2 weeks, after voiding cystourethrogram
demonstrates no extravasation of urine. The graft may be placed as a ventral, dorsal, or lateral onlay.
Dorsal and lateral onlay procedures allow for the advantage of securing the graft to the corpora cavernosa
(dorsal) or the ischiocavernosus muscle (lateral). This technique is performed with the hope of improving
graft host bed immobilization and approximation. If a ventral urethrotomy and onlay are to be used, then a
spongioplasty maneuver should be used to facilitate graft immobilization. This requires a relatively normal
corpus spongiosum without fibrosis. Some reports have demonstrated superiority of the dorsal onlay

technique, whereas some data do not demonstrate a difference. [6]

Urethral
strictures. A buccal mouth graft has been harvested from the inner aspect of the cheek. The graft size is

measured to accommodate the length of urethra involved in the onlay.

Urethral
strictures. The buccal mucosal grafts have been secured to the corpora cavernosa. The anastomosis will run
along either side of the dorsum of the urethral edges to complete the dorsal onlay. The glans penis (distal)
is at the top of the picture. The catheterized urethra with a dorsal urethrotomy is on the left.
Bladder mucosal graft: This is not as popular as other free tissue grafts because of difficulty in
harvesting and handling the tissue.

Pedicled skin flaps

These procedures are based on the principal of mobilizing an island of epithelium-bearing tissue with a
pedicle of fascia to provide its own blood supply. Penile skin represents an ideal tissue substitute because it
is thin and mobile and has an excellent blood supply. Moreover, the distal penile skin is typically nonhairbearing.

Skin island onlay flaps: Transverse, longitudinal, and circumferential island flaps refer to the type of
skin incision made to fashion the tissue flap. Dorsal and ventral onlay refer to the position in which the
flap is sutured to the edge of the incised urethra, as in the dorsal or ventral position with respect to the
urethra and corpora cavernosa. Penile incision is carried out through the skin, dartos fascia, and down to
Buck fascia. A skin island flap is elevated on the penile dartos fascia, which serves as the vascular supply.
A lateral urethrotomy is made along the course of the strictured area. The skin island flap is then
transposed to the incised strictured area, oriented into proper position, and sutured to the edges of the
urethrotomy incision with an absorbable monofilament suture. A watertight subepithelial suture line should
complete the flap placement. The skin is closed with interrupted sutures.
Hairless scrotal island flap: A nonhair bearing area of skin in the midline of the scrotum is used. The
tunica dartos of the scrotum is used as the vascular pedicle. This procedure typically is used in complex
urethroplasty procedures and is combined with penile skin island flaps to provide additional vascularized
tissue for reconstruction.
Skin island tubularized flap: It can be used in combination with onlay flap when a large obliterated
segment of urethra is present. It involves tubularizing the pedicled skin flap over a sound and

anastomosing the tubularized edge to the native urethral stump.

Urethral

strictures. Photograph of open urethroplasty depicting the pedicled flap.

Urethral strictures. Photograph depicting pedicled flap anastomosed to the left side of the urethra. Suturing

of the right side of the pedicled flap to the urethra completes the anastomosis.
Urethral strictures. The anastomosis of the pedicled flap is complete. The pedicle of the flap (left side)
originates from the dorsolateral aspect of the penis. The glans penis (distal) is at the top of the photograph.
Preoperative Details
The patient should be evaluated and deemed medically stable for the selected procedure. Urine culture
should be sterile. Urethral stricture disease should be thoroughly evaluated with radiographic and/or

endoscopic techniques. The procedure selection should be discussed thoroughly with the patient in advance,
and the discussion should include information on the risks and benefits of the procedure and postoperative
care. Risks include, but are not limited to, bleeding, infection, recurrence of stricture, and urethrocutaneous
fistula formation.
Intraoperative Details
Position the patient in the supine, split-legged, or exaggerated lithotomy position. Take great care to pad
pressure points and position joints to avoid inappropriate strain or torque.
For open repair procedures, shave and prepare the perineum, penis, and scrotum.
Administer intravenous antibiotics prior to making the incision.
Postoperative Details
Patients are placed on bedrest for 24-48 hours, depending on the extent of the procedure.
Intravenous antibiotics are continued for 24 hours and then followed with oral culture-specific
antibiotics or antibiotics with good gram-negative coverage.
Antimuscarinic agents are often used to prevent bladder spasms.
Drains, if necessary, are typically removed on postoperative day 1-3.
Wounds should be washed with soap and water daily after drains are removed.
The patient may be discharged when afebrile, ambulatory, tolerant of a regular diet, and competent in
managing drains, catheters, and wound care.
Follow-up
Patients undergoing internal urethrotomy should return to the outpatient clinic for catheter removal
on postoperative day 3-5.
Patients undergoing open repair should return to the outpatient clinic on postoperative day 3 for
wound evaluation and removal of drains.
Prior to removal of the suprapubic catheter, a voiding cystourethrogram is conducted with contrast,
instilled through the suprapubic tube. If contrast extravasation is not evident and the suture line is intact, the
urethral catheter is removed and the suprapubic tube capped.
If the patient continues to void well, the suprapubic catheter is removed after 1 week.
When all tubes are removed and no evidence of infection is present, antibiotics may be discontinued.
Urethral evaluation should be conducted with retrograde urethrogram or flexible cystoscopy at 4
months and 1 year postoperatively.
Complications
Postoperative urinary tract infection and wound infections are rare complications of surgery to repair
urethral strictures. Although there is no universal protocol for prescribing antibiotics postoperatively, most
surgeons provide a short course of antimicrobials to minimize infections. Importantly, a sterile culture
should be documented prior to bringing the patient to the operating room. In the event that a urine culture is
positive for bacterial growth, culture-specific antibiotics should be prescribed prior to the procedure.

Complications associated with individual procedures include the following:

Urethral dilation: Recurrence of the urethral stricture is the most common complication. Dilation of a
urethral stricture is appropriate for patients with isolated epithelial strictures without scarring of the corpus
spongiosum. Although rare, dilations can lead to urethral trauma caused by passage of the instrument
through the urothelium into the corpus spongiosum or perispongial tissues. This risk can be minimized
with careful technique and appropriate selection of patients for dilation.
Internal urethrotomy: Recurrence of the stricture is the most common complication, with up to 80%
of strictures recurring after an internal urethrotomy. Persistent postoperative bleeding can occur. The
placement of a urinary catheter postoperatively provides intraluminal tamponade of superficial blood
vessels. Extravasation of irrigation can precipitate a fibrotic response within the perispongial tissues.
Permanent urethral stents: Distal migration of a urethral stent can lead to the complications of pain
while sitting or during intercourse. Large multicenter studies have identified short-term risks of perineal
discomfort and dribbling. Long-term risks include painful erections, mucous hyperplasia, recurring
strictures, and urinary incontinence.

Open reconstructive techniques

o
Large series describing the use of an end-to-end anastomosis after excision of the strictured
urethral segment report high success rates. Barbagli et al (2007) reported on a series of 153 patients
undergoing this repair for bulbar urethral strictures. Most of the strictures were less than 2 cm in length.
Ninety-one percent of patients responded after the single repair.[7]
o
Postoperative chordee and penile shortening after an excision and primary anastomosis is a
concern. Appropriate patient selection and mobilization of the distal urethra may minimize these risks.
Younger patients are less likely to experience these complications, as they have more compliant urethral
tissue.
o
Other reported complications include ejaculatory dysfunction. Recent reports assert that
sparing periurethral musculature such as the bulbospongiosus muscle can minimize postoperative
ejaculatory dysfunction. Less commonly, decreased penile glans sensitivity, coldness of the glans during
erection, and a glans that is not swollen during erection have been documented.
o
Onlay procedures use tissue transfer techniques, including skin flaps, rather than a graft, such
as buccal mucosa. Complications include postvoid dribbling caused by postoperative diverticulum,
retraction of the ventral skin of the penis, and urethrocutaneous fistula. Most experts agree that surgical
technique and experience with tissue transfer techniques play a large role in maximizing outcomes and
minimizing complications.
o
Oral complications after buccal mucosal harvesting: Buccal mucosal harvesting is an
important tool in the urologists armamentarium in treating urethral stricture disease. The harvesting
procedure is considered well-tolerated but does carry a risk of long-term complications. Several authors
have monitored patients postoperatively after a buccal mucosal harvesting procedure. Oral pain over the
harvest site resolves within the first month postoperatively. Persistent numbness, tightness, or coarseness
over the harvest site has been reported in patients as late as 2 years postoperatively. Dublin and Stewart
(2004) reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported
that they would undergo the same procedure again.[8] Most experts agree that the potential for long-term
complications such as persistent neurosensory deficits and tightness, albeit rare, should be discussed with
the patient preoperatively.
Outcome and Prognosis
Urethral dilation and internal urethrotomy
A prospective randomized comparison of internal urethrotomy and urethral dilation for male urethral
strictures found no significant difference in efficacy between the two procedures when used as initial
treatment.[3] Recurrence rates increased as the length of the stricture increased. Recurrence rates at 12 months
were 40%, 50%, and 80% for stricture lengths of less than 2 cm, 2-4 cm, and greater than 4 cm, respectively.
The recurrence rate for strictures 2-4 cm long increased to 75% at 48 months of follow-up.
Permanent urethral stents
Five-year follow-up data demonstrated a long-term success rate of 84% and high level of patient
satisfaction.[4] Failures typically occurred in patients with extensive stricture disease. The North American
Study Group 11-year data demonstrated an overall success rate of less than 30%. [9] A European group
reported 2 out of 15 satisfied patients 10 years postimplantation. [10] An Italian multicenter study following 94
cases reported on the short- and long-term complications.[11] Short-term complications (7-28 d following the
procedure) included perineal discomfort (86%) and dribbling (14%). Long-term complications included
painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%).
Additionally, some unique complications are associated with permanently implantable stents. The stents are
designed for placement within the bulbous urethra. If they are placed distally, there is a risk of pain upon
sitting and intercourse.
Excision with primary anastomosis
This form of repair for anterior urethral strictures is considered to be the criterion standard. Historically, this
technique has been reserved for strictures shorter than 2 cm. Better understanding of the anatomy has led to
successful application of this repair to longer strictures. Jordan and Schlossberg (2007) reported 3
recurrences among 220 patients undergoing primary repair, with a mean follow-up period of 44 months.

[12]

Mundy (2006) performed an analysis of a large series of urethral reconstructions and described a durable
rate after primary repair that does not deteriorate with time.[13]
Free graft repair
These procedures have an overall success rate of 84.3%. Mundy's analysis demonstrated a 95% success rate
with graft reconstructions when the follow-up was limited to 1 year. Longer follow-up showed deterioration
over time.[13]
Pedicled skin flaps
The overall success rate is 85.5%. Skin island onlay flap with preservation of the urethral plate provides
better success rates than the tubularized flap. Tubularized island flaps have lower success rates than skin
island onlay flaps secondary to stricture formation at the site of anastomosis with the native urethra.[14]
A meta-analysis showed equivalent results when comparing graft versus flap reconstruction. [15] Many authors
believe grafts are better suited for proximal reconstruction than flaps for distal reconstruction when all other
variables are equivalent.[16]
Postoperative erectile dysfunction
Overall, the rates of erectile dysfunction after urethral reconstruction are low. Reported rates are as low as
2%.[12] Patients with severe straddle injuries were particularly at risk. A series of 200 patients who underwent
anterior urethroplasties demonstrated that the rate of erectile dysfunction was comparable to that after
circumcision. Patients who had longer segments of their urethra reconstructed were at higher risk. In this
analysis, erectile dysfunction did improve over time.[17]
A study to evaluate whether the type of one-stage urethroplasty has any influence on recovery from erectile
dysfunction found that although the procedure has a probability of causing erectile dysfunction in as many
as 20% of patients, the type of urethroplasty has no bearing on recovery, which generally occurs within 6
months.[18]
Future and Controversies
Many techniques are available for the treatment of urethral stricture disease. Based on the literature, each
technique clearly cannot be applied successfully to every situation. Urologist who treats patients with
urethral strictures must be experienced in several techniques. Each technique has advantages and
disadvantages. Recently, buccal mucosa free graft urethroplasty has received favorable attention because of
its excellent early results and decreased level of difficulty compared with those of pedicled skin flaps. So far,
a prospective randomized study comparing free grafts with tissue flaps has not been conducted.
The role of tissue engineering and stem cells in urethral reconstruction
Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering
with the objective of creating functional replacement tissue. El Kassaby et al recently published a
randomized comparative study of buccal mucosal and acellular bladder matrix grafts. An off-the-shelf
matrix derived from the bladder was used. This biomaterial was obtained from donors and prepared via a
multistep process, resulting in the removal of all cellular components. The tissue matrix that remains
consists of collagen, elastin, growth factors, and macromolecules. Predicated on biocompatibility and the
ability to recruit urethral tissue growth in several experimental and clinical studies, this matrix was used.
With a mean follow-up period of 25 months in patients with a healthy urethral bed, the success rates for the
acellular bladder matrix were similar to those using buccal mucosa. In patients who had undergone two or
more prior urethral surgeries with significant spongiofibrosis, the success rate significantly deteriorated for
the acellular matrix relative to buccal mucosa. This study demonstrates promise for the use of acellular
matrices as a viable option for urethral repair in patients with a healthy urethral bed, no fibrosis of the
corpora spongiosis, and good urethral mucosa.[19]
The Wake Forest Institute for Regenerative Medicine recently published an article discussing the potential
applications of stem cells in urology. Many of the successful experiments using stem cells for regenerative
medicine have been within the field of urology using bladder, kidney, and urethral tissue. [20] Without

question, this is an exciting and interesting field that may revolutionize the way urethral stricture disease is
treated in the future.

http://health.nytimes.com/health/guides/disease/urethral-stricture/overview.html
Urethral stricture is an abnormal narrowing of the tube that carries urine out of the body from the bladder
(urethra).
REFERENCE FROM A.D.A.M.
Back to TopCauses
Urethral stricture may be caused by inflammation or scar tissue from surgery, disease, or injury. It may also
be caused by pressure from an enlarging tumor near the urethra, although this is rare.
Other risks include:

A history of sexually transmitted disease (STD)

Any instrument inserted into the urethra (such as a catheter or cystoscope)
Benign prostatic hyperplasia (BPH)
Injury or trauma to the pelvic area
Repeated episodes of urethritis
Strictures that are present at birth (congenital) are rare. Strictures in women are also rare.
Back to TopSymptoms

Blood in the semen

Bloody or dark urine
Decreased urine output
Difficulty urinating
Discharge from the urethra
Frequent or urgent urination
Inability to urinate (urinary retention)
Incontinence
Painful urination (dysuria)
Pain in the lower abdomen
Pelvic pain
Slow urine stream (may develop suddenly or gradually)
Spraying of urine stream
Swelling of the penis
Back to TopExams and Tests
A physical examination may show the following:

Decreased urinary stream

Discharge from the urethra
Enlarged (distended) bladder
Enlarged or tender lymph nodes in the groin (inguinal) area
Enlarged or tender prostate
Hardness (induration) on the under surface of the penis
Redness or swelling of the penis
Sometimes the exam reveals no abnormalities.

Tests include the following:

Cystoscopy
Post-void residual (PVR) volume
Retrograde urethrogram
Tests for chlamydia and gonorrhea
Urinalysis
Urinary flow rate
Urine culture
Back to TopTreatment
The urethra may be widened (dilated) during cystoscopy by inserting a thin instrument to stretch the urethra
while you are under local anesthesia. You may be able to treat your stricture by learning to dilate the urethra
at home.
If urethral dilation is not successful or possible, you may need surgery to correct the condition. Surgical
options depend on the location and length of the stricture. If the stricture is short and not near the urinary
sphincter, options include cutting the stricture via cystoscopy or inserting a dilating device.
An open urethroplasty may be done for longer strictures. This surgery involves removal of the diseased part
followed by reconstruction. The results vary depending on the size and location, the number of treatments
you have had, and the surgeon's experience.
In cases of acute urinary retention, a suprapubic catheter may be placed as an emergency treatment. This
allows the bladder to drain through the abdomen.
There are currently no drug treatments for this disease. If all else fails, a urinary diversion -appendicovesicostomy (Mitrofanoff procedure) -- may be done. This allows you to perform selfcatheterization of the bladder through the wall of the abdomen.
Back to TopOutlook (Prognosis)
Treatment usually results in an excellent outcome. However, repeated therapies may be needed to remove
the scar tissue.
Back to TopPossible Complications
Urethral stricture may totally block urine flow, causing acute urinary retention. This condition must be
treated quickly.
Back to TopWhen to Contact a Medical Professional
Call your health care provider if symptoms of urethral stricture occur.
Back to TopPrevention
Practicing safer-sex behaviors may decrease the risk of getting sexually transmitted diseases and urethral
stricture.
Treating urethral stricture quickly may prevent complications such as kidney or bladder infection or injury.

http://emedicine.medscape.com/article/1893882-overview#showall
Background
Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned
component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly
to refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to

empty his or her bladder appropriately and urethral catheterization is either undesirable or impossible,
suprapubic cystostomy offers an effective alternative.
Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows:

Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis
Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall,
above the pubic symphysis, with or without ultrasound guidance or visualization through flexible
cystoscopy
This article focuses on the percutaneous approach because this method can potentially be performed in
outpatient, bedside, or urgent care settings.
Relevant Anatomy
The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective
tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic
space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to
neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.
The body of the bladder receives support from the external urethral sphincter muscle and the perineal
membrane inferiorly and the obturator internus muscles laterally (see the image below).

Gross anatomy of the bladder.

For more information about the relevant anatomy, see Bladder Anatomy. See alsoFemale Urinary Organ
Anatomy and Male Urinary Organ Anatomy.
Indications
At least 4 situations exist in which suprapubic cystostomy is considered:
Acute urinary retention in which a urethral catheter cannot be passed (eg, because of prostatic
enlargement secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or false passages, or
bladder neck contractures secondary to previous surgery)

Urethral trauma

Management of a complicated lower genitourinary tract infection

Requirement for long-term urinary diversion (eg, because of neurogenic bladder)

Acute urinary retention without urethral catheterization

For a patient who is difficult to catheterize transurethrally, various steps are suggested before suprapubic
cystostomy is performed (see the image below).[1]

Algorithm
for
managing
difficult-to-catheterize patient. Arrows indicate next reasonable step; horizontal lines indicate that either
option is reasonable.
Failure to pass a urethral catheter may result from a false passage created by multiple attempts at urethral
catheterization or from urethral stricture disease. After a reasonable attempt at catheterization has been
made, including use of a coud catheter, and if a urologist is not available to perform a flexible cystoscopy
with potential catheter placement over a wire, a suprapubic cystostomy is reasonable.
Urethral trauma
In the setting of urethral trauma, functional bypass of the urethra may be required because of the possibility
of urethral disruption. Urethral disruption is usually associated with pelvic fractures or saddle-type injuries
and should be suspected when the triad of (1) blood at the urethral meatus, (2) inability to urinate, and (3) a
palpably distended bladder is observed. The urethral injury should be addressed by a urologist; however, a
suprapubic cystostomy may be a valuable measure for emergency drainage of the bladder.
Complicated lower genitourinary infection
In a complicated infection of the lower genitourinary tract (eg, acute bacterial prostatitis with urinary
retention, urinary diversion with suprapubic cystostomy should be considered. A suprapubic catheter is
necessary until the infection is fully treated with antimicrobials.
Another indication for suprapubic catheter placement is the Fournier gangrene, which often necessitates
multiple genitourinary debridement procedures and, potentially, skin grafting. A suprapubic cystostomy
diverts the urine from these surgical sites very effectively. A urethral catheter would impede wound care and
surgical management of this complicated, dangerous disease.
Long-term urinary diversion

Suprapubic catheterization may also be considered as an option in patients who require long-term urinary
diversion. The British Association of Urological Surgeons issued practice guidelines suggesting that
clinicians should consider whether a suprapubic catheter would be preferable to an urethral catheter for
patients who require a long-term indwelling catheter.[2]
A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord
injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who are unable to void and
who are unable or unwilling to perform clean intermittent catheterization.[3, 2]
Patients who undergo phallic reconstruction or fistula repair[1] may also require longer-term urinary
diversion. In a retrospective study that included more than 10 years of follow-up data from 179
predominantly male patients with spinal cord injuries, similar rates of urinary tract infections, bladder and
renal calculi, and renal function preservation were reported for those managed with urethral catheters and
those managed with suprapubic catheters.[4]
In this study,[4] urethral strictures, urethral fistulas, and scrotal abscesses were found only in the urethral
catheter group; 3 patients with urethral strictures and 3 patients with urethral-cutaneous fistulas switched to
suprapubic catheters as a result of these complications. Catheter-specific complications included erosion
associated with urethral catheters and leakage around the suprapubic catheter site and from the urethra.
Contraindications
Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances:
The bladder is not distended, is not easily palpable, or cannot be localized with ultrasonographic
assistance

The patient has a history of bladder cancer

Relative contraindications include the following:

Coagulopathy
Previous lower abdominal or pelvic surgery (because of the possibility of adhesions between the
bowel and the bladder)

Pelvic cancer, with or without a history of irradiation (because of the possibility of adhesions)

Placement of orthopedic hardware for pelvic fracture repair Although some reports suggest that
suprapubic tubes leading to infection of hardware is a relatively rare complication, [5] consult with the
orthopedist before performing suprapubic catheterization in patients with hardware
If percutaneous placement is contraindicated and an open surgical approach to suprapubic cystostomy is
necessary to provide appropriate dissection through adhesions, avoid bowel injury, and achieve effective
hemostasis, this would probably have to be done by a general surgeon or urologist in an operative setting.[3]

Technical Considerations
Procedural planning
There are 2 key issues that must be kept in mind when placement of a suprapubic cystostomy is being
considered. The first issue is whether the patients bladder can be sufficiently well drained with a urethral
catheter. If this is the case, urethral catheterization may be a more appropriate choice because it is often
easier and is associated with less short-term morbidity, especially in women and men who develop acute
urinary retention and may regain the ability to void with straightforward medical management (eg, alphablocker therapy).
On the other hand, suprapubic cystostomy may be preferable to urethral catheterization when the catheter is
needed for long-term bladder management, as in patients with neurogenic bladders. For instance, male
patients with a suprapubic cystostomy have a decreased incidence of traumatic hypospadias and a reduced
risk of urinary tract infection, prostatitis, urethritis, and epididymitis. Male patients also retain sexual
function. Female patients have a decreased incidence of urinary tract infection and can avoid development of
a patulous urethra.

If the procedure can be planned in advance, referring the patient to a urologist for an informed discussion of
elective procedures might be best. In those emergent situations where the patient is unable to empty his or
her bladder and a urethral catheter cannot be placed, suprapubic cystostomy is a viable option.
The second issue is the method that will be used to place the suprapubic cystostomy. As noted (see
Background), either an open approach or a percutaneous approach to suprapubic catheterization may be
taken. Most individuals with training in general surgery or urology find the open procedure straightforward.
Most other physicians prefer a percutaneously placed suprapubic cystostomy, which can be performed by
means of 5 different methods (see Technique). Unfortunately, the percutaneous option is not always
available.

Complication Prevention

Regardless of how a suprapubic cystostomy is placed, it is always advisable to distend the bladder during
localization of the surgical site. This affords the physician the best opportunity to find the bladder quickly
and avoid bowel injury.
In nonemergency circumstances, when the urethra cannot be cannulated and the bladder must be
decompressed, the bladder probably is already distended with urine. If the urethra can be cannulated with a
Foley catheter or a flexible cystoscope, the bladder can be distended with normal saline.To prevent gramnegative bacteremia, an appropriate preprocedural intravenous gram-negative antibiotic should be
administered before instrumentation of the genitourinary tract.[3]

What are the symptoms?

Usually the symptom starts with pain and difficulty in urination. The urine stream is very slow and may
develop either suddenly or gradually: the urine output and urinary frequency is decreased, thereby urgency is
increased. Sometimes patient gets scared to see blood in semen or urine. There is mild lower abdominal
pain. Some victims experience discharge from the urethra and penis swelling.
How do we diagnose?
You may first notice symptoms of prostate enlargement by yourself. But your doctor may find that your
prostate is enlarged during a routine check-up. Rectal Examination is usually the first test done. The doctor
inserts a gloved-finger into the rectum and feels the part of the prostate next to the rectum. This gives him a
general idea about the size and condition of the gland. Ultrasound may be recommended for accurate study.
PSA -- Prostatic Specific Antigen -- could rule out malignancy. Stricture can be easily diagnosed by its
symptoms and routine examination such as ultrasonography and cytoscopy.
What treatment is advisable?
Clinically stricture urethra is often noticed with prostatic enlargement. Men who have prostatic
enlargement with urethral stricture symptoms, usually need some kind of treatment at sometime. Most
patients ignore the symptoms until they face a "acute crisis." Early treatment is needed when the gland is just
mildly enlarged. During "crisis" dilation of the urethra may be attempted. It is a procedure adopted to stretch
the urethra by inserting a thin instrument. Urethral stricture may totally block urine flow, causing acute
urinary retention, a condition that must be alleviated quickly.
Homoeopathic medicines have wonderful power to resolve the scar tissue formation and enlargement.
These are benign tumours. Their action is similar to a fibroid uterus, warts, lipoma and cancer. Homoeo
medicines respond very well with non-specific urethritis and venereal infections. They also avoid surgery in
maximum number of cases.
I have come across few cases of prostatic enlargement and stricture urethra. The prognosis is good. I have
cured a number of cases of non-specific urethritis those which were labelled as incurable. I have also
cured few cases of bleeding diathesis confirmed with growth in urethral passage. Most of the victims get

scared of cancer and ask, Does it develop into a Cancer, doctor? Take treatment. Homoeopathy will cure.

I am now in my forties and have had several medical procedures performed over the years to treat the
urethral strictures. In my case, I have two strictures, one is is in the anterior urethra in what is known as the
bulbar urethra. The other stricture is about 3/4 of the way along the urethra. The first stricture was detected
when I was a one year old, the second was most likely caused by an injury I sustained when I was six years
old due to a straddle injury. I was walking on a raised railway tie and fell, straddling the railway tie. Yes it
did hurt.

http://strictureurethra.wordpress.com/article/anatomy-and-pathophysiology-of-urethral-strictures/

Anatomy and Pathophysiology of

Urethral Strictures
Sanjay B. Kulkarni MS, FRCS
February 8, 2012

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Mang Chen

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The male urethra is divided in to anterior part of meatus, penile and bulbar
portions and posterior part of membranous and prostatic urethra.
The anterior urethra is surrounded by corpora spongiosa and the narrowing of the
urethral lumen due to spongiofibrosis is called a stricture. The posterior urethra is
devoid of corpora spongiosa and the urethral narrowing is termed as stenosis.
In the penile portion the urethra lies in the center of spongiosa and in the bulbar
portion the urethra lies dorsally in the spongiosa. So dorsal urethrotomy causes
less bleeding and is more popular compared to ventral urethrotomy during
urethroplasty.
Normal urethra is pink as the blood filled spongy tissue surrounds the urothelium.
Spongiofibrosis does not allow the blood flow and urethra is white at the site of
the stricture.
Stricture due to trauma in the bulbar urethra can be treated by excision and end
to end anastomosis as we have normal urethra on both sides of the trauma.
In a non traumatic bulbar stricture, we have white strictured urethra and gray
urethra between the white and pink normal urethra due to subepithelial
spongiofibrosis. Anastomosis of the two gray urethras may lead to restricture
formation later.
The bulbar urethra has blood supply from proximal to distal end with the bulbar
arteries. It also gets blood supply in a retrograde fashion through the cavernosa

in to glans and penile urethra. It also gets blood supply laterally from cavernosa
through circumflex vessels.
When we mobilize the bulbar urethra from cavernosa the lateral blood supply is
lost. If we transect the bulbar urethra the distal portion loses its proximal blood
supply.
And the distal spongiofibrotic urethra already has compromised blood flow. So
transection of bulbar urethra should be avoided whenever possible. Unless it is
already transected by trauma.
Bulbar urethra can be opened dorsally or ventrally with longitudinal urethrotomy.
Ventral urethrotomy does not need mobilization of the bulbar urethra, so Asopas
technique of ventral urethrotomy and dorsal onlay graft works well.
http://link.springer.com/content/pdf/10.1007/978-1-59745-103-1_6#page-1
http://gardamd.blogspot.com/2012/05/trauma-uretra_26.html

Trauma Uretra

PENDAHULUAN
Trauma saluran kemih sering tak terdiagnosa atau terlambat terdiagnosa karena perhatian penolong sering
tersita oleh jejas-jejas ada di tubuh dan anggota gerak saja, kelambatan ini dapat menimbulkan komplikasi yang
berat seperti perdarahan hebat dan peritonitis, oleh karena itu pada setiap kecelakaan trauma saluran kemih harus
dicurigai sampai dibuktikan tidak ada.7
Trauma saluran kemih sering tidak hanya mengenai satu organ saja, sehingga sebaiknya seluruh sistem
saluran kemih selalu ditangani sebagai satu kesatuan. Juga harus diingat bahwa keadaan umum dan tanda-tanda
vital harus selalu diperbaiki/dipertahankan, sebelum melangkah ke pengobatan yang lebih spesifik. 7
Trauma urethra biasanya terjadi pada pria jarang pada wanita. sering ada hubungan dengan fraktur pelvis
dan straddle injuri. Trauma uretra biasanya lebih sering pada anak-anak laki-laki dibandingkan dewasa yaitu pada
usia sekitar 15 tahun. Urethra pria terdapat dua bagian yaitu anterior yang terdiri dari urethra pars glanularis, pars
pendulans, pars bulbosa dan posterior yang terdiri dari pars membranacea dan pars prostatika. Bagian-bagian uretra
dapat mengalami laserasi, transeksi atau kontusio. Penangannya berdasarkan berat ringannya trauma. 1

TINJAUAN PUSTAKA
A. ANATOMI URETRA
Uretra adalah saluran yang dimulai dari orifisium uretra interna dibagian buli-buli sampai orifisium uretra
eksterna glands penis, dengan panjang yang bervariasi. Uretra pria dibagi menjadi dua bagian, yaitu bagian anterior
dan bagian posterior. Uretra posterior dibagi menjadi uretra pars prostatika dan uretra pars membranasea. Uretra
anterior dibagi menjadi meatus uretra, pendulare uretra dan bulbus uretra. Dalam keadaan normal lumen uretra
laki-laki 24 ch, dan wanita 30 ch. Kalau 1 ch = 0,3 mm maka lumen uretra laki-laki 7,2 mm dan wanita 9 mm. 3
1. Urethra bagian anterior
Uretra anterior memiliki panjang 18-25 cm (9-10 inchi). Saluran ini dimulai dari meatus uretra, pendulans
uretra dan bulbus uretra. Uretra anterior ini berupa tabung yang lurus, terletak bebas diluar tubuh, sehingga kalau
memerlukan operasi atau reparasi relatif mudah.
2. Urethra bagian posterior
Uretra posterior memiliki panjang 3-6 cm (1-2 inchi). Uretra yang dikelilingi kelenjar prostat dinamakan
uretra prostatika. Bagian selanjutnya adalah uretra membranasea, yang memiliki panjang terpendek dari semua
bagian uretra, sukar untuk dilatasi dan pada bagian ini terdapat otot yang membentuk sfingter. Sfingter ini bersifat
volunter sehingga kita dapat menahan kemih dan berhenti pada waku berkemih. Uretra membranacea terdapat
dibawah dan dibelakang simpisis pubis, sehingga trauma pada simpisis pubis dapat mencederai uretra membranasea.
B. PEMBAGIAN
Berdasarkan anatomi, trauma uretra dibagi atas trauma uretra posterior yang terletak proksimal diafragma
urogenital dan trauma uretra anterior yang terletak distal diafragma urogenital. Hal ini karena keduanya
menunjukkan perbedaan dalam hal etiologi trauma, tanda gejala klinis, pengelolaan serta prognosisnya. 1,2

Trauma uretra posterior

Trauma uretra posterior yang terdiri dari pars membranacea dan pars prostatika. Trauma uretra posterior
hampir selalu disertai fraktur tulang pelvis. Akibat fraktur tulang pelvis, terjadi robekan pars membranacea karena
prostat dengan uretra pars prostatika tertarik ke cranial bersama fragmen fraktur, sedangkan uretra pars
membranasea terikat di diafragma urogenital. Trauma uretra posterior dapat terjadi total atau inkomplet. Pada
trauma total, uretra terpisah seluruhnya dan ligamentum puboprostatikum robek sehingga buli-buli dan prostat
terlepas ke cranial. Diafragma urogenital yang mengandung otot-otot yang berfungsi sebagai spincter urethra
melekat/menempel pada daerah os pubis bagian bawah. Bila terjadi trauma tumpul yang menyebabkan fraktur
daerah tersebut, maka urethra pars membranacea akan terputus pada daerah apeks prostat pada prostato
membranaeous junction.1,2

Media file 1: Urethrogram menunjukkan partial urethral disruption.6

Media file 2: Urethrogram menunjukkan complete urethral disruption.6

Patologi1
Trauma uretra posterior biasanya disebabkan oleh karena trauma tumpul dan fraktur pelvis. Uretra biasanya

terkena pada bagian proksimal dari diafragma urogenital dan terjadi perubahan posisi prostat kearah superior
(prostat terapung = floating prostat) dengan terbentuknya hematoma periprostat dan perivesikal.

Gejala klinis
1.Pasien biasanya mengeluh tidak bisa kencing dan sakit pada daerah perut bagian bawah.
2.Darah menetes dari uretra adalah gejala yang paling penting dari ruptur uretra dan sering merupakan satusatunya gejala, yang merupakan indikasi untuk membuat urethrogram retrograde. Kateterisasi merupakan
kontraindikasi karena dapat menyebabkan infeksi prostatika dan perivesika hematom serta dapat
menyebabkan laserasi yang parsial menjadi total.
3.Tanda-tanda frakturn pelvis dan nyeri suprapubik dapat dijumpai pada pemeriksaan fisik.
4.Pada pemeriksaan colok dubur, bisa didapatkan prostat mengapung (floating prostate) pada ruptur total dari

uretra pars membranacea oleh karena terputusnya ligament puboprostatika.

Trias ruptur uretra posterior4
- Bloody discharge
- Retensio urine
- Floating prostat

Diagnosis
Trauma uretra posterior dapat didiagnosis dengan anamnesis, pemeriksaan fisik dan pemeriksaan penunjang.

Trauma uretra posterior harus dicurigai bila terdapat darah sedikit di meatus uretra disertai patah tulang pelvis.
Selain itu tanda setempat, pada pemeriksaan colok dubur ditemukan prostat seperti mengapung karena tidak
terfiksasi lagi pada diafragma urogenital. kadang sama sekali tidak teraba prostat lagi karena pindah ke cranial.
Pemeriksaan colok dubur harus dilakukan dengan hati-hati karena fragmen tulang dapat mencederai organ lain,
seperti rectum. Pemeriksaan radiologi dapat menunjukkan adanya fraktur pelvis dan retrogras urethrogram akan
menunjukkan ekstravasasi.2

Terapi
Bila ruptur uretra posterior tidak disertai cedera organ intraabdomen atau organ lain, cukup dilakukan

sistostomi dengan terlebih dahulu dengan membuka buli-buli dan melakukan inspeksi buli-buli secara baik untuk
meyakinkan ada atau tidaknya laserasi buli-buli. Reparasi uretra dilakukan 2-3 hari kemudian dengan melakukan
anastomosis ujung ke ujung dan pemasangan kateter silikon selama tiga minggu. Bila disertai cedera organ lain
sehingga tidak mungkin dilakukan reparasi 2-3 hari kemudian, sebaiknya dipasang kateter secara langsir (rail
roading).2

Keterangan (rail roading) :2

Selang karet atau plastik diikat ketat pada ujung sonde dari meatus uretra.
Sonde uretra pertama masuk dari meatus eksternus dan sonde kedua melalui sistostomi yang dibuat lebih dahulu saling
bertemu, ditandai bunyi denting yang juga dirasa di tempat rupture.
Selanjutnya sonde dari uretra masuk ke kandung kemih dengan bimbingan sonde dari buli-buli.
Sonde dicabut dari meatus uretra.
Sonde dicabut dari kateter Nelaton dan diganti dengan ujung kateter Foley yang dijepit pada kateter Nelaton
Ujung kateter ditarik kearah buli-buli sehingga ujung kateter Foley muncul di buli-buli. kateter Nelaton dilepas,
kemudian balon dikembangkan dan diklem.
Selanjutnya dipasang kantong penampung urin dan traksi ringan sehingga balon kateter Foley tertarik dan
menyebabkan luka rupture merapat. Insisi di buli-buli ditutup.

Komplikasi1
1.striktur uretra, impotensi dan inkotinensia
2.komplikasi akan tinggi bila dilakukan repair segera dan akan menurun bila kita melakukan hanya sistostomi
suprapubik dan repair dilakukan belakangan. Sebagian ahli mengerjakan reparasi uretra (uretroplasti) setelah
3 bulan pasca trauma dengan asumsi bahwa jaringan parut pada uretra telah stabil dan matang sehingga
tindakan rekonstruksi membuahkan hasil yang lebih baik.

Trauma uretra anterior

Trauma uretra anterior yang terdiri dari uretra pars glanularis, pars pendulans, pars bulbosa. Trauma uretra
anterior biasanya disebabkan oleh straddle injury (cedera selangkangan) dan iatrogenik seperti instrumentasi atau
tindakan endoskopik. Trauma uretra pars bulbosa terjadi akibat jatuh terduduk atau terkangkang sehingga uretra
terjepit antara objek yang keras, seperti batu, kayu atau palang sepeda dengan tulang simfisis. 1,2

Patologi
Uretra anterior terbungkus di dalam korpus spongiosum penis. Korpus spongiosum bersama dengan corpora

kavernosa penis dibungkus oleh fasia Buck dan fasia Colles.

Jika terjadi rupture uretra beserta korpus spongiosum darah dan urin keluar dari uretra tetapi masih
terbatas pada fasia Buck, dan secara klinis terlihat hematoma yang terbatas pada penis. Namun jika fasia Buck ikut
robek, ekstravasasi urin dan darah hanya dibatasi oleh fasia Colles sehingga darah dapat menjalar hingga skrotum
atau ke dinding abdomen. Oleh karena itu robekan ini memberikan gambaran seperti kupu-kupu sehingga
disebut butterfly hematoma atau hematoma kupu-kupu.3

Gejala klinik1

Riwayat jatuh dari tempat yang tinggi dan terkena daerah perineum atau riwayat instrumentasi disertai adanya darah
menetes dari uretra yang merupakan gejala penting
Nyeri daerah perineum dan kadang-kadang ada hematom perineal
Retensio urin bisa terjadi dan dapat diatasi dengan sistostomi suprapubik untuk sementara, sambil menunggu
diagnosa pasti. Pemasangan kateter uretra merupakan kontraindikasi
Trias ruptur uretra anterior4
- Bloddy discharge
- Retensio urine
- Hematome/jejas peritoneal/ urine infiltrate

Diagnosis
Kecurigaan rupture uretra anterior timbul bila ada riwayat cedera kangkang atau instrumentasi dan darah

yang menetes dari meatus uretra. Pada kontusio uretra, pasien mengeluh adanya perdrahan per-uretam atau
hematuria. Jika terdapat robekan pada korpus spongiosum, terlihat adanya hematom pada penis atau hematoma
kupu-kupu. Pada keadaan ini seringkali pasien tidak dapat miksi. 2,3

Terapi
Pada rupture uretra anterior total, langsung dilakukan pemulihan uretra dengan anastomosis ujung ke ujung

melalui sayatan perineal. Dipasang kateter silicon selama 3 minggu.

Bila rupture parsial, dilakukan sistostomi dan pemasangan kateter foley di uretra selama 7-10 hari, sampai
terjadi epitelisasi uretra yang cidera. kateter sistostomi baru dicabut bila saat kateter sistostomi diklem ternyata
penderita bisa buang air kecil.2

Golden periodnya di kerjakan dalam 6 jam pertama setelah trauma.

Komplikasi

Perdarahan, infeksi/sepsis dan striktur uretra.1

Selain klasifikasi diatas trauma uretra juga diklasifikasikan oleh beberapa bagian.
Klasifikasi trauma uretra Colapinto & McCallum 1977: 3
: Uretra teregang (stretched) akibat ruptur ligamentum puboprostatikum dan hematom periuretra. Uretra masih intack.
: Uretra pars membranacea ruptur diatas diafragma urogenital yg masih intack. Ekstravasasi kontras ke ekstraperitoneal
pelvic space.
III : Uretra pars membranacea ruptur. Diafragma urogenital ruptur. Trauma uretra bulbosa proksimal. Ekstravassasi kontras
ke peritoneum.

Klasifikasi trauma uretra menurut Pediatric Radiologi 5

Uretra posterior intak tetapi teregang (retrograde urethrogram)

Trauma uretra posterior murni parsial atau komplit dengan robekan uretra pars membranosa diatas diafragma
urogenital.
Trauma uretra parsial atau komplit kombinasi anterior/ posterior dengan disrupsi diafragma urogenital.
Trauma leher vesika urinaria dengan ekstensi di dalam uretra.
Trauma dasar vesika urinaria dengan extravasasi periuretra seperti pada trauma uretra tipe IV
Trauma uretra anterior parsial atau total.

ar 1 : Retrograde urethrogram menunjukkan tipe I trauma uretra denagn peregangan yang minimal ( minimal stretching)
dan slight luminal irregularity uretra posterior. Tidak tampak extravasasi material kontras.

ar 2 : Retrograde urethrogram menunjukkan tipe II urethral distruption. Ekstravasasi material kontras (panah tebal) dari
uretra posterior tampak superior menuju diafragma urogenital yang intak (panah terputus).

bar 3 : Rerograde urethrogram menunjukkan tipe III trauma uretra. Ektravasasi pada kedua organ
ekstraperitoneal yaitu pelvis dan perineum (proksimal dan distal diafragma urogenital).

mbar 4 : Retrograde urethrogram menunjukkan tipe III urethral tear pada diafragma urogenital (panah solid) dan
tipe IVurethral distruption pada leher vesika urinaria (panah terputus).

Straddle injury. Retrograde urethrogram menunjukkan tipe V trauma uretra dengan ekstravasasi material
kontras dari uretra bulbosa distal

Male urethra

Penis with urethra

In the human male, the urethra is about 8 inches (20 cm) long and opens at the end of the penis. The urethra provides
an exit for urine as well as semenduring ejaculation.
The urethra is divided into four parts in men, named after the location:
Region

Description

Epithelium

pre-prostatic
urethra

This is the intramural part of the urethra and varies between 0.5 and
1.5 cm in length depending on the fullness of the bladder.

Transitional

prostatic urethra

Crosses through the prostate gland. There are several openings: (1)
the ejaculatory duct receivessperm from the vas deferens and
ejaculate fluid from the seminal vesicle, (2) several prostatic
ducts where fluid from the prostate enters and contributes to the
ejaculate, (3) the prostatic utricle, which is merely an indentation.
These openings are collectively called the verumontanum.

Transitional

membranous
urethra

A small (1 or 2 cm) portion passing through theexternal urethral

sphincter. This is the narrowest part of the urethra. It is located in
Pseudostratified columnar
the deep perineal pouch. The bulbourethral glands(Cowper's gland) are
found posterior to this region but open in the spongy urethra.

spongy
urethra (orpenile
urethra)

Runs along the length of the penis on its ventral (underneath) surface.
It is about 1516 cm in length, and travels through the corpus
spongiosum. The ducts from the urethral gland(gland of Littre) enter
here. The openings of thebulbourethral glands are also found here.
[1]
Some textbooks will subdivide the spongy urethra into two parts, the

Pseudostratified
columnar
proximally,Stratified
squamous distally

bulbous and pendulous urethra. The urethral lumen runs effectively

parallel to the penis, except at the narrowest point, the external urethral
meatus, where it is vertical. This produces a spiral stream of urine and
has the effect of cleaning the external urethral meatus. The lack of an
equivalent mechanism in the female urethra partly explains why urinary
tract infections occur so much more frequently in females.
The length of a male's urethra, and the fact it contains a prominent bend, makescatheterization more difficult. The
integrity of the urethra can be determined by a procedure known as retrograde urethrogram.
[edit]Histology
The epithelium of the urethra starts off as transitional cells as it exits the bladder. Further along the urethra there
are pseudostratified columnar and stratified columnar epithelia, then stratified squamous cells near the external
urethral orifice.
There are small mucus-secreting urethral glands, that help protect the epithelium from the corrosive urine.
[edit]Length

of the urethrae

The female urethra is about 4 cm in length.[2] There is inadequate data for the typical length of the male urethra;
however, a study of 109 men showed an average length of 22.3 cm (SD = 2.4 cm), ranging from 15 cm to 29 cm.[3]