CHAPTER II

LITERATURE

2.1.

Anatomy of Male Urethra

The penis is composed of 2 corpora cavernosa and the corpus

spongiosum, which contains the urethra, whose diameter is 8-9 mm. these corpora
capped distally by the glans. Each corpus is enclosed in a fascial sheath (tunica
albuginea) and all are surrounded by a thick fibrous envelope known as Bucks
fascia. A covering of skin, devoid of fat, is loosely applied about these bodies. The
prepuce forms a hood over the glans.
Beneath the skin of the penis (and scrotum) and extending from the base
of the glans to the urogenital diaphragm is Colles fascia, which is continous with
Scarpas fascia of the lower abdominal wall.
The proximal ends of the corpora cavernosa are attached to the pelvic
bones just anterior to the ischial tuberosities. Occupying a depression of their
ventral surface in the midline is the corpus spongiosum, which is connected
proximally to the undersurface of the urogenital diaphragm, through which
emerges the membranous urethra. This portion of the corpus spongiosum is
surrounded by the bulbouspongiousus muscle. Its distal end expands to form the
glans penis. The suspensory ligament of the penis arises from the linea alba and
pubic symphysis and inserts into the fascial covering of the corpora cavernosa.

Figure 1. Fascial Planes of the lower genitourinary tract

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. Although the male urethra is a single structure, it is composed of a
heterogeneous series of segments: prostatic, membranous, and spongy. The male
urethra originates at the bladder neck and terminates at the urethral meatus on the
glans penis. It is roughly 23-25 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. Other systems for naming the parts of the urethra have been
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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.
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. It is invested in the prostate, a
glandular and fibrostromal organ that secretes seminal fluids and has clinical
relevance. 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 utriclemeet the lumen of the urethra.
Membranous urethra 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. 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.
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
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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.
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 mucous membrane of the bladder, ureters, and kidneys;
externally, with the integument covering the glans penis; and is prolonged into the
ducts of the glands which open into the urethra, the bulbo-urethral 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. The uretral mucosa that
transverse the glans penis is formed of squamous epithelium. Proximal to this, the
mucosa is transitional in type. Underneath the mucosa is the submucosa which
contain connective and elastic tissue and smooth muscle.
The submucous tissue consists of a vascular erectile layer; outside this is
a layer of unstriped muscular fibers, arranged, in a circular direction, which
separates the mucous membrane and submucous tissue from the tissue of the
corpus cavernosum urethrae. In the submucosa contain connective and elastic
tissue, smooth muscle and the numerous glands of Littre, whose ducts connect
with urethral lumen. The urethra is surrounded by the vascular corpus spongiosum
and the glans penis.

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2.1.1. Vascular Supply

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
2.1.2. Innervation
Most of the afferent fibers from the bladder and urethra course in the pelvic
splanchnic nerves. Pain fibers from the urethra course in the pelvic splanchnic and
pudendal nerves.
2.2.

Physiology
Urethra has two functions such as for urinate and reproductive system. The

urethra drains urine from the urinary bladder to an exterior opening of the body,
the external urethral orifice. In females, the urethra is about 3 to 4 cm (1.5 in) long
and opens to the outside of the body between the vagina and the clitoris. In males,
the urethra is about 23 to 25cm long and passes through the prostate gland, the
urogenital diaphragm, and the penis. In these regions, the urethra is called the
prostatic urethra, membraneous urethra, and spongy (penile) urethra, respectively.
In both males and females, a skeletal muscle, the external urethral sphincter,
surrounds the urethra as it passes through the urogenital diaphragm.
The bladder neck interconnects the bladder with the posterior urethra
below. It contains the internal sphincter. The internal sphincter. keeps urine out of
the bladder neck and also out of the posterior urethra which leads off from the
bladder neck immediately. But its main function is to prevent retrograde
ejaculation at sexual intercourse. The urogenital diaphragm contains the sphincter
urethrae which is the external sphincter that is under the control of will. It is this
sphincter that is opened when there is the need to micturate.
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Urethra is an important organ in the male. It is used for both reproductive

and urinary functions. It passes semen from its prostatic part into the spongy part.
The spongy part is the one that transverses the penis. It is also called penile
urethra. When ejaculation is to take place in the male, semen is released from
the seminal vesicle or from the tail of epididymis into the prostatic urethra in the
first

phase

of ejaculation.

The

second

phase

is

controlled

by

the bulbospongiosusmuscle which assists the penile urethra to release forcibly its
contained semen to the outside, and in reproductive capacity, into the vagina.
2.3.

Urethral Stricture
The term urethral stricture refers to anterior urethral disease, or a scarring

process involving the spongy erectile tissue of the corpus spongiosum. Urethral
strictures are fibrotic narrowing composed of dense collagen and fibroblasts
which usually extends through the tissue of the corpus spongiosum and into
adjacent tissue. In contrast, posterior urethral strictures is an obliterative process
in the posterior urethra that has resulted in fibrosis and is generally the effect of
distraction in that area caused by either trauma or radical prostatectomy.
2.3.1. Epidemiology
Urethral stricture incidence increase gradually with increasing age,
particularly for those older than 55. In non industrialized countries, urethral
stricture is more commonly infectious or inflammatory in origin. Most often in
men.
2.3.2. Etiology
Etiology of urethral stricture divided into congenital urethral stricture and
acquired urethral stricture. Congenital urethral stricture is uncommon in infant
boys. Urethral strictures can result from inflammatory, ischemic, or traumatic
processes. Most acquired strictures are due to infection or trauma. Although
gonococcal urethritis is seldom a cause of stricture today, infection remain a major
cause particularly infection from long-term use of indwelling urethral catheters.
Large catheters and instruments are morelikely than small ones to cause ischemia
and internal trauma. External trauma, for example, pelvic fracture can partially or

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completely sever the membranous urethra. Straddle injuries can produce bulbar
strictures.
2.3.3. Patofisiology
In general, a urethral stricture is a fibrotic process with varying degrees of
spongiofibrosis that results in poorly compliant tissue and decreased urethral
lumen caliber. The normal urethra is a lined mostly by pseudostratified columnar
epithelium. Beneath the basement membrane there is connective tissue layer of
spongiosum rich in vascular sinusoids and smooth muscle. The connective tissue
composed of mainly fibroblast and an extracellular matrix that contain collagen,
proteoglycans, elastic fibers and glycoproteins. The most dramatic histologic
changes of urethral strictures occur in the connective tissue. Strictures are the
consequence of epithelial damage and spongiofibrosis. After trauma, the
epithelium became ulcerated and covered with stratified columnar cells. The
stricture itself was noted to be rich in myofibroblast and giant multinucleated
cells. Both were felt to be related to stricture formation and collagen production.
An increase in collagen result in fibrosis.

2.3.4. Clinical Finding

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a. Symptoms and Signs

As the urethral lumen gradually strictures down, obstructive
voiding symptoms worsen and in an insidious pattern. Typical symptoms
include weak urinary stream, straining to void, hesitancy, incomplete
emptying, urinary retention, post-void dribbling and urinary tract
infections. Other fairly common symptoms can include urinary frequency,
urgency, nocturia, dysuria, or occasionally suprapubic pain.
Others symptoms are blood in the semen, bloody dark urine,
discharge from the urethra, pain in the lower abdomen, and pelvic pain.
Indurations in the area of the stricture may be palpable.
b. Laboratory Findings
If urethral strictures is suspected, urinary flow rates should be
determined. The patient is instructed to accumulate urine until the bladder
is full and then begin voiding. After the patients repeats this procedure 810 times over several days in a relaxed atmosphere. The mean peak flow
can be calculated. With strictures creating significant problems, the flow
rate will be less than 10 mL/s (normal 20 mL/s).
Urine culture may be indicated. The midstream specimen is usually
bacteria free, with some pyuria (8-20 WBC per high power field) in a
carefully obtained first a liquor of urine.
c. X-Ray Findings
Urethrogram or voiding cystourethrogram

(or

both)

will

demonstrate the location and the extent of the stricture. Sonography has
also been a useful method of evaluating the urethral stricture. Urethral
fistula and diverticula are sometimes noted. Vesical stones, trabeculations,
or diverticula may also be seen.
d. Instrumental Examination
Urethroscopy allows visualization of the stricture. Small caliber
strictures prevent passage of the instrument through the area. Direct
visualization and sonourethrography aid in determining the extent,
location, and degree of scarring. Additional areas of scar formation
adjacent to the stricture may be detected by urethroscopy.
2.3.5. Differential Diagnosis

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Neurogenic bladder, bladder stone, bladder neck stenosis, urethral

stricture, urethral stone, urethral tumor, benign prostatic hyperplasia, prostate
carcinoma, prostatitis, meatal stenosis, phimosis, and paraphimosis.
2.3.6. Treatment
a. Dilation
Dilation of urethral strictures is not usually curative, but it fractures
the scar tissue of the stricture and temporarily enlarges the lumen. As
healing occurs, the scar tissue reforms. Dilatation may initially required
because of the severe symptoms of chronic retention of urine. The urethra
should be liberally lubricated with a water-soluble medium before
instrumentation. A filiform is passed down the urethra and gently
manipulated through the narrow area in the bladder. A follower can then be
attached and the area gradually dilated to approximately 22F. A 16 F
silicone catheter can then be inserted. If difficulty arises in passing the
filliform under the direct vision.
An alternative method of urethral dilatation employs Van Buren
Sounds. First, a 22F sound should be passed down to stricture site and
gentle pressure applied. If this fails, a 20F sound should be used. Smalleer
sounds should be used with care, because they can easily perforate the
urethral wall and produce false passages. Bleeding and pain are major
problems caused by dilatation.
b. Urethrotomy under endoscopic direct vision
Lysis of urethral strictures can be accomplished using a sharp knife
attached to an endoscope. The endoscope provides direct vision of the
stricture during cutting. A filiform should be passed through the stricture
and used as a guide during lysis. The stricture is usually incised
circumferentially with the multiple incisions. A 22f should pass with ease.
A catheter is left in place for a short time to prevent bleeding and pain.
Result of this procedure have been satisfactory in short term follow up in
70-80% of patient, but long term success rates are much lower. The
procedure has several advantages : (1) minimal anesthesia is required- in
some cases, only topical anesthesia combined with sedation; (2) it is easily
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repeated if the stricture recurs and (3) it is very safe, with few
complications.
c. Internal Urethrotomy
Internal urethrotomy is any procedure that opens the stricture by
incising it transurethrally. This procedure involves incision through the
scar to healthy tissue to allow the scar expand (release of scar contracture)
and the lumen to heal enlarged. Internal urethrotomy separate the scarred
epithelium so that the healing occurs by secondary intention. In healing in
the secondary intention, epithelialization progreses from the wound edges.
As it progress from the wound edge, epithelialization slows. In an effort to
aid epithelialization, nature invokes the forces of wound contraction.
Wound contraction closes the wound defect and limits the size of the area
that require epithelialization. If epithelialization progresses completely
before wound contraction significantly narrows the lumen, the internal
urethrotomy may be a success. If wound contraction significantly narrow
the lumen before completion of epithelialization, the stricture has reccured.
Predictor success is the extent of luminal narrowing, the narrower the
percent of narrowing, the worse the outcome.
Complication of internal urethtotomy are recurrence of stricture,
bleeding, extravasation of irrigation fluid into the perispongiosal tissues,
fistula between the corpus spongiosum and the corpora cavernosa.
The data shows the strictures at the bulbous urethra that are less
than 1,5cm in length and not associated with dense, deep spongiofibrosis
can be managed with internal urethrotomy.
d. Surgical reconstruction
If urethrotomy under direct vision fails, open surgical repair should
be performed. Short strictures (<2cm) of the anterior urethra should be
completely excised and primary anastomosis done. If possible, the
segment to be excised should extend 1 cm beyond each end of the stricture
to allow for removal of any existing spongiofibrosis and improve
postoperative healing.
Strictures >2cm in length can be manage by patch graft
urethroplasty. The urethra is incised in the midline for the full length of the
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strictures plus an additional 0.5 cm proximal and distal to its end. A fullthickness skin graft obtained preferably from the penile skin or buccal
mucosa and all subcutaneous tissue is carefully removed.the graft is then
tailored to cover the defect and meticulously sutured into place.
Strictures involving the membranous urethra ordinarily result from
external trauma and present problems in reconstruction. Most can be
corrected by a perineal approach with excision of the urethral rupture
defect and direct anastomosis of the bulbar urethra to the prostatic urethra.
2.3.7. Prognosis
A stricture should not be considered cured until it has been observed for
at least 1 year after theraphy, since it may recur at any time during the period.
Urinary flow rate measurements and urethrograms are helpful to determine the
extent of residual obstruction.
2.3.8. Complication
Complication include of chronic prostatitis, cystitis, chronic urinary
infection, diverticula, utherocutaneus fistulas, periurethral abscesses, and urethral
carcinoma. Vesical calculi may develop from chronic urinary stasis and infection.

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