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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 4  |  Page : 160-164

Have our strictures changed: A study of the current characteristics and management of urethral stricture disease in Zaria, Nigeria


1 Department of Surgery, Ahmadu Bello University, Zaria, Kaduna, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Kaduna, Nigeria

Date of Submission05-Oct-2019
Date of Decision14-Jun-2021
Date of Acceptance23-Feb-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Nasir Oyelowo
Department of Surgery, Ahmadu Bello University, Zaria, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/smj.smj_52_19

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  Abstract 


Introduction: Urethral stricture is a common cause of lower urinary tract symptoms in middle-aged and elderly men. Its presentation and management are closely linked with its etiology and this varies across geographical regions of the world as well as overtime. We hereby review the etiology, characteristics, and presentation of men with urethral strictures in a tertiary hospital in northern Nigeria over a year and compare it with previous studies in the region. Patients and Methods: The study was a prospective study from January-December 2016, all patients with urethral strictures and who consented to the study were enrolled in the study. Data was collected using a structured study proforma and analyzed using SPSS version 23. Results: The mean age was 44.1 years with a range of 13-71 years. The age interval 30 – 39 years accounted for most of the patients 24 (28.6%). 43% of the patients had short segment urethral strictures (<2cm) while 57% had long segment strictures (>2cm). The bulbar urethra was the site of most strictures with a frequency of 65%. Strictures were found in the penile and peno-bulbar urethra in 25% and 21% respectively. Only 10% of patients studied had multiple strictures. The etiology was an infection in the majority of the patients with a frequency of 53.3%. Post-traumatic strictures occurred in 33.3% while iatrogenic and catheter –Induced strictures were seen in 7.1% and 6% respectively. 8.3% had recurrent strictures, 1.2 % had previous dilations and 2.4 % had previous DVIU. 88% had no previous intervention for the stricture before the presentation. The complications from urethral strictures observed in the patients were acute urinary retention in 83.4% urethrocutaneous fistulae in 2.4% and urosepsis in 1.2% of the patients. 11% presented with no complication. 68% of these patients were managed by excision and end to end anastomosis, 15 % had a penile pedicled flap 12%, a buccal mucosa graft urethroplasty and 5% with staged urethroplasty. Conclusion: Though there is a gradual rise in post-traumatic and iatrogenic strictures in our environment, Post-inflammatory strictures still predominate. It is however infrequently accompanied by fistulae as seen decades ago. These strictures are mostly long segments single bulbar strictures.

Keywords: Etiology, management, urethral stricture


How to cite this article:
Oyelowo N, Ahmed M, Bello A, Lawal AT, Lawal BB, Olagunju J, Sudi A, Awaisu M, Tolani MA, Maitama HY. Have our strictures changed: A study of the current characteristics and management of urethral stricture disease in Zaria, Nigeria. Sahel Med J 2021;24:160-4

How to cite this URL:
Oyelowo N, Ahmed M, Bello A, Lawal AT, Lawal BB, Olagunju J, Sudi A, Awaisu M, Tolani MA, Maitama HY. Have our strictures changed: A study of the current characteristics and management of urethral stricture disease in Zaria, Nigeria. Sahel Med J [serial online] 2021 [cited 2022 May 24];24:160-4. Available from: https://www.smjonline.org/text.asp?2021/24/4/160/337489




  Introduction Top


Urethral strictures are narrowing and loss of distensibility of the urethral due to fibrosis of the corpus spongiosum from inflammation or ischemia.[1] Strictures are common and always have been a cause of lower urinary tract symptoms in the middle aged and elderly.[2]

It is a disease of both the developing and developed worlds, though the etiology varies among them.[3],[4],[5] The etiology also seems to evolve over time within the same region. In the developed world, this was attributed to better treatment of sexually transmitted diseases, a surge in endourological procedures, and industrialization resulting in less of postinflammatory strictures and more of iatrogenic as well as traumatic strictures. However, in the developing world, the picture is different with some reports of the predominance of postinflammatory strictures while others reported iatrogenic and posttraumatic strictures.

The emphasis on the etiology of strictures is because it typically gives the characteristics of the stricture which is the basis of the choice of treatment and subsequently prognosis.[6]

Postinflammatory strictures are known to be characterized as multiple, long-segment, incomplete strictures with severe spongiofibrosis. Substitution urethroplasties may be indicated for these strictures typically with a penile skin flap or a buccal mucosa graft. The success rate is usually in the range of 70%–80%.[7]

However, traumatic strictures are usually single,short segment with mild-moderate spongiofibrosis. Excision and end-end anastomosis may be feasible with reported success rate of 95%-99%.[8] Internal urethrotomy may also be done in patients with short-segment incomplete strictures.[9]

We hereby review the etiology, stricture characteristics, presentation, and management of men with urethral strictures in a tertiary hospital in northern Nigeria over a year and compare it with previous studies in the region.


  Patients and Methods Top


Study location

The study was conducted over the study period January 2016–December 2016 in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. This is a tertiary health-care center with referrals of patients with urethral stricture disease from mainly the northern and central regions of the country.

Inclusion criteria

All new patients with urethral stricture managed within the study period and who consented to the study were enrolled.

Exclusion criteria

Patients with strictures from failed hypospadias repair and stenosis at the posterior urethra were excluded.

Study design

This was a cross-sectional study involving patients with urethral stricture who were managed during the study period. Sample size estimation was done using the equation n = Z2 (pq)/d2 (n = minimum sample size = 84, P = sensitivity from previous study = 94.1% = 0.94,[10] q = complimentary proportion = [1 − p] = 0.06, Z = standard normal deviation = 1.96 [95% confidence level], and d = level of precision = 0.05). Data were collected using a study pro forma and descriptive analysis was done.

Ethical considerations

Informed written consent from every patient was obtained following adequate counseling. All the procedures have been carried out as per the guidelines given in the Declaration of Helsinki 2013. Ethical approval (ABUTHZ/HREC/N23/2015) from the Institutional Health Research Ethical Committee was also obtained before the commencement of the study.

Study procedure

Patients with lower urinary tract symptoms due to urethral stricture and who consented to the study were consecutively recruited. These were patients who came through the outpatient clinic and those that presented via the accident and emergency with complications of urethral stricture (acute urinary retention and urosepsis).

Clinical evaluation was done to determine the etiology, diagnosis, and complications of the disease. The stricture was confirmed by a retrograde urethrogram after obtaining a sterile urine culture. Sonourethrography was also done to evaluate the extent of spongiofibrosis. Patients with acute urinary retention, obstructive uropathy, or urosepsis had urinary diversion as an emergent procedure. Patients who were fit for surgery were counseled on the diagnosis and need for surgery to attempt cure while those unfit for surgery were managed definitively by urethral dilation. The choice of urethroplasty was based on the stricture characteristics. Stricture excision and anastomotic urethroplasty was performed on short-segment strictures while substitution urethroplasty on long-segment strictures.

Outcome measures

The primary outcome measure of this study is the current distribution of the characteristics of urethral strictures (etiology, site, number, and length of the strictures) and complications of the disease in our center. The secondary outcome measure is the distribution of the choice of definitive treatment of these strictures.


  Results Top


A total of 84 patients were managed during the study period. The mean age of the patients was 44.19 years with a standard deviation of ±12.54 and a range of 13–71 years. The age interval of 30–39 years accounted for most of the patients 24 (28.6%). The age distribution is shown in [Figure 1].
Figure 1: Age distribution of the patients

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Most of the patients were traders 21 (25%). Men, who are members of the armed forces, constituted 13 (15%) of the patients while students were the least of the study group 8 (9.5%). The distribution of the occupation of the patients is shown in [Table 1].
Table 1: Occupations of patients in the study

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All the patients had lower urinary tract symptoms. Acute urinary retention was seen in 70 (83.3%), 2 (2.4%) had a previous history of urethrocutaneous fistulae, and a patient (1.2%) had resolved urosepsis. Eleven (13.1%) had no added symptoms apart from lower urinary tract symptoms. The etiology of stricture found during history taking is shown in [Figure 2], with poorly treated urethritis been the most common cause of stricture seen responsible for more than half (53.6%) of the strictures studied. None of the patients had an idiopathic cause.
Figure 2: Etiology of strictures in the patients

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Seven (8.3%) patients had previously failed urethroplasties, 2 (2.4%) patients had previous DVIU, and a patient (1.2%) had previous urethral dilations. Seventy-four (88.1%) had no previous treatment. Seventy-two (85.7%) patients had a suprapubic cystostomy at presentation, 14 (16.7%) patients had demonstrable periurethral induration, and 8 (9.5%) patients had a urethral discharge. Four (4.8%) had none of these on examination.

The characteristics of the strictures found in the patients are shown in [Table 2], with the bulbar urethra being the most common site of the strictures seen in 56 (65%) patients.
Table 2: Characteristics of the strictures in patients

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The majority of the patients, 57 (68%), had excision of the strictures and end-end anastomosis. The frequency of the type of urethroplasties performed is depicted in [Figure 3].
Figure 3: Management of urethral strictures

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  Discussion Top


Urethral stricture is currently a disease of the middle aged worldwide. The mean age at presentation of patients with strictures is similar in both the developed and developing countries usually in the fifth decade.[11],[12] We found a mean age of 44.1 years which is similar to the age found in recent studies in China, the UK, Italy, India, and Senegal.[2] This contrasts with the previous perception as earlier literature on strictures reported a higher prevalence in the elderly.

The etiologies, however, differ in both the developed and developing countries over time with more posttraumatic and iatrogenic strictures noted in most developed countries and a predominance of postinflammatory strictures in the developing countries. Prevention and adequate treatment of urethritis have significantly reduced the incidence of postinflammatory strictures in the developed countries.[13],[14] In the developing countries, postinflammatory strictures still exist due to a lack of adequate awareness of the effect of sexually transmitted diseases, low socioeconomic status, and poor health-seeking behavior.[15] A significant number of those who present to the health-care centers are prone to poor treatment of the urethritis either due to inadequate dosage of the antibiotics, inadequate duration of treatment, or use of drugs with limited efficacy resulting in recurrent urethritis and stricture.[16] Hence, the prevalence of urethritis and postinflammatory strictures are still relatively high in some developing countries.

In our study, we found the most common cause of stricture as postinflammatory. This is largely due to the above reasons. Posttraumatic stricture is on the rise largely due to motor vehicular crashes as well as social violence and conflicts in most of the countries with patients presenting with strictures among other injuries from explosion of land mines or gunshot to the perineum. Ahmed and Kalayi in 1989 found similar but higher rates of postinflammatory strictures (66.5%) in our center compared to our study where postinflammatory strictures now account for 53.3%.[17] With regards to post-traumatic strictures, it's incidence has remained relatively the same over time in this center. Ahmed et al in 1989 found an incidence of 31.7% in their review of etiologies of strictures in Zaria while we found an incidence of 33.3% in this study. However, most of the strictures were multiple in their series and managed by dilation (85%) and urethroplasty (26%) as compared to our study where only 10% were multiple and all our strictures are now managed by urethroplasty.

In other parts of Nigeria, postinflammatory strictures still constitute a significant number of their strictures as reported by Ekeke, Ntia, Tijani, and Ofoha.[13],[14],[18] Some of these studies' included stenosis of the posterior urethra from pelvic fractures as post-traumatic strictures which we excluded in this study due to the current restriction of the term urethral strictures to the anterior urethra.This may explain why post inflammatory strictures may not be the most prevalent etiology of stricture in some of these reviews.

The reported frequencies of both post-inflammatory and post traumatic strictures in the region are: Ahmed et al. in Zaria (1990) Infection accounted for 66.50%, posttraumatic stricture 31.50%. Ntia et al. Sokoto (2006) found infection as etiology in 44.70% and posttraumatic strictures in 47.40%. Ofoha et al. in Jos, however, found infection in 53.30% and posttraumatic 40.30%.

It is also interesting to note that although most of our strictures are postinflammatory, they are usually single and bulbar with excision and anastomotic urethroplasty feasible in 68% of our patients. These observed characteristics of strictures as well as the low incidence of perineal abscess and fistulae in this study may reflect an improvement in the diagnosis and treatment of urethritis and it's complications as compared to decades ago in our environment. Substitution urethroplasty either as buccal mucosa graft or pedicle penile flap was required in 27% and staged urethroplasty in only 5%, a reflection of the aim of management of our strictures which is a cure.

Therefore, although we found a slower decline in the incidence of postinflammatory strictures in our environment as compared to other parts of the world, the characteristics of the strictures have changed as well as its management over time. Excision and anastomotic urethroplasty is feasible in most of our patients. A multicenter longitudinal study in Nigeria will strengthen the findings from this study which is limited to a snapshot from a single center.


  Conclusion Top


A significant number of our patients still present with postinflammatory strictures, although the incidence is also on the decline compared to the past and as noted in other parts of the world. The strictures are, however, mostly single and bulbar with anastomotic urethroplasty possible in most of the cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Eshiobo I. A review of the epidemiology and management of urethral stricture disease in sub-Saharan Africa. Curr Med Issues 2019;17:118-24.  Back to cited text no. 2
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Bugeja S, Payne SR, Ian Eardley AR. The standard for the management of male urethral strictures in the UK: A consensus document. J Clin Urol 2021;14:21-2.  Back to cited text no. 3
    
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Makanga W, Agbo CA. One-stage urethroplasty for strictures at a rural hospital. Ann Afr Surg 2019;16:6-9.  Back to cited text no. 4
    
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Verla W, Oosterlinck W, Spinoit AF, Waterloos M. A comprehensive review emphasizing anatomy, etiology, diagnosis, and treatment of male urethral stricture disease. Biomed Res Int 2019;90:46-54.  Back to cited text no. 5
    
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Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011;59:797-814.  Back to cited text no. 7
    
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Chu YC, Wang TM, Wang HH, Chu SH, Chen HW, Chiang YJ, et al. Outcomes of urethroplasty for anterior urethral strictures : A single center experience. Uro Sci 2020;31:46-50.  Back to cited text no. 8
    
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Eze BU, Chacha FK, Mbaeri TU. Direct visual internal urethrotomy in supine position in a patient with complex deformities of both lower limbs and neurogenic bladder: A case report. Eur J Med Heal Sci 2021;3:34-7.  Back to cited text no. 9
    
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Fuehner C, Dahlem R, Fisch M, Vetterlein MW. Update on managing anterior urethral strictures. Indian J Urol 2019;35:94-100.  Back to cited text no. 10
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Ofoha CG, Ramyil VM, Dakum NK, Shu'aibu SI, Akpayak IC, Magnus FE, et al. Predictors of urethral stricture recurrence following urethroplasty: A retrospective review at the Jos University Teaching Hospital, Nigeria. Pan Afr Med J 2019;32:190.  Back to cited text no. 11
    
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Selim M, Salem S, Elsherif E, Badawy A, Elshazely M, Gawish M. Outcome of staged buccal mucosal graft for repair of long segment anterior urethral stricture. BMC Urol 2019;19:38.  Back to cited text no. 12
    
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Ekeke ON, Amusan OE. Clinical presentation and treatment of urethral stricture : Experience from a tertiary hospital in Port Harcourt, Nigeria. Afr J Urol 2017;23:72-7.  Back to cited text no. 13
    
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Ugezu AM, Ugezu AI, Nwofor AME. Urethral stricture management experience at NNewi south east Nigeria. Afr J Urol 2004;10:107-11.  Back to cited text no. 14
    
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Osoba AO, Alausa O. Gonococcal urethral stricture and watering-can perineum. Br J Vener Dis 1976;52:387-93.  Back to cited text no. 15
    
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Kibukamusoke JW. Gonorrhoea and urethral stricture. Br J Veneral Dis 1965;42:135-6.  Back to cited text no. 16
    
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