What is Urethral Stricture Disease?

The urethra's main job in males and females is to pass urine outside the body. This thin tube also has an important role in ejaculation for men. When a scar from swelling, injury or infection blocks or slows the flow of urine in this tube, it is called a urethral stricture. Some people feel pain with a urethral stricture.

What Happens under Normal Conditions?

The bladder empties through the urethra and out of the body (called voiding). The female urethra is much shorter than the male's. In males, urine must travel a longer distance from the bladder through the penis.

In males, the first 1" to 2" of the urethra that urine passes through is called the posterior urethra. The posterior urethra includes:

• the bladder neck (the opening of the bladder)
• the prostatic urethra (the part of the urethra by the prostate) 
• the membranous urethra
• a muscle called the external urinary sphincter

Strictures that happen in the first 1" to 2" of the urethra that urine passes through are called posterior strictures.

In males, the final 9" to 10" of the urethra is called the anterior urethra. The anterior urethra includes:

• the bulbar urethra (under the scrotum and perineum- the area between the scrotum and anus)
• the penile urethra (along the bottom of the penis)
• the meatus (the exit at the tip of the penis)

Strictures that happen in the last 9" to 10" of the urethra that urine passes through are called anterior strictures. 

What are Symptoms of Urethral Strictures?

Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, the flow is reduced. When a stricture is narrow enough to decrease urine flow, you will have symptoms. Problems with urinating, UTIs, and swelling or infections of the prostate may occur. Severe blockage that lasts a long time can damage the kidneys.

Some signs are:

• bloody or dark urine
• blood in semen
• slow or decreased urine stream
• urine stream spraying
• pain with urinating
• abdominal pain
• urethral leaking
• UTIs in men
• swelling of the penis
• loss of bladder control

How are Urethral Strictures Diagnosed??

There are several tests to determine if you have a urethral stricture including:

• physical exam
• urethral imaging (X-rays or ultrasound)
• urethroscopy (to see the inside of the urethra)
• retrograde urethrogram

Urethroscopy

The doctor gently places a small, bendable, lubricated scope ( a small viewing instrument) into the urethra. It is moved up to the stricture. This lets the doctor see the narrowed area. This is done in the office and helps your doctor decide how to treat the stricture.

Retrograde Urethrogram

This test is used to see how many strictures there are, and their position, length and severity. This is done as an outpatient X-ray procedure. Retrograde in this case means "against the flow" of urine. Contrast dye (fluid that can be seen on an X-ray) is inserted into the urethra at the tip of the penis. No needles or catheters are used. The dye lets the doctor see the entire urethra and outlines the narrowed area. It can be combined with an antegrade urethrogram (antegrade means "with the flow" of urine). Dye inserted from below fills the urethra up to the injured area. Dye inserted from above fills the bladder and the urethra down to the stricture. These tests together let the doctor find the gap to plan for surgery.

Also, if you have trauma to the urethra, you may have this X-ray procedure after emergency treatment. Contrast dye can be injected through the catheter that was placed for healing.

How Can Urethral Strictures be Prevented?

• Avoid injury to the urethra and pelvis.
• Be careful with self-catheterization
  • Use lubricating jelly liberally
  • Use the smallest possible catheter needed for the shortest time
• Avoid sexually transmitted infections.
  • Gonorrhea was once the most common cause of strictures.
  • Antibiotics have helped to prevent this.
  • Chlamydia is now the more common cause.
  • Infection can be prevented with condom use, or by avoiding sex with infected partners.
  • If a problem occurs, take the right antibiotics early. Urethral strictures are not contagious, but sexually transmitted infections are.

How are Urethral Strictures Treated?

There are many options depending on the size of the blockage and how much scar tissue is involved.

Treatments include:

• dilation – enlarging the stricture with gradual stretching
• urethrotomy – cutting the stricture with a laser or knife through a scope
• open surgery – surgical removal of the stricture with reconnection and reconstruction, possibly with grafts (urethroplasty)

There are no available drugs to help treat strictures.

Without treatment, you will continue to have problems with voiding. Urinary and/or testicular infections and stones could develop. Also, there is a risk of urinary retention (when you can't pass urine), which could lead to an enlarged bladder and kidney problems.

What Can Be Expected after Treatment?

Because urethral strictures can come back after surgery, you should be followed by a urologist. After the catheter is removed, your doctor will want to check you with physical exams and X-rays as needed. Sometimes the doctor performs urethroscopy to check the repair. In some patients, the stricture may return but may not need additional treatment. But if it causes obstruction, it can be treated with urethrotomy or dilation. Repeat open surgery may be needed for serious strictures that come back.

Content provided courtesy & permission of the American
 Urological Association Foundation, and is current as of 5/2010. 
Visit us at www.urologyhealth.org for additional information.

What is Testicular Trauma?

The testicles are vital for reproduction and normal male hormones. Because they're in the scrotum, which hangs outside the body, they don't have muscles and bones to protect them like most organs have. This makes it easier for the testicles to be struck, hit, kicked, or crushed. Timely evaluation and proper treatment are critical for the best outcomes.

What Happens under Normal Conditions?

The testicles are 2 male organs that make sperm and male hormones. They're in the scrotum, the skin sac that hangs below the penis. Each testicle is encased in a tough, fibrous cover (the tunica albuginea) that protects it.

Sperm cells are made in the testicle and travel to the epididymis, a rubbery gland along the back of the testicle. In the epididymis, thousands of sperm-making ducts from the testicle join to form a single coiled tube. Sperm stop briefly in the epididymis to mature before mixing with semen and leaving through a tube (the vas deferens) that joins with the urethra. The vas deferens is covered by a thick muscle wall. But the epididymis has a thin, fragile coating, and so is at higher risk for swelling or injury.

Testicular Trauma

Testicular trauma is when a testicle is hurt by force. Trauma to the testicle or scrotum can harm any of its contents. When the testicle's tough cover is torn or shattered, blood leaks from the wound. This pool of blood stretches the scrotum until it's tense, and can lead to infection.

What are the Symptoms of Testicular Injury?

The first sign of trauma to the testicle or scrotum is most often severe pain. Pain around the testicle may also be due to infection or swelling of the epididymis ("epididymitis"). Because the epididymis has a very thin wall, it easily becomes red and swollen by infection or injury. If not treated, in rare cases the blood supply to the testicle can get blocked. This can lead to loss of the testicle.

Men who suffer more than a minor injury to the scrotum should seek care by a urologist. Reasons to seek medical care are:

• any penetrating injury to the scrotum
• bruising and/or swelling of the scrotum
• trouble peeing or blood in the urine
• fevers after testicular injury

Though not linked to the injury, a large number of testicular tumors are found after minor injuries when men are more likely to carefully check their testicles. Many men don't notice the painless, solid lump bulging from the smooth testicular cover until they have a reason to look. Even if you think this is a simple bruise, it's a medical emergency. Testicular cancer caught early can often be cured. But tumors found late often need drawn-out treatment with surgery, radiation, and chemotherapy.

What Causes Testicular Injury?

Testicular injuries can be caused by penetrating forces (such as stab wounds or gunshot wounds) or blunt forces (such as a kick or baseball to the scrotum). These can cause all or part of the testicle to rip, as well as loss of the whole testicle. An injury from a penetrating object, such as a knife or bullet that punctures the scrotum, may cause a minor scrape to the skin or major damage to the blood vessels to the testicle. An injury caused by a direct blow can tear the cover of the testicle or harm its blood vessels.

How is Testicular Trauma Diagnosed?

Your urologist can often figure out how bad the injury to the testicle is with a physical exam. After asking questions about how the injury occurred, as well as other questions about your health, he/she will look at your scrotum. It's often easy for your urologist to feel the tough testicle cover, as well as the thin, soft epididymis. He/she will also feel the structures that run into the testicle--the artery, vein and vas deferens--to make sure they're normal.

If all seem normal with no injury, your urologist will likely give you pain meds, such as acetaminophen or ibuprofen. You'll also be told to wear a jock strap to support the scrotum.

If it's not clear if injury has occurred, your urologist may ask for a scrotal ultrasound scan. Ultrasound uses sound waves bouncing off organs to make a picture of what's inside your body. Based on the same sonar sound waves that guide submarines, this device can safely image parts of the sac, including the testicle, epididymis and spermatic cord, to check the blood flow.

Though no imaging test is 100% perfect, ultrasound is easy to do, uses no X-rays, and clearly shows the structure of the scrotum. In rare cases, the ultrasound leaves more questions than answers. Your urologists may ask for magnetic resonance imaging (MRI), a more sophisticated imaging technique.

How are Testicular Injuries Treated?

If any imaging study suggests testicular injury, the usual course of action is surgery. Under anesthesia, a cut is made in the scrotum and the contents are checked. If the testicle has torn, it can be repaired if it has good blood supply and the other testicle has enough of its cover. Your urologist will most often fix the tear with stitches and close the scrotum skin. In some cases, he/she will leave a plastic tube in the scrotum for a short time to drain blood and other fluids.

Sometimes an injury is so bad the testicle can't be fixed. In this case, your urologist will remove the testicle. This doesn't mean you can't father a child, though. Only 1 working testicle is needed for normal fertility. A single testicle will most often make normal amounts of sperm and testosterone. If your other testicle is normal, you should be able to get your partner pregnant.

If your physical exam and ultrasound suggest the injury has caused epididymitis, you'll likely be treated without surgery. You may be given anti-inflammatory meds (such as ibuprofen) and again be told to wear a jock strap. If needed, your urologist may also give you an antibiotic. It takes about 6 to 8 weeks for the swelling to go away. You may have to have many follow-up visits with your urologist to chart your progress. If conservative measures (meds and jock strap) don't work, surgery may be needed and the testicle may have to be removed.

Frequently Asked Questions

I've noticed pain in my scrotum and testicle but I don't remember any injury. What should I do?

There are many possible causes of scrotal or testicle pain, such as epididymitis, swelling of the testicle, and problems with other parts of the scrotum. You should be checked by a urologist to find the source.

I was hit by a knee during a basketball game and have since noticed a new lump in my scrotum. It doesn't hurt, but should I do anything about it?

Like many young men, you're likely checking yourself for the first time now that you've had a sporting injury. There's a good chance that the lump or "new" mass you've just felt is a normal part of the anatomy (your epididymis). But it could be an injury or even testicular cancer. Any new lump should be checked at once by a trained urologist. With his/her skill, a urologist will ease your mind and point you to swift and proper treatment.

I'm 55 years old and noticed a lump in my scrotum after being hit in the groin during a pick-up game of baseball. Could this be testicular cancer, or am I too old for that?

Testicular cancer can show up at any age, though most cases are seen between 15 and 35 years of age. Any man with a new lump in his scrotum should see a urologist right away. Often, you won't need any further tests because your urologist can make a diagnosis with a physical exam. He/she may also ask for an ultrasound, though. While some masses are safe (benign), many can be cancer (malignant). The good news is that testicular cancer caught early can be treated with good results. Don't be afraid to call a urologist.

I noticed blood in my urine after being hit with a baseball. I don't feel any lumps. Should I still report this to my urologist?

Absolutely. Blood in the urine that's visible to the naked eye is almost always due to a urological problem. You need to see a urologist right away to find the reason.

What can I do to prevent injury to my testicles?

There are many common-sense steps you can take to lower your risk of testicular trauma. Wear a seat belt when driving a car. If you work around machinery that has exposed chains or belts, make sure your clothes are tucked in and loose belts or other items that can catch aren't exposed. Wear a jock strap when playing sports. If the activity has a chance of rough contact (as in baseball, football, or hockey), use a hard cup.

Content provided courtesy & permission of the American
 Urological Association Foundation, and is current as of 5/2010. 
Visit us at www.urologyhealth.org for additional information.

What is Penile Trauma?

While the penis is one of the least harmed organs, accidents can happen. Though not common, large hospitals may see a number of cases of penile injuries each year.

How Does the Penis Normally Work?

The main roles of the penis are to carry urine and sperm out of the body. There are 3 tubes inside the penis. One is called the urethra. It is hollow and carries urine from the bladder through the penis to the outside. The other 2 tubes are called the corpora cavernosa. These are spongy tubes that are soft until filled with blood during an erection. The 3 tubes are wrapped together by a very tough fibrous sheath called the tunica albuginea. The urethra acts as a channel for semen to be ejaculated.

What is Pelvic Organ Prolapse?

Under normal conditions in women, the pelvic organs are held in place by a "hammock" of supportive pelvic floor muscles and tissue. When these tissues are stretched and/or become weak, pelvic organs can drop and bulge through this layer and into the vagina.

 A cystocele is when the bladder drops and pushes into the vagina.  A uterine prolapse is when the uterus drops and pushes into the vagina.  A rectocele is when the rectum pushes into the vagina.  An enterocele is when the small bowel falls and pushes into the vagina.   

In severe cases, the prolapsed organ or organs push the vaginal lining into the opening of the vagina. Sometimes it can even protrude (drop) through the vaginal opening. Pelvic organ prolapse is common in women. The symptoms can be bothersome but it can be treated.

What are the Symptoms of Pelvic Organ Prolapse?

The most common symptom is the feeling of a vaginal bulge. A bulge in the vagina is something you can see or feel.

Other signs and symptoms that may be related to prolapse are:

• frequent voiding or the urge to pass urine
• urinary incontinence (unwanted loss of urine)
• not feeling relief right after voiding
• frequent urinary tract infections
• pain in the vagina, pelvis, lower abdomen, groin or lower back
• heaviness or pressure in the vaginal area
• sex that is painful
• tissue sticking out of the vagina that may be tender and/or bleeding
• Some cases of prolapse may not cause any symptoms.

What Causes Pelvic Organ Prolapse?

Prolapse can develop for many reasons. The major cause is stress on this supportive "hammock" when giving birth. Women who have many pregnancies, deliver vaginally, or have long or difficult childbirth are at higher risk.

Other factors that can lead to prolapse are:

• heavy lifting
• chronic coughing (or other lung problems)
• constipation
• frequent straining to pass stool
• obesity
• menopause (when estrogen levels start to drop)
• prior pelvic surgery
• aging

How is Pelvic Organ Prolapse Diagnosed?

Prolapse can be found with a clinical history and a pelvic exam. The exam may be done while you are lying down, straining or pushing, or standing. Your health care provider may measure how serious the prolapse is and what parts of the vagina are falling.

Other tests and imaging studies may also be done to check the pelvic floor, such as:

• cystoscopy
• urodynamics
• x-rays
• ultrasound
• MRI

How is Bladder Prolapse Treated?

Conservative Management

Conservative measures involve

• No treatment. Some women have pelvic organ prolapse and do not have bothersome symptoms. You do not need to treat your prolapse if it is:
• not causing you problems
• not blocking your urine flow

2. Behavior therapy this can includes:

• kegel exercises (which help strengthen pelvic floor muscles)
• pelvic floor physical therapy
• a pessary (a vaginal support device)

3. Drug therapy this includes:

• estrogen replacement therapy

Surgery

The goal of surgery is to repair your body and improve symptoms. Surgery can be performed through the vagina or the abdomen. There are several ways the surgery can be done, they include:

• Open surgery- when an incision (cut) is made through the abdomen
• Minimally invasive surgery- uses small incisions (cuts) in the abdomen
• Laparoscopic-the doctor places surgical instruments through the abdominal wall
• Robot-assisted laparoscopic- robotic instruments are placed through the abdominal wall. They are attached to robotic arms, and are controlled by the surgeon.

Surgery also involves options of:

• native tissue repair (using one's own tissue and sutures)
• augmentation with surgical material
  • polypropylene mesh
  • biological graft

Before having surgery you should have an in-depth talk with your surgeon. You should learn about the risks, benefits, and other choices for repairing your prolapse with surgery. It is important that you give informed consent. This can only be done after your doctor has answered all of your questions.

Most commonly, your surgeon will recommend one of two types of surgical repairs for your pelvic organ prolapse. 

Sacrocolpopexy is an abdominal surgery that pulls the top of the vagina up by attaching it to a piece of permanent synthetic mesh that is attached to your sacrum.  This provides support to the vagina and can keep your pelvic organs in place.  In some cases, additional support needs to be provided to certain organs depending on how severe your prolapse is and which organs are involved.

A colpocleisis is a vaginal surgery that brings the walls of the vagina together providing internal support for the pelvic organs, preventing them from falling into the vaginal opening.  This procedure is only for women who no longer have vaginal intercourse, as the vaginal opening would be closed after this procedure.

If prolapse is left untreated, over time it may stay the same or slowly get worse. In rare cases, severe prolapse can cause obstruction of the kidneys or urinary retention (inability to pass urine). This may lead to kidney damage or infection.

Content provided courtesy & permission of the American
 Urological Association Foundation, and is current as of 5/2010. 
Visit us at www.urologyhealth.org for additional information.

What is Meatal Stenosis?

Sometimes the opening of the penis where urine passes can become blocked. This can cause problems with urination. This article should help you understand this condition and how it can be treated.

How Does the Penis Normally Work?

The main roles of the penis are to carry urine and sperm out of the body. The urethra is the tube that carries urine and sperm through the penis to the outside. The opening to the outside is called the "meatus."

 What is Meatal Stenosis?

Meatal stenosis is when the opening at the end of the penis becomes narrow. This condition is usually acquired but can exist from birth.

 What are Symptoms of Meatal Stenosis?

The symptoms of meatal stenosis relate to the stream of urine being partly blocked.

These can include:

• Pain or burning while urinating
• Getting sudden urges to urinate ("urgency")
• Needing to urinate often ("frequency")
• A urinary stream that sprays or is hard to aim
• A small drop of blood at the tip of the penis when finished urinating

What Causes Meatal Stenosis?

Meatal stenosis is mostly linked with circumcision and is rarely seen in uncircumcised males. It’s likely that the newly exposed tip of the penis (including the meatus) suffers from a mild injury causing meatus to narrow (stenosis). Uric acid and ammonia crystals are the most common cause for the narrowing of the meatus. These crystals are found in the urine and can be left in the diaper before your baby is changed. These crystals may cause a low grade inflammation which can cause the meatus to narrow over time.

Meatal stenosis can also result from mild ischemia (not enough blood to that part of the body) that occurs during circumcision. Finally, it can also be caused by a mild injury to the tip of the penis as it rubs against the diaper or the child’s own skin after circumcision.

Meatal stenosis can also occur after hypospadias repair. While this isn’t common, it’s seen in up to 1 in 25 patients who have this surgery.

The risk of meatal stenosis is also higher with:

• Injury to the penis tip
• Inflammatory skin conditions (including balanitis and BXO)
• Long-time use of urinary catheters (tubes)

Diagnosis

Meatal stenosis is found by your health care provider with a physical exam. A physical exam will show a small, narrowed meatus. This means the pathway is partly blocked. The lower part of the meatus is often stuck together. There’s no need to measure the opening, as that could cause more harm.

How is Meatal Stenosis Treated?

The best way to treat meatal stenosis is with surgery. The stuck bottom part of the meatus is cut apart. This type of surgery is called a “meatotomy.” After surgery, meatal stenosis rarely comes back as long as proper care is taken.

Meatal stenosis can also be treated by stretching the opening wider (“dilation”). But this can tear the meatus. While this may relieve symptoms for a while, it can cause more scars to form. The new scars make the meatus narrower and cause worse symptoms.

 What Can I Expect after Treatment for Meatal Stenosis?

Meatotomy works very well. Pain at the tip of the penis can be helped with oral pain killers or warm baths. Bleeding is rare and usually controlled with direct pressure. Recovery time is fast: typically 1 to 2 days. Spreading lubricating ointment or petroleum jelly on the tip of the penis several times a day for 1 to 2 weeks can ease discomfort and help the wound to heal.

Content provided courtesy & permission of the American
 Urological Association Foundation, and is current as of 5/2010. 
Visit us at www.urologyhealth.org for additional information.

What is Hypospadias?

Most boys are born with a penis that looks normal and works well. But some boys are born with a common condition called hypospadias. Hypospadias forms a penis that not only doesn't work well but also doesn't look normal. Pediatric urologists have come up with many surgical techniques to fix this problem. The following information should help you speak to your son's urologist.

How Does the Penis Normally Work?

The main roles of the penis are to carry urine and sperm out of the body. The urethra is the tube that carries urine and sperm through the penis to the outside. The opening to the outside is called the "meatus." Both tasks are easier when the meatus is at the tip of the head ("glans") of the penis.