Urology/Scar tissue in prostatic urethra
QUESTION: I am a 55 year old man and I live in Quebec, Canada. Recently I had a cystoscopy and I was told that I have scar tissue in the prostatic urethra. On the screen I could see tissue in the center of the urethra with small openings in three corners, and the scope could not get into the bladder. A possible cause is that when I was hospitalized last year for a heart condition, the nurse said that she made an error while installing a catheter in my urethra, after which I had blood in my urine for many days and eventually a blood clot that blocked urination a few days after the catheter was removed. A urologist removed the clot and a few days later I went home. For about two months after that, I passed some blood just at the beginning of each urination. Urine has been without any blood for a year now, and the flow is good during the day but urination is more frequent during the night (at least every two hours). My questions are : (1) can this scar tissue be left as is ?, (2) if not what kind of surgery is required ?, (3) how much (how little) tissue has to be removed ?, (4) how long will it take to heal ?, (5) will it recur ?
ANSWER: Joe, it is difficult for me to give you an exact answer as so much depends on what I would see on cystoscopy (as these are subject to interpretation). however, I will do the best I can based on the data you provided.
I suspect that you have some underlying degree of benign prostatic hypertrophy (BPH - an enlarged prostate gland). The scar tissue noted could be in the prostatic urethra or just distal to it in either the membranous or perineal (pendulous) urethra. As long as you are relatively asymptomatic, treatment is not absolutely necessary. The bleeding you had last year is typical of bleeding from the prostate. Apparently your only symptom is night-time frequency (nocturia) every 2 hours. "Strictures" usually produce a decrease in size and force of the urinary stream. The nocturia usually is from BPH.
For you to understand the treatment of BPH versus a stricture, I am going to explain each to you.
BPH: Benign enlargement of the prostate gland (benign prostatic hyperplasia or BPH) occurs to varying degrees in all men as they age. The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder. Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating. The prostate is checked by digital examination through the rectum. This gives the doctor an idea as to the size and benignity of the gland. However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.
The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate. This delicate balance can be upset by any factor that decreases the bladder muscles ability to contract with sufficient force to open the prostate (such as medications, anesthesia, too much alcohol, ignoring the desire to urinate, etc.) or those factors that might cause the prostate to suddenly swell (ie acute prostatitis, sitting for extended periods of time, biking, horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding. This complex of symptoms is termed “prostatism”. If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely. This leads to the accumulation of “residual urine” which may predispose to urinary infections and kidney damage from back pressure.
However, relatively asymptomatic men with BPH do NOT necessarily require therapy. Treatment is indicated to relieve symptoms and prevent complications. In many cases medications can be used. Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against. Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined. The prescription drugs Proscar and Avodart actually shrink the prostate. They work best in the larger glands and improvement may not be noted for up to 6 months. In cases refractory to medication, interventional measures are indicated. The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate. For huge glands, open surgery may be necessary. In the past decade a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy. These include laser prostatectomy, microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate). TUMP is actually a minimally invasive, out-patient treatment that can be tried initially if the patient's gland size is appropriate.
Here is an explanation of a TUR of the prostate gland. The prostate gland can be thought of as being composed basically of three parts which from inside to out are: the prostatic portion of the urethra (urinary canal), the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate. In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule. This surgery can be likened to coring out an apple from the inside leaving only the skin. The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction. This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra! At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction. A catheter is left in for a few days to drain the bladder and to initiate the healing process.
STRICTURE: Symptoms such as weak stream, dribbling after urination and splitting of the stream suggest an obstruction in the lower urinary tract. The most common causes are a stricture (narrowing of the urethra) or a swollen prostate gland that encroaches on the lumen of the urethra. Strictures can be congenital or acquired. They can be located anywhere from the neck of the bladder, to the prostate gland, to other areas of the urinary canal (urethra), to the meatus (where the urethra ends at the tip of the penis). A number of conditions that cause the prostate gland to swell may cause similar symptoms. These include prostatitis, prostatic congestion, and benign prostatic hypertrophy (BPH). In order to ascertain the specific cause, it is necessary to seek consultation with a urologist. An endoscopioc examination of the lower urinary canal with a cystoscope is usually necessary to establish the correct diagnosis. An alternative diagnostic tool would be a retrograde urethrogram. This is an x-ray evaluation of the urethra obtained by injecting contrast material through the urethral meatus under pressure. The treatments of stricture are generally simple and effective. The initial treatment is simple dilation (stretching) of the strictures with progressively larger instruments called sounds. Depending on the severity of the stricture and the diameter to which the stricture heals, the dilation is done prophylactically thereafter, but at least once annually. If the stricture is too narrow or dense for sounds, special instruments called filliforms and followers are used. If the stricture tends to reform too rapidly, it is best to sharply incise the stricture with a bayonet type instrument under direct vision through a cystoscope. This is called an internal urethrotomy. It is quite successful. A last resort for the most recalcitrant strictures is formal open surgical repair. It is important to treat strictures as they not only interfere with the stream, but they can predispose to recurrent urinary tract infections.
I hope I haven't confused you with too much information. Again, it may not be absolutely necessary to be treated. If you have further questions let me know. Good luck.
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QUESTION: Dr. Goldstein, Thank you very much for your answer. The information you give me about BPH and strictures is quite helpful. However, may I ask for some clarifications ?
First, the scar tissue I saw of the screen during cystoscopy was covering approximately 55% of the area of the urethra at the center, with three openings in the corners covering each about 15% of the area. This scar tissue prevents going into the bladder and therefore a Foley catheter could probably not be inserted without injury; if I need to be hospitalized in the future for other health problems, could this blocking be risky, so would it be prudent to restore access to the bladder ASAP ?
Second, to remove the scar tissue, would a urethrotomy be sufficient of is a TUR required ?
Thanks in advance.
P.S. If you can edit my original question, can you please remove my location from the first sentence.
ADDENDUM: My initial response was based on the description suggesting a thin web-like stricture. If the stricture is truly in the prostatic urethra, especially if very thickened, it may require resection or laser vaporization of a portion of the prostate. The urologist who did the study can surely define the type of procedure needed based on his endoscopic findings.
Joe, the scar tissue as you describe it could be either treated with an internal urethrotomy (cold knife called a urethrotome) or with a laser probe. Probably nothing more would be necessary on the prostate per se. Both of these are simple procedures that could be accomplished on an out-patient basis under anesthesia. Now that I understand the anatomy a bit better, it would be wise to have this done electively (as opposed to ASAP) , perhaps after the holidays. Good luck and Happy Thanksgiving!