Feb 19, 2020

Interview Transcript

Interviewer: We're here with Dr. Jeremy Myers. He is a specialist of urological surgery. So, Dr. Myers, what exactly is a urethral stricture?

Dr. Myers: Well, a urethral stricture is, quite simply, a scar in the urethra, which is the pee channel running from the bladder and out the penis. And it almost exclusively happens in men. It's very rare that it occurs in women. And so that's where we deal with it most.

Interviewer: And what can cause some of these scars?

Dr. Myers: Most of the scars are what we call idiopathic, which means they just come up. And they come up in a particular area of the urethra, below the scrotum. But you can also get the scars from a bad infection, such as a sexually transmitted disease, which is very rare. And you can also get it from trauma. The classic trauma that can cause it is when a man lands on the perineum, like on a rail skateboarding or snowboarding.

Interviewer: Yeah, and the saddle injury, I think, is something I read too, right? Horseback riding?

Dr. Myers: That's exactly right. In the West, we see this from horseback riding and sometimes from ATVs. And, sometimes, it's accompanied by a pelvic fracture when it arises from trauma, but this is a small portion of the strictures. Almost all of them just arise for no known reason.

Interviewer: Since these structures are kind of internal, and it's not something you necessarily see, how does a person or a man, kind of . . . How do . . . What are some of the symptoms of having a stricture?

Dr. Myers: The strictures are pretty rare, and so it's very often that they're misdiagnosed or not recognized for some time. I remember talking to an internist once, and they said, "Oh, I didn't even realize that could happen." So they're not really on the radar a lot for the medical community as a whole. So patients are often diagnosed as having a prostate infection or a voiding dysfunction or a urinary tract infection, and then their symptoms don't get better, and then they're sent to a urologist who can diagnose the stricture.

Interviewer: So, essentially, they have difficulty passing urine and other complications because the urethra is actually smaller or not flexible, is that what happens?

Dr. Myers: That's exactly right. The urethra narrows down in a lot of cases just to a pinpoint, and so, the most obvious symptom of that is a very slow flow. And most guys will tolerate a slow flow alone. But there's a lot of other symptoms that come up. Men can have urinary tract infections. And then also, their bladder stiffens because it's squeezing so hard against the scar and so they have to urinate more frequently and may have urgency of urination. And so, a guy might be up four or five times a night urinating, and it may just be due to the blockage.

Interviewer: So, if it's commonly misdiagnosed, what does it take to actually diagnose a proper stricture?

Dr. Myers: Well, the suspicion is increased for a urologist in a younger man, who really should be voiding very well. In older men, the symptoms may be attributed to a large prostate. That's really common. But in a younger man, we can diagnose it or suspect it based upon their flow. And so, when someone comes to a urologist, we typically have them pee in a special toilet that allows us to measure their flow, and if they have a very slow flow and they're a younger man, then it's suspicious. They might have a scar. And where we go from there is pretty variable. The strictures can be diagnosed with a special x-ray of the urethra, or more commonly, a urologist has a scope that's flexible just like a catheter, and he'll pass, or she'll pass the scope up the urethra and then be able to visualize a scar. And that's a very easy way of diagnosing the scar.

Interviewer: So after it's been diagnosed, what are some of the options available to treat and kind of give some relief to these people?

Dr. Myers: The options basically fall into a couple categories. One is using a scope to either break open or to cut the scar, and that's the . . . the medical term for that is a dilation or urethrotomy, and they work about the same. Essentially, a urologist passes the scope up to the area of the scar and then uses dilators to sequentially stretch the scar and break it open, or they'll take a tiny knife that comes out of the scope that they can visualize and they'll kind of cut the scar almost like a Mercedes sign.

Typically, after this, a patient will have a catheter for a few days, and then the catheter is removed. And the hope was stretching or cutting the scar is that the urethra will heal over the catheter and will heal to a reasonable size where the patient is not having any symptoms. The unfortunate part of dilation or internal cutting is that it's rarely successful, and it probably only works in maybe 20% to 30% of cases. The studies on it are pretty mixed about its success rate. And so it's minimally invasive in the sense you'll only have a catheter for a short time, and it just uses a scope in the urethra. But, unfortunately, it's rarely a long-term solution for men.

So the other way that we treat urethral strictures is to do an actual surgery, where we cut into the body, and that's called a urethroplasty surgery. And that's what we specialize at the University of Utah in. Essentially, the idea of a urethroplasty is we cut over the scar in the body, which is mostly in the perineum, which is the area between the anus and the scrotum, and then we very carefully find the area of scarring by just passing a catheter down the penis and feeling where the catheter stops within the urethra. And then we cut out the area of the scar, and we create a very fine connection or anastomosis between the two ends of the urethra that are freed up and stretch. And that cures the stricture.

So that's a surgery that can take anywhere from two to four hours depending on how the surgery is done and what's required. And the catheter has to be in a longer time, and you can imagine an incision below the scrotum can be pretty tender. So it's much more invasive, but it's also much more successful. And the success rates of those surgeries are about 80% to 90%, just depending on the types of surgeries.

Interviewer: Well, that's significantly better results then. And how long of a healing process is that?

Dr. Myers: So, usually, the catheters are in for anywhere from two to four weeks, just depending on the nature of the stricture and what has to be done to fix it. And so, during that time, the catheter is really pretty uncomfortable, and most men will be off work during that time, or if they do non-physical work, they can maybe go back to work after a couple of weeks. The recovery is not like a hernia, so you can't tear open the repair but, usually, when a catheter is in, guys don't want to be doing anything too physical at all because of the discomfort of the catheter. So I'd say the realistic recovery where men are really feeling quite a bit better is about a month or so, and that's why it's much more invasive than the internal cutting, where the recovery really is just five or seven days.

Interviewer: So it, you know, it's an invasive procedure, and it sounds like there's going to be a bit of a recovery, but, you know, when it's all said and done, you know, what are some of the satisfaction rates of some of your patients?

Dr. Myers: We've actually studied this really well at Utah in conjunction with a number of other centers in the country, and if you look at satisfaction with a surgery, men rate themselves as satisfied or very satisfied with the surgery in about 87%. And, most of the time, when they're not satisfied with surgery, they have some side effects, such as a sexual side effect, which is, fortunately, pretty rare or the surgery fails them and, obviously, you wouldn't be satisfied with the result. So that's a very . . . a powerful number to give men when they're considering a pretty invasive surgery is that 85% or more are satisfied or are very satisfied with the results.

Another thing that men experience is their urinary symptoms, and then some men also have a lot of anxiety and depression related to the stricture. And this can be anxiety about not being able to urinate, not having the normal function that men have or anxiety about being in a public bathroom or needing to find the bathroom urgently. And the rates of depression and anxiety are much higher in men with strictures. And we did a study where we showed that these rates normalize and get much better after a stricture surgery. So, overall, a lot of things get better. The urinary symptoms get better after the surgery. So it's a good surgery even though no man would ever want to think about undergoing a surgery like that. It's a very personal and private spot, but it really fixes the problem with a pretty good certainty.

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