Benign Urethral Lesions

The urethra is an important part of the urinary tract. While its primary job in both genders is to pass urine outside the body, this channel also has an important role in ejaculating semen from the reproductive tract of men. Most of us will undergo few, if any, problems with our urethra. But a few of us may experience the discomfort and dysfunction associated with benign urethral lesions. What are they and can they be treated? The information below should help you talk with your urologist.

What happens under normal conditions?

The urethra is a tube-like organ whose function is to transport urine from the bladder out of the body. In males, the urethra begins at the bladder and extends through the prostate gland, perineum and the entire length of the penis. In females, the urethra is much shorter and extends from the bladder to just in front of the vagina and opens outside the body. Normally, urine flow is painless and can be controlled, the stream is strong, the urine is clear and there is never any visible blood in the urine.

Causes can include abscesses, pelvic fractures, straddle injuries, infections or injury caused by surgical instruments (e.g., catheters, cystoscopes, resectoscopes, etc.).

Benign neoplasms: Linked to the presence of genital warts on the penile shaft, these lesions are often the product of human papilloma virus (HPV). Urethral wart-like growths are suspected when there is bleeding from the urethra, a visible lesion on the opening of the urethra or changes in the urinary stream, accompanied by a history of genital warts.

Balanitis xerotica obliterans (BXO): BXO is a chronic condition with unknown causes that affects the end of the penis and is marked by pale, shiny, whitish skin around the opening of the urethra. The scarring and thinning of the membrane begin (in most cases) in young adulthood and can progress, leading to a narrowing of the urethra and difficulty passing urine. Other symptoms include soreness and itching in the area and sometimes ulceration.

Urethral stricture disease:  Results in scar tissue or inflammation at one or more points in the urethra and of variable severity. Complications of urethral stricture disease include but are not limited to a decrease in urine flow rate, frequent urination, urinary tract infections, bleeding and inflammation/infection of the prostate. Diagnosis is usually made by urinalysis, retrograde urethrogram and cystoscopy.

Urethral polyps: A urethral polyp is an irregularity that is usually present at birth. It is usually composed of fibrous tissue but may include some smooth muscle, small cysts or nerve tissue all covered by a thin protective layer of tissue. Symptoms include a lump in the vulva, blood in the urine or a blockage. Urethral polyps are diagnosed with cystoscopy, a fiber-optic technique that allows a urologist to readily view the polyp, and a voiding cystourethrogram (VCUG). By combining an X-ray of the urethra with dye in the area, the doctor can easily view the structures. 

Paraurethral cyst: Also known as Skene's glands, paraurethral glands are located in the urethrovaginal wall at the opening into the urethra in females. A paraurethral cyst will be evident to a doctor by its appearance — a glistening, tense and bulging yellowish-white mass reducing the size of the urethral opening. Other symptoms include a misdirected urinary stream and possibly painful urination.

Urethral caruncle: Urethral caruncles are polypoid (or stalk-like) masses, hanging from one area of the external urethral opening. The primary sign of this problem is a thin, reddish membrane protruding from one portion of the urethral opening. Other symptoms include bleeding and urination problems such as frequency, urgency and pain. A urethral caruncle is usually spotted during an examination for another condition. They are relatively common in the urethral epithelium of women who do not use hormone replacement therapy (HRT) after menopause. Marked by a purplish mucosal mass, this condition can cause a variety of symptoms, including difficult or painful urination, blood in the urine and tenderness around the opening of the urethra.

Urethral prolapse: A rare and more bothersome abnormality of the female urethra than other benign lesions is called urethral prolapse, which occurs most commonly in young girls though it also may surface at any age. It is marked by the urethra's membrane and underlying spongy tissue protruding out the opening of the urethra. This leads to pain, vaginal bleeding and occasionally urine retention. A diagnosis is usually made by simple physical examination.

The nature and location of any benign lesion will influence how it is treated. Abscesses, urethral injuries and infections require immediate attention. A urologist has a variety of medications and procedures to deal with these lesions.

Abscesses linked to gonococcal urethritis can be treated successfully today with antibiotics. Additionally, your urologist may drain the abscess and divert the urine flow until your condition improves and you can urinate normally.

Treating urethral stricture disease is based on the accurate delineation of individual scars. The cornerstone of this process is urethrography, an imaging technique that utilizes retrograde instillation of a contrast dye into the urethra to determine the length and location of the strictures. If these strictures are very dense or if they completely destroy the channel, a more detailed urination study through an incision above the pubic bone may be necessary.

Urethral strictures are often treated by increasing the diameter of the channel either through dilation or endoscopic incision. Techniques such as direct vision internal urethrotomy (DVIU), are very successful for short strictures (less than two centimeters), particularly in the bulbar and membranous regions of the urethra.

Dilation performed under local anesthetic jelly utilizes a series of increasingly large tubes or dilators that are passed from the urethral opening into the bladder. The insertion of the dilators may be conducted under the guide of a urethroscope. Dilation produces some discomfort, usually made worse by tighter, dense strictures. The urologist may place a urethral catheter into the urethra 24 hours or longer after to drain the bladder.

DVIU is also carried out under general anesthesia, although some urologists elect to perform it with a local anesthetic in the office. In either case, with the aid of a cystoscope, the surgeon makes a deep incision through the stricture with a small endoscopic knife. By making a single cut through the scarred stricture, the doctor exposes healthy epithelial tissue beneath, which should allow the urethra to re-cover itself. Long strictures, as well as any scars in the pendulous urethra, respond less well to DVIU or dilation. Instead, those scars, along with completely destroyed urethras, can be dealt with by surgical reconstruction, which has varying results.

A surgical procedure called urethroplasty is performed by making an incision in the penis and then removing the stricture. Your doctor will then probably follow up by rejoining the tissue at the ends of the urethra or inserting a skin graft to partially or completely restore the urethra at the stricture. While this procedure requires no overnight hospital stay, a catheter will remain in place for approximately three weeks.

Permanent, implantable metal stents have been employed for bulbar urethral strictures. But while initial clinical trials have yielded promising results in men exhibiting shorter scars (two centimeters or less) with some co-factors, the stent's application is limited. Because the brace is permanent once inserted, it has been most successful in patients with bulbar urethral scars, strictures that are otherwise difficult to manage due to the poor quality of the corpus spongiosum. Skin grafts and repeated urethrotomy, urethral incision repairs, often tried in those circumstances have resulted in recurrent stricture disease.

Treating benign neoplasms is difficult. Lasers can be used to destroy visible lesions connected to this condition. Some physicians advocate topical cream treatments. But as of now, no technique reliably eliminates the condition or prevents the virus from recurring in the future.

Local antibacterial and anti-inflammatory agents are used to treat BXO.

Treatment for urethral polyps consists of removing the polyp using cystourethroscopy, a minimally-invasive technique using a fiber-optic instrument that allows the urologist to peer into the space and, with additional miniaturized instruments, remove the growth.

In the case of paraurethral cysts, no treatment is necessary if there are no symptoms since they usually spontaneously rupture and decompress. If, however, a blockage develops, the urologist may pierce the cyst with a scalpel blade to relieve the milky drainage.

For patients with a urethral caruncle but no symptoms, the primary treatment option is reassurance but may also include topical estrogen cream or hormone replacement therapy (HRT). If the caruncle is large or small and causing problems, the urologist will probably choose to remove the growth and cauterize the base.

Treatment for a urethral prolapse consists of surgically removing the prolapsed tissue and repositioning the membrane using stitches to prevent further protrusions.

Benign lesions associated with human papilloma virus (HPV) and gonorrhea are notoriously difficult to address, even though antibiotics are effective in controlling the problem. So it is not uncommon to repeat treatment because such urethral lesions resurface.

After either dilation or direct vision internal urethrotomy (DVIU), you can expect some blood alongside the Foley catheter and occasionally in the urine draining from it. If you have heavy bleeding, your urologist may elect a large-bore catheter, which will probably be left in for a longer period.

The main complications associated with both dilation and internal urethrotomy are high rates of stricture. Recurrence depends on the length of the stricture, with shorter ones usually doing better with these therapies than longer ones. For instance, scars less than two centimeters in length have a 50 percent long-term cure rate with DVIU. Several studies have suggested that daily, intermittent catheterization up to three months after the procedure may reduce recurrence.

Strictures more than a centimeter, on the other hand, exhibit success rates significantly lower than 50 percent. In addition, the chance for long-term cure with either DVIU or dilation is very low. Nevertheless, in some men DVIU or dilation may be appropriate, even though the urologist knows that intermittent catheterization or a repeat procedure will be necessary.

Complications associated with urethroplasty can include recurrent stricture disease, bleeding, infection and lower extremity complications due to patient positioning. Three weeks after surgery, your doctor will probably order a voiding cystourethrogram, a contrast imaging study of your urethra, to determine if the area is healing properly.

Doctors usually follow any stricture procedure with uroflow studies to monitor the force of the urine stream from the urethra as well as other factors. In addition, repeat radiographic studies are commonly performed at three and 12-month intervals after a urethroplasty to monitor any recurrence. While most strictures develop within a year of surgery, they have been known to show up 10 years later.

Common misspellings: prostrate