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Urethral Stricture:
Modern
Aspect:
Etiology
:
Urethral
stricture divided into two varieties:
A.
Congenital :
1.
Urethral Stenosis : Distensibility of urethral wall is reduced
or it may be due decreased laxity of paraurethral tissues.
2.
Meatal Stenosis :
B.
Traumatic :
1.
Rupture of bulbous urethra due to RTA
2.
Rupture of membranous urethra (Intrapelvic rupture), rupture of
pelvis and Rupture of bladder.
C.
Inflammatory :
1.
Post gonorrhoreal :- Urethritis
2.
Post gonorrhoreal chancre – primary syphilitic chancre at
meatus usually head with fibrosis resulting in meatal stenosis.
3.
Non specific infections : may spread from bladder or during
catheterization, cystoscopy or surgery
4.
Instrumental :
a.
Indwelling catheter repeated and prolonged catheter necessary in
post operative cases and motor dysfunction may cause repeated
friction of the mucosa carry urethritis causes stricture.
b.
Endoscopy : Following caliber of large endoscope notably a
resectoscope causes stricture.
c.
Post prostatectomy : Post operative bladder neck stenosis.
d.
Amputation of penis : post amputation scarring of remaining
urethra and periurethral tissues.
Pathogenesis
:
1.
Partial loss of uroepithelial lining.
2.
After dilatation and internal urethrotomy – base areas are
created slow epithelial proliferation cleft closure and
spongiofibrosis result in a tendency to restenosis.
Post
gonorrhoreal stricture :
Clinical
Features :
1.
Passage of flakes (desquamated epithelium) in urine.
2.
Urethral discharge at early morning.
3.
Dysurea
4.
Straining
5.
prolonged micturition
6.
Dribbling occur due urine trickling from dilated urethra above
stricture.
7.
Frequency of micturition is increased at day and night
8.
Possible to palpate the stricture from outside as an induration
in the urethral floor.
9.
Burning micturition
10.
Occasionally haematuria secondary to localized
inflammatory changes instrumentation and passage of calculi
11.
Retention of urine
12.
Incontinence of urine
13.
Strangury
14.
Decreased stream of micturition.
Effect
of Urethral Stricture :
1.
On Urethra :
Urethra above the stricture may get dilated or diverticulum may
be found due to increased pressure from bladder due to
straining.
2.
On Bladder :
-
Musculature of bladder is hypertrophied
-
Trabeculation and divertiulum may be found
-
Calculi are prone to form in stagnant pool and residual urine
-
Long standing cases bladder atony may occur
3.
On Ureter and Kidney :
4.
On Sexual Organ :
-
Seminal vesiculits
-
Prostatitis
-
Orchitis
Effect
of Straining:
Herniation, haemorrhoids, prolapse etc.
Diagnosis:
A)
Routine Investigation
1.
Blood for HB, TLC, DLC, ESR, V DRL
2.
Urine Routine
3.
X ray KUB
4.
Urodynamic study / volumetric study.
B)
Specific Investigations
1.
Kidney function test
2.
Urine culture and sensitivity.
3.
IVP
4.
Retrograde urethrography
5.
Cystoscopy
Retrograde
Urethrography :
It is
helpful to confirm the diagnosis -
1.
localize the lesion
2.
understand the extent and nature of stricture
3.
for comparison between before and after treatment
Ayurvedic
Aspect
:
Causes
(Etiology)
1.
Drinking water or eating when the bladder is full and urge to
pass urine is present.
2.
Suppressing micturition
3.
Excessive indulgence in intercourse
4.
Exhaustion and injury lead to diseases of urinary bladder.
5.
Akalyonigamana, Ayonigamana, Mastrubation
6.
Forceful control of sexual desire, extensive sexual practice and
trauma to reproductive organ by means of surgery i.e. shashtra,
kshar and Agni
7.
Dhwajbhanga (extragenital intercourse, intercourse with a lady
having vaginal, gynaecological disorder, who has not done
intercourse since long period of time, during menstruation)
Shushruta
Described Urinary Tract Disorder of Two Type :
1)
Mutraghat
2)
Mutrakruchra
1)
Mutraghat : Obstruction to passage of urine - 12 types
1)
Vatkundalika
2) Vatashtila
3) Vatbasti
4)
Mutrateet
5) Mutrajathar
6) Mutrotsang
7)
Mutrakshya
8) Mutragranthi 9)
Mutrashukra
10)
Ushanvat 11) Pittajmutrotsad
12) Kaphajmutrotsad
Mutrakrichra
:
Obstruction
to urine is much or less but micturition is usually associated
with pain, burning and difficulty.
Type
:
A)
Vataj
B) Pittaj
C) Kaphaj
D)
Sannipataj
E)
Abhighataj
F)
Ashmarij
G)
Sharkaraj H)
Shakrut
Mutramarga
Sankoch (Lakshana - Sign and Symptoms)
a.
Difficult, frequent, painful, prolonged micturition with
straining with little amount of urine
b.
Sign of retention of urine
c.
Pain in lower abdomen, flank, scrotum, perineum
d.
Haematuria
e.
Physical appearance of urine change dark, yellowish,
reddish.
f.
Stream of Urine is either thin or bifurcated.
Samprapti
of Mutramarga Sankoch (Pathogenesis)
According
to Charaka, the basti is vatsthana an apan vayu is seated at
testicles, bladder, guda, penis etc. and responsible for normal
evacuation of bladder, bowel, and ejaculation. The diseases
occurring in this region are mainly due to vat dusthi.
Increase
in khar, Ruksha guna responsible for local constriction and
hardening of tissues leading to constriction of urethra.
Increase in chala guna leading to frequent micturition and cause
pain. When vayu get stage of prakopa it causes mutra sanga, tod
(thrombing pain), Sankoch (Stricture), shosha and shoola.
Kapha prakop is manifested with sthairya as local stasis, gaurav
as heaviness in penis in mutrosanga, uplepa (narrowing of lumen)
due to hypertrophied scar tissues, bandha (obstruction to normal
flow) chirkaritwa (chronicity)
Hence combination of Vat +++ and kapha + is causative factor
doshas behind the mutramarga sanchoch i.e. urethral stricture.
Urethral passage is lined by mucosa which is shleshmadharakala /
internal lining which may be considered as updhatu of Mansa. It
gets affected and diseased mucosa promoted the disease to
submucosal structure and their involvement lead to stricture.
Twachas is updhatu of Mansa which is nourished by Rasa and Rakta
hence in this disease Rasa Rakta, Mansa are affected Dhatus.
Mutravaha strotas is involved hence Mutra is among the dushyas.
As Mutra prasek is common pathway for Mutra and Shukra in male
so Shukra is also involved in this disease.
Dosh
Dushya Samurchana of Mutramarga Sankoch
Dosha
Vat
+ + +
Kapha
+
Dhusyas
Dhatu
- Ras
-
Rakta
-
Mansa – Twacha
-
Shukra
Mala - Mutra.
Sadhya
Sadhyatwa (Prognosis) :
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