September 30, 2017
Uroflowmetry: Testing the urine flow rate
This is the first step. “The normal urinary flow rate in young and middle aged men is generally greater than 15?ml/second and the flow pattern a bell shaped curve. ” “In those who have a urethral stricture the peak flow rate is typically low but the flow pattern is characteristically flat” [Source]
“With a flow rate of less than 5?ml/second, abnormalities such as those listed above are much more likely and the patient is potentially at risk of acute retention, although this is a lot less common than one would expect from the severity of the narrowing of the urethra that is seen in such a situation. In these patients treatment is advisable even if symptoms of voiding difficulty are not troublesome.” [Source] (Sanjeev: I’m having pain while voiding)
Both “RUG/VCUG is costly and some-times logistically difficult to perform, and exposes men to radiation” [Source] These tests “show the exact site and length of the stricture and most of its potential complications” [Source]
Retrograde urethrogram (RUG)
See Wikipedia entry.
The penis is postioned at approximately the 10 o’clock position. The round opaque structure in the distal penis is the inflated Foley balloon. The Foley catheter tip is faintly radiopaque, but can be better seen as a filling defect after administration of contrast. [Source]
Voiding cystourethrogram (VCUG)
See Wikipedia entry.
The voiding urethrogram evaluates the posterior urethra. The Foley balloon is advanced into the bladder and contrast is instilled until the bladder is dilated. The bladder should be so dilated, that the patient “feels like he absolutely needs to pull off to the side of the road so he can urinate”. The Foley is then removed and the patient is encourage to urinate. Images are obtained of the open posterior urethra. As this is not a dedicated cystogram, imaging the bladder is a secondary concern. [Source]
“If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). ” [Source]
September 23, 2017
My FB post.
September 19, 2017
Average rates across the world:
Ages 14 to 45 — The average flow rate for males is 21 mL/sec. The average flow rate for females is 18 mL/sec.
Ages 46 to 65 — The average flow rate for males is 12 mL/sec. The average flow rate for females is 18 mL/sec. [Source] SEE ALSO: http://www.malcolmfrazer.com.au/pdf/Publications/Liverpool%20Nomograms.pdf
MY MEASUREMENTS post urethrotomy
Final closure to the issue: urine flow test on 6 February 2018. This was considered OK, with average rate of 17.5 ml/sec – which is broadly consistent with my readings in November. The surgery has been a success.
September 19, 2017
Note: my surgery was for Rigid Cystoscopy and Optical Urethrotomy (direct visual internal urethrotomy – DVIU).
EVEN IF MY SURGEON HAD DONE A DVIU DURING RADICAL PROSTATECTOMY, THIS ISSUE WOULD HAVE REMAINED A LIFELONG ISSUE
When urethral strictures are identified at the time of catheter placement for another surgical procedure, assessment of the need for catheterization should be made. [Source: Male Urethral Stricture: American Urological Association Guideline]
Urethral strictures may be dilated in this setting [when a stricture is suspected during surgery]to allow catheter insertion, and dilation over a guidewire is recommended to prevent false passage formation or rectal injury. Alternatively, DVIU may be performed, particularly if the stricture is too dense to be adequately dilated. SP cystotomy may also be performed to provide urinary drainage at the time of surgery if these initial maneuvers are unsuccessful, or when subsequent definitive treatment for urethral stricture is planned in the near future. [Source: Male Urethral Stricture: American Urological Association Guideline]
[Sanjeev: My surgeon felt something blocking the catheter during the prep for the prostatectomy. He did not do dilation or DVIU at that stage but moved on with the prostatectomy. I understand that using a large cathether is essential for such a surgery. In my case the goal of fixing the bigger issue – cancer – led to a secondary injury that is going to remain with me lifelong. EVEN IF HE HAD CONDUCTED A DVIU AT THAT STAGE, THE SITUATION I NOW HAVE WOULD HAVE BEEN UNCHANGED. Therefore, there was NO WAY to avoid what I’ve now got.]
URETHROTOMY IS GUARANTEED TO FAIL
After 1 urethrotomy Pansadoro and Emiliozzi found a 5-year stricture-free survival rate of 6%, which closely matched our 5-year stricture-free survival rate of 7%. Treatment eventually failed in all 7% of the patients by 79 months. [Source] – i.e. 100 PER CENT RECURRENCE WITHIN FIVE YEARS, WITH MOST RECURRING WITHIN 3-6 MONTHS.
The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. [Source]
RECOMMENDATION: NO MORE THAN ONE URETHROTOMY
“During the last 30 years urethroplasty has improved in efficacy and safety, while urethrotomy is increasingly considered neither cost-efficient nor effective in the long term. Urethroplasty is reported to have lifetime success rates ranging from 75% to 100%. Repeat and unsuccessful urethrotomies impose costs to the patients in the form of lost wages, unnecessary health care expenditures, decreased quality of life and unnecessary anesthesia. The fact that urethrotomy has a low success rate is a strong argument for opting for the more effective urethroplasty instead of a less effective urethrotomy.” [Source]
NOTE: THIS ISSUE IS NOT STENOSIS!
It is hard to get information on this issue from the internet. First thing to note is that it is quite different to meatal stenosis, which is a narrowing of the opening (this is how it looks). “Meatal stenosis is a common complication of circumcision.” Curing stenosis is relatively easy and is done through a surgical procedure called meatotomy during which the meatus is crushed with a straight mosquito hemostat and then divided with fine-tipped scissors. (here is a video of how it is done]
WHAT A MEATAL (or fossa navicularis) STRICTURE LOOKS LIKE?
What it looks like – picture.
It appears this issue was very common with prostatectomies in the past (Some Common Complications After Prostatectomy, J. Cosbie Ross and L. F. Tinckler, The British Medical Journal, Vol. 2, No. 5153 (Oct. 10, 1959). The issue still occurs in around 2 per cent of the patients.
Male Urethral Stricture: American Urological Association Guideline (2017)
Male Urethral Stricture: American Urological Association Guideline (full guideline needs online journal access) says that uncomplicated urethral stricture confined to the meatus or fossa navicularis should be treated with simple dilation or meatotomy, with or without guidewire placement.
However, urethroplasty is needed for to patients with recurrent meatal or fossa navicularis strictures. Meatal and fossa navicularis strictures refractory (i.e. stubborn to) to endoscopic procedures are unlikely to respond to further endoscopic treatments (e.g. Urethrotomy).
Patients who opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment, such as urethroplasty should be advised that success of a subsequent reconstructive procedure may be lower when following a plan of repeated endoscopic surgery and/ or intermittent self-dilation. Similar to other types of stricture, exact delineation of length and etiology is important for guiding treatment.
Dilation is a bad idea. In my case, when the stricture recurs, I should undergo urethroplasty (or whatever the term is called).
TREATMENT OPTION 1: DILATION [not recommended]
Pictures of Dilation of the Urethral Meatal Stricture
What are the Treatments for Meatal Stricture / Meatal Stenosis? [Sanjeev: these are quite different things]
- Intermittent self meatal dilatation – In some men it is possible that the narrowing of your urethra may re-occur. To reduce this risk you may be taught how to perform intermittent self meatal dilatation. [Sanjeev: it appears it will recur in almost all cases, and instead, aggravate things.]
What is Meatal Dilatation? Meatal Dilatation is a procedure which involves you passing a short catheter into the end of your urethra. The catheter is passed beyond the narrow section and this helps to keep the urethra open.
What Are The Alternatives?
- Meatal dilatation – If your urethra is not too narrow, it can be dilated or stretched in theatre under local anaesthetic or a general anaesthetic (when you are put completely to sleep) using catheters (soft, hollow plastic tubes) which are graduated in size.
- Meatotomy – A small operation to stretch or cut through the narrow tissue in your urethra may be necessary. This is called a ‘meatotomy’. Occasionally an additional procedure called circumcision (removal of the foreskin) may be necessary if repeated infections and inflammation (balanitis) at the tip of the penis has resulted in a tight foreskin. [Sanjeev: this is – as described – ONLY meant for a stenosis; not applicable in my case]
What are the risks of Meatal Dilatation?
- Pain. At first it may be a little painful or uncomfortable to pass the catheter, especially if you have had recent surgery. This, however, should improve with time and most men are able to tolerate the procedure with little discomfort.
- Bleeding. You may see a little blood on the end of the catheter after performing the procedure or experience a little bleeding from the urethra. This is nothing to worry about and should soon stop. If the bleeding becomes heavy and prolonged then contact your healthcare professional. [Sanjeev: actually bleeding is a BAD thing during dilation, as it will simply aggravate scarring]
- Infection. It is important to wash your hands and penis before performing meatal dilatation so that no bugs are passed up into the bladder. However, if you experience pain or burning when passing urine, notice that your urine is cloudy or smelly or, especially, if you start to feel unwell (i.e. high temperature, abdominal pain or flu like symptoms), contact your GP or healthcare professional immediately as you may have a urine infection.
- Recurrent Stricture If you notice a reduction in your flow of urine or if it becomes difficult to pass the catheter into the urethra, it may be because the narrowing has re-occurred. If this happens seek advice from you healthcare professional. [Sanjeev: This is STUPID. The advice should be provided upfront, including discussion of all risks]
- For how long and how often should I perform Meatal Dilatation? As everyone is different, a personalised regime will be agreed between yourself and your healthcare professional as to how often and for how long you should perform the procedure.
These are usually sterile hydrophilic coated single use catheters with NO drainage eyes. They are used for keeping the urethra patent in patients with strictures or who have had surgery to the urethra. Dilatation catheters will not drain the bladder. Shorter length meatal dilators are available for men who need only to dilate the meatus to avoid meatal stenosis, or to dilate a sub-meatal stricture. If the stricture is higher in the urethra then a full length dilatation catheter (40cm) will be needed. [Source: Trust Guideline for the Management of Teaching Clean Intermittent Self-catheterisation (CISC)]
DILATION IS NOT A GREAT IDEA
Treatment approach to pre-TURP urethral strictures:
– Meatal/sub-meatal stricuture: Do a formal meatotomy instead of excess dilation
“For urethral strictures in the penile urethra to the bulbar urethra, dilation is not recommended.” [Source]
CAN DILATION WORK IN SOME CASES? – UNLIKELY
It is said in the Male Urethral Stricture: American Urological Association Guideline that stricture recurrence is significantly lower among patients performing self-catheterization. Data suggests that performing self-catheterization for greater than four months after DVIU reduced recurrence rates compared to performing self-catheterization for less than three months. [Sanjeev: I find this hard to believe – given the study which showed that RECURRENCE IS GUARANTEED WITH DVIU – see this study].
TREATMENT OPTION 2: MEATOPLASTY/ URETHROPLASTY – fixes 90 per cent of the time
URETHROPLASTY CAN FAIL IF YOUR SURGEON IS NOT EXTRAORDINARLY COMPETENT
” the success of open urethroplasty is very dependent on the surgical technique and the expertise of the surgeon. When urethral surgery is not properly performed, early recurrence of the stricture is a very common complication. … Although stricture recurrence is always a possibility, even when the surgery is performed by a qualified experienced specialist, recurrences more commonly occur when surgery is performed by urologists not exclusively specialized in male urethral and penile reconstructive surgery. When the surgery is not properly performed, failure is an expected outcome.” [Source]
ONE-STAGE MEATOPLASTY IS POTENTIALLY AN OPTION IN MY CASE
SUB-MEATAL STRICTURE SOMETIMES REQUIRES TWO STAGE SURGERY
“For the most complex strictures of the anterior urethra, including the urethral meatus, a staged surgical approach is adopted, removing the stricture then placing a graft in the open space. This is allowed to heal open to the air for a period of 6-12 months, before it is “re-tubularized” into a urethra. This is usually reserved for individuals with strictures in the pendulous urethra, very scarred strictures, repeated failures, and very long strictures.” [Source]
A TEN PERCENT RECURRENCE RATE EXISTS EVEN FOR URETHROPLASTY
“Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate.” [Source]
Meatoplasty using skin flap. Using this technique, the urethral meatus is augmented using a penile skin flap (figure 1).
Meatoplasty with oral mucosal graft. Using this technique, the urethral meatus is augmented by a transplant of an oral graft (figure 2).
Meatoplasty with skin graft. Using this technique, the urethral meatus is augmented by a transplant of a skin graft.
Jordan Flap Meatoplasty – a lot of details here.
DETAILS – IN A PAPER: Meatoplasty using double buccal mucosal graft technique – Apul Goel, Anuj Goel, Diwakar Dalela, Satya N. Sankhwar, International Urology and Nephrology, December 2009, Volume 41, Issue 4, pp 885–887
Glanular/meatal stricture can be seen as an isolated problem or as part of more extensive urethral stricture disease. Various treatment options are available, including penile flap and buccal mucosa, for the treatment of stricture at this location
September 13, 2017
What is it?
See: http://urethralstricture-cure-in-ayurved.com/ (Uttarbasti is introduction of Sesame oil + Honey + Rock salt into urethra). Basically a glass syringe 40ml is used for this purpose.
Alternative (see this), “Medicated oil or decoction is introduced into the urinary bladder with the help of a rubber catheter through the urethral opening under aseptic conditions.”
I had a sub-meatal stricture and attempted this myself (pretty straightforward with a standard 5mm or 10 mm plastic syringe from the pharmacy). In my case this therapy DID NOT WORK. It did not slow down the rapid recurrence of the stricture after urethrotomy.
I therefore needed to get urethroplasty done – which has worked.
Papers that claim that uttarbasti works:
K. Rajeshwar Reddy’s study
This seems to be a tolerable quality paper: Clinical evaluation of Apamarga-Ksharataila Uttarabasti in the management of urethral stricture
Even though this study is published by a shoddy journal (An international quarterly journal of research in ayurveda), it is featured on the website of the US National Library of Medicine, National Institutes of Health. That doesn’t make it a good study, but perhaps its results can be considered – with a pinch of salt.
In the present study, total 60 patients of urethral stricture were divided into two groups and treated with Uttarabasti (Group A) and urethral dilatation (Group B). The symptoms like obstructed urine flow, straining, dribbling and prolongation of micturation were assessed before and after treatment. The results of the study were significant on all the parameters.
Basically, uttarbasti works in the short term as well as dilation but has SIGNIFICANTLY fewer rates of recurrence.
But note that patients selected for this study had “mild to moderate” stricture. No one had a severe stricture.
Rajendra H Amilkanthwar’s work
Rajendra H Amilkanthwar is probably the most prominent ayurvedic doctor to make this claim. He got a clinical trial approved by the US government in 2007 but DID NOT COMPLETE IT. His claims (which clearly did not qualify the stringent requirements of the US government) are published in a paper: Role of uttarbasti in management of mutra marga sankoch (urethral stricture) – Rajendra H Amilkanthawar
Interestingly, he claims that his research has been uploaded on the US government website, which seems to be false:
The author is working as a assistant professor in the subject of Shalyatantra (Surgery in Ayurveda) from last twenty years in Govt. Ayurvedic Colleges in Maharashtra state. He has previously worked at Nagpur & Osmanabad and currently working at Govt. Ayurved College, Nanded in Maharashtra, India.
He is involved in the field of research since 1992. He is working in the field of urology applying the innovative techniques from Ayurveda – the traditional health science of India. With special interest in Urethral Stricture, he has treated over 1500 patients from India and abroad. He has got immense success with the procedure of Uttarbasti in the condition of urethral stricture. Over 95 % patients have been cured.
Research work was accepted by NISCAIR and published in Indian Journal of Traditional Knowledge (IPC Int.Cl7 : A61K35/78; A61K25/00; A61P13/02; A61P13/00.
The work has been conducted under the scheme of Research Fellowship for Teachers, sponsored by Maharashtra University of Health Science, Nashik. The work has been successfully completed and uploaded on clinical trials.gov, an official website of National Institute of Health of US. [Sanjeev: this claim is false, since no completed work has been uploaded]
Research work presented in MASICON surgeons’ conference and many national and international conferences. [Source]
A further case study:
This one takes a single case and is not robust. It also does not undertake longer term follow up.
A case study here that is very sketchy, refers to some ayurvedic medicines and has no formal documentation.
Pre and post procedural urethrography was carried out in all patients. Findings of urethrography revealed increase in the caliber of urethral lumen. Pre and post procedural urine flow rate was recorded. Pre procedural average urine flow rate was 30-50ml/10sec while after completion it improved up to 140-160ml/10sec. No post procedural complications, delayed complications and adverse effects were observed. [Source]
Centres that claim to use this method to treat patients:
Most of the patients require ten sittings which are usually done on alternate days.
Total duration of treatment is approximately 20 days.
This patient wrote a blog post on in which Sunil was cited.
INJECTING OILS OR OTHER THINGS INTO THE PENIS TIP
Uttarbasti involves injecting oil + honey into the urethtra through the penis tip.
Likewise here is a person who has injected hydrogen peroxide into his penis tip [You’ll need to find a 4 to cc syringe,…a plastic one preferred, so you can easily round off the sharp EDGE of it’s output,..so that when you insert it into your urethra/end of penis or in women the other part. You dilute the 3% Hydro to 1.5% via tap water. From that solution in a small cup, or premixed as 1.5%, in an old Hydrogen Peroxide container.
Draw into your syringe at least 2 CC’s of this 1.5%,…and after urinating inject this amount into your Urethra, up into and past the Prostate, or if you figure the infection is below, in or above the rostate,..simply feel for what will be instant relief, as the 1.5% starts to bubble away at the infection. Hold the tip of the Syringe SEALED in the end of the Penis/womens part,.. and keep it sealed against the syringe tip, by clamping the end of the penis closed, clsing the emptied end of the syringe as the Urethra plug. Hold this dilute solution of Peroxide in your Urethra for 25 to 35 seconds,..and then removing the plug/syringe, as you will have a sensation of peeing, as part of the infection fluids and 1.5% hydrogen peroxide are expelled. Repeat this twice in the morning”
There is a claim made by someone (a patent) that a herbal mixture can cure strictures.
While on this subject, there seems to be some claims on the internet that homeopathy has reduced the need for dilation: https://hubpages.com/health/Homeopathy-Safe-Natural-Cure-For-Urethral-Strictures
- but a couple of patients admitted it didn’t work; and finally had to undergo the plasty operation.
Aloe vera for urethral stricture
I’ve had superb results with aloe vera and have used it virtually everywhere – including for an anal fissure (which medicine could not cure). I have also applied aloe vera AND honey directly into my eye and it had only a positive effect (although in my case this was unnecessary since the cause was unrelated to the eyes: it had to do with cheek muscles).
Aloe Meatal Catheter: http://hunterurology.com/products/5-aloe-meatal-catheter– Clearly someone has already got the idea of using aloe vera as a coating for urinary stricture.
Overall it is evident that if done safely and with elimination of bacterial contamination, insertion of a small object into the meatus is safe.