Intermittent self catheterization versus regular outpatient dilatation in urethral stricture: a comparison

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

Poor quality of life in patients with urethral stricture treated with intermittent self-dilation

PURPOSE

We assessed patient perceptions of regular intermittent self-dilation in men with urethral stricture.

MATERIALS AND METHODS

We constructed and distributed a visual analog questionnaire to evaluate intermittent self-dilation via catheterization by men referred for urethral stricture management at a total of 4 institutions. Items assessed included patient duration, frequency, difficulty and pain associated with intermittent self-dilation as well as interference of intermittent self-dilation with daily activity. The primary outcome was patient perceived quality of life. Multivariate analysis was performed to assess factors that affected this outcome.

RESULTS

Included in the study were 85 patients with a median age of 68 years, a median of 3.0 years on intermittent self-dilation and a median frequency of 1 dilation per day. On a 1 to 10 scale the median intermittent self-dilation difficulty was 5.0 ± 2.7, the median pain score was 3.0 ± 2.7 and median interference with daily life was 2.0 ± 1.3. Overall quality of life in patients with stricture was poor (median score 7.0 ± 2.6 with poor quality of life defined as 7 or greater). On univariate analysis younger age (p <0.01), interference (p = 0.03), pain (p <0.01) and difficulty performing intermittent self-dilation (p = 0.03) correlated with poor quality of life in a statistically significant manner. On multivariate analysis only difficulty catheterizing (p <0.01) and younger age (p = 0.05) were statistically significant predictors. Patients with stricture involving the posterior urethra had a statistically significant increase in difficulty and decrease in quality of life (each p = 0.04).

CONCLUSIONS

Most patients with urethral stricture who are on intermittent self-dilation rate difficulty and pain as moderate, and inconvenience as low but report poor quality of life.

Effect of intraurethral captopril gel on the recurrence of urethral stricture after direct vision internal urethrotomy: Phase II clinical trial

OBJECTIVE

The purpose of this study is to evaluate the effect of intraurethral captopril gel as an antifibrotic agent on patients with urethral stricture.

MATERIALS AND METHODS

In the first phase of clinical trial, 13 rabbits were included and local side-effects of captopril gel were evaluated. In the second phase, 56 patients were enrolled from April 2004 to January 2006. After internal urethrotomy the patients were classified into three patient groups: (i) received placebo gel (group I); (ii) received 0.1% captopril gel (group II); and (iii) instilled 0.5% captopril gel intraurethrally (group III).

RESULTS

In phase I, no significant local side-effects were seen in the urethra of rabbits. In phase II, the mean age of the patients was 39.5 and the mean follow-up duration was 16 months. The most common etiology of the urethral stricture in the patients was iatrogenic (35.7%), most of their strictures had a depth of 0.5 cm or less (67.8%), and the length of most strictures was between 1 and 2 cm (41.1%). The patients' maximum urine flow increased more in groups II and III, than in group I (P < 0.04, P < 0.05, respectively). The recurrence rate was less in groups II and III than in group I (P < 0.05). In terms of the maximal urine flow and recurrence rate, no significant difference was seen between group II and group III (P = 0.13, P = 0.21, respectively).

CONCLUSION

Captopril gel is a safe, effective and non-toxic agent for decreasing the recurrence rate of the urethral stricture after internal urethrotomy. However, more studies, including more cases and a longer follow up, are needed to prove the effect of captopril gel on patients' urethra.

Using stainless steel chopstick for self-performing urethral sounding in preventing recurrence of anterior urethral stricture

Male urethral stricture is prone to recurrence, ranging from 40% to 80% according to the length of stricture no matter what treatment is introduced. Therefore, it has long been a common challenge for urologists to handle the problem. Sounding or self-dilation has proved to be effective in reducing the recurrence rate significantly. However, a standard equipment set of urethral bougie is too expensive for a patient's own use. On the other hand, the performance of regular outpatient sounding is time-consuming and costly. We present an easy way to perform urethral self-dilation using a stainless steel chopstick, which has proved to be cost effective and satisfactory for patients. From February 2001 to February 2003, 6 patients, with a mean age of 64.6 years (range 47-79), were introduced to this maneuver after a urethrotomy and were taught how to perform self-sounding with a stainless steel chopstick (18 Fr equivalent). The distance of advancement was determined individually by calibrating the location of the stricture. The long-term result of this maneuver was later checked with a telephone questionnaire about urination status in April 2005. The urethral strictures were located at penile in 3 patients, bulbar in 1, and navicular fossa with meatus in 2. The mean period for performing self-dilation was 15.3 weeks (range, 2-52). The mean follow-up period was 41.5 months (range, 26-55). No recurrence of stricture was found.

COMPLICATIONS ASSOCIATED WITH CLEAN INTERMITTENT CATHETERIZATION IN CHILDREN WITH SPINA BIFIDA

PURPOSE

Clean intermittent catheterization (CIC) is commonly used in the management of voiding dysfunction associated with neurospinal dysraphism. We determined the incidence of genitourinary complications associated with this technique in a population of children with spina bifida.

MATERIALS AND METHODS

The charts of all children younger than 13 years attending a multi-disciplinary spina bifida clinic between 1987 and 2002 were reviewed. Children in whom CIC had been performed for a minimum of 5 years were identified. Catheterization was performed with a polyvinyl chloride catheter and a water-based lubricant. All genitourinary complications that had occurred in this group were recorded. The caregiver of each patient was then contacted by telephone to confirm the accuracy of our data.

RESULTS

There were 32 females and 27 males identified in whom CIC had been performed for a minimum of 5 years. Mean duration of CIC was 10.5 years (range 5 to 15). Of the patients 45 (76%) learned to perform CIC independently at a mean age of 8 years (range 4.7 to 15.3). Two complications were gross hematuria and a false passage in the bulbar urethra. Both complications occurred in males early in the course of CIC, and while being performed by a caregiver. Neither complication was associated with long-term sequelae.

CONCLUSIONS

The incidence of genitourinary complications associated with CIC in children with spina bifida is low. We identified 2 complications during a period of 570 patient-years for an incidence of 3.5 complications/1000 patient-years (95% confidence interval -1.3, 8.3) of observation.

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

PURPOSE

The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.

METHODS

The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.

RESULTS

Thirty-two patients were included. They have been followed up for up to 2(1/2) years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.

CONCLUSIONS

Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.

Coated catheters for intermittent catheterization: smooth or sticky?

OBJECTIVE

To evaluate the current range of hydrophilic-coated catheters for intermittent self-catheterization, focusing on the adherence of the catheter to the urethral mucosa at the end of catheterization.

PATIENTS AND METHODS

In a prospective randomized study, 61 community-based men tested each of four different hydrophilic-coated catheters available in the UK at the time. Subjects used each of the four test catheters for 1 week in a random order, and were provided with the number and size of catheter they normally used. To assess the products, the subjects: (i) timed seven catheterizations using a stop-watch to determine the time taken from extracting the catheter from the water-filled package, to removing the catheter from the penis, having emptied the bladder; (ii) recorded the severity of 'sticking' on catheter removal on a three-point scale (not at all, a little, a lot); and (iii) completed a product-performance questionnaire.

RESULTS

There were no significant differences in ratings of 'sticking' between the 'Easicath' and 'Lofric' (P > 0.05), but there were significant differences between these two products and the 'Aquacath' and the 'Silky', which were found to 'stick' more (P < 0.001). The 'Silky' was reported to stick significantly more than the 'Aquacath' (P < 0.001).

CONCLUSIONS

Adherence to the urethral mucosa on catheter removal was a common problem, occurring with all catheters, but two products were significantly more likely to stick than the other two. The clinical importance of 'sticking' and the long-term implications are currently unknown. The relative 'sticking' of uncoated catheters has also not been established.