Have our strictures changed? Analysis of Current Characteristics and Management of Urethral Stricture Disease in Zaria, Nigeria


 Introduction:
 Urethral stricture is a common cause of lower urinary tract symptoms in the middle aged and elderly men. Its presentation and management is closely linked with its etiology and this varies across geographical regions of the world as well as over time.
We hereby review the etiology, characteristics and presentation of men with urethral strictures in a tertiary hospital in northern Nigeria over a year and compare it with previous studies in the region.
Patients and Methods
The study was a prospective study from January-December 2016, all patients with urethral strictures and who consented to the study were enrolled into the study. Data was collected using a structured study profoma and analyzed using SPSS version 23.
Results
The mean age was 44.1 years with a range of 13-71 years. The bulbar urethra was the site of most strictures with a frequency of 65%. The etiology was infection in majority of the patients with a frequency of 53.3%. Post traumatic strictures occurred in 33.3% while iatrogenic and catheter –Induced strictures were seen in 7.1% and 6% respectively. 88% had no previous intervention for the stricture prior to presentation.The complications from urethral strictures observed in the patients were acute urinary retention in 83.4% urethrocutaneous fistulae in 2.4% and urosepsis in 1.2% of the patients. 11% presented with no complication.68% of these patients were managed by excision and end to end anastomosis, 15 % had a penile pedicled flap 12% , a buccal mucosa graft urethroplasty and 5% with staged urethroplasty
The trends in etiology of urethral stricture disease in the region reported is: Ahmed etal in zaria (1990) Infection accounted for 66.50% , post traumatic stricture 31.50%. Ntia et al Sokoto (2006)found infection as aetiology in 44.70% and post-traumatic strictures in 47.40%. Ofoha et al in Jos however found Infection in 53.30% and post traumatic 40.30%
Conclusion
Though there is a gradual rise in post-traumatic and iatrogenic strictures in our environment, Post inflammatory strictures still predominates. It is however infrequently accompanied by fistulae as seen decades ago. These strictures are mostly long segments single bulbar strictures

accompanied by fistulae as seen decades ago. These strictures are mostly long segments single bulbar strictures Introduction Urethral strictures are narrowing and loss of distensibility of the urethral due to fibrosis of the corpous spongiosum from inflammation or ischemia [1]. Strictures are common and always have been a cause of lower urinary tract symptoms in the middle aged and elderly [2].
It's a disease of both the developing and developed world; though the etiology varies amongst them [3][4][5].The etiology also seems to evolve overtime within the same region. In the developed world, this was attributed to better treatment of sexually transmitted diseases, surge in endourological procedures and industrialization resulting in less of post inflammatory strictures and more of iatrogenic as well as traumatic strictures. However in the developing world, the picture is different with some reports of predominance of post inflammatory strictures while others reported iatrogenic and post traumatic strictures.
The emphasis on the etiology of strictures is because it typically gives the characteristics of the stricture which is the basis of the choice of treatment and subsequently prognosis [6].
Post inflammatory strictures are known to be characterized as multiple, long segment, incomplete strictures with severe spongiofibrosis. Substitution urethroplasties may be indicated for these strictures typically with a penile skin flap or a buccal mucosa graft.
Success rate is usually in the range of 70-80% [7].
Traumatic strictures are however usually that of a short segment, single strictures with mild to moderate spongiofibrosis and an excision and end-end anastomosis may suffice with a success rate of 95-99%. Internal urethrotomies may also be done in patients with short segment incomplete strictures.
We hereby review the etiology, stricture characteristics, presentation and management of men with urethral strictures in a tertiary hospital in northern Nigeria over a year and compare it with previous studies in the region.

Patients And Methods
The study was conducted over a year period from January -December 2016. All patients with urethral stricture managed within the study period and who consented to the study were enrolled into the study while patients with strictures from failed hypospadias repair and stenosis at the posterior urethra were excluded. Furthermore, approval from the ethical committee was also obtained. Patients had clinical and radiological evaluation ( sonourethrography and retrograde urethrogram ) to characterize the stricture. Data was collected on a study profoma and analysed using SPSS version 22. Electronic data base was searched to review studies on etiology, presentation and management of strictures for comparison.

Results
A total of 84 patients were managed during the study period. The mean age of the patients was 44.19 years with standard deviation of 12.54, and a range of 13-71 years.
The age interval 30 -39 years accounted for most of the patients 24 (28.6%). The age distribution is as shown in the figure below. (see Figure 1) Most of the patients were traders 21 (25%). Men, who are members of the armed forces constituted 13 (15%) of the patients while students were the least of the study group 8 (9.5%). The distribution of the occupation of the patients is shown in the table 1 below  Prevention and adequate treatment of urethritis has significantly reduced the incidence of post inflammatory strictures in the developed countries [11,12]. In the developing countries post inflammatory strictures still exist due to lack of adequate awareness of the effect of sexually transmitted diseases, low socioeconomic status and poor health seeking behavior [13]. A significant number of those who present to the health care centers are prone to poor treatment of the urethritis either due to inadequate dosage of the antibiotics, inadequate duration of treatment or use of drugs with limited efficacy resulting in recurrent urethritis and stricture [14]. Hence the prevalence of urethritis, and post inflammatory strictures are still relatively high in some developing countries.
In our study, we found the most common cause of stricture as post inflammatory. This is

Ethics and Consent
Ethical approval was obtained prior to commencement of the study from the Health Research Ethics Committee of Ahmadu Bello University Teaching Hospital Zaria with a reference number of ABUTH/HREC/TRG/36 All patients included in the study were counseled and a written informed consent was signed prior to enrollment into the study.

Figure 1
Age distribution of the patients Management of Urethral Strictures