Benign Urethral Lesions

The urethra is an important part of the urinary tract. While it's 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 people will not have any, problems with the 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.

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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 and the urine is clear with no visible blood.

What are some causes of benign urethral lesions?

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

What are some types of benign urethral lesions?

Non-cancerous growths: Linked to the presence of genital warts on the penile shaft, these lesions are often the product of the human papilloma virus (HPV). Urethral wart-like growths are suspected when there is a visible lesion on the opening of the urethra or changes in the urinary stream, accompanied by a history of genital warts. There may also be blood in the urine and pain or burning with urination.

Lichen Sclerosis (LS) or Balanitis xerotica obliterans (BXO): Lichen Sclerosis is a chronic skin condition with unknown causes that affects the end of the penis. This is marked by pale, shiny, whitish skin around the opening of the urethra that turns over time into scar. This process is thought to begin in early and progress throughout adulthood, leading to a narrowing of the urethra (urethral stricture) and difficulty passing urine. Other symptoms include soreness, itching and cracking of the skin sometimes resulting in ulcerations and bleeding.

Urethral stricture disease: Urethral strictures result from scar tissue formation at one or more points in the urethra. This disease process is completely described in the Urethral Stricture section on this website. The symptoms of urethral stricture disease include decreased 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 uncommon, irregular growth that usually arises at birth. It is most common in females and 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 of the vagina, blood in the urine or a blockage of the urinary stream. Urethral polyps are diagnosed with cystoscopy, a procedure that allows a urologist to readily view the polyp, and a voiding cystourethrogram (VCUG).

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 appears as a glistening, tense and bulging yellowish-white mass reducing the size of the urethral opening. Common symptoms include a misdirected urinary stream, urinary blockage and painful urination.

Urethral caruncle: Urethral caruncles are polypoid (or stalk-like) masses, hanging from one area of the urethral opening. These are usually spotted during an examination for another condition. They are relatively common in women who do not use hormone replacement therapy (HRT) after menopause. Symptoms can include bleeding and pain with urination, frequency, urgency and tenderness around the opening of the urethra. The primary sign of this problem is a thin, reddish membrane protruding from one portion of the urethral opening.

Urethral prolapse: A rare and more bothersome abnormality of the female urethra than other benign lesions is called urethral prolapse. This 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 of the opening of the urethra. This leads to pain, vaginal bleeding and occasionally urine retention. A diagnosis is usually made by simple physical examination.

How are benign lesions treated?

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 need to surgically drain the abscess and divert the urine flow with a catheter in the bladder (Foley catheter) or draining the bladder through the abdomen (suprapubic tube) 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). 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 and rejoining the tissue at the ends of the urethra or inserting a skin graft to partially or completely restore the urethra at the stricture. A catheter usually is needed for several weeks after this procedure.

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.

Treating non-cancerous urethral growths can be difficult. The lesions associated with genital warts (from Human Papilloma Virus) can be treated with lasers to destroy the 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 Lichen Sclerosis (LS) and (BXO).

Treatment for urethral polyps consists of removing the polyp using cystourethroscopy, a minimally-invasive technique that allows the urologist to peer into the urethra 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, infection or pain develops, the urologist may pierce the cyst with a scalpel blade to drain it and relieve the symptoms.

For patients with a urethral caruncle but no symptoms, no treatment is needed. Some advocate topical estrogen cream or hormone replacement therapy (HRT) to resolve the caruncle. If the caruncle is large or causes problems, the urologist may 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.

What can be expected after treatment for benign urethral lesions?

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 recur.

The main complications associated with both dilation and internal urethrotomy for the treatment of urethral strictures include high rates of stricture recurrence. This depends on the length of the stricture, with shorter ones usually doing better with these therapies than longer ones. Several studies have suggested that daily, intermittent catheterization up to three months after the procedure may reduce recurrence.

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

Doctors usually follow any stricture procedure with repeat clinic visits, physical examination and questioning to monitor the force of the urine stream from the urethra. In addition, repeat radiographic studies (retrograde urethrograms) 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.

Reviewed December, 2007

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Glossary Terms

abdomen:
	Also referred to as the belly. It is the part of the body that contains all of the internal structures between the chest and the pelvis.
abnormality:
	A variation from a normal structure or function of the body.
abscess:
	An accumulation of pus anywhere in the body.
anesthesia:
	Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.
anesthetic:
	A substance that causes lack of feeling or awareness.
antibiotic:
	Drug that kills bacteria or prevents them from multiplying.
bacteria:
	Single-celled microorganisms that can exist independently (free-living) or dependently upon another organism for life (parasite). They can cause infection and are usually treated with antibiotics.
bacterial:
	Of or pertaining to a bacteria.
benign:
	Not malignant; not cancerous.
bladder:
	The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.
bulbar:
	Bulb-shaped.
bulbar urethral stricture:
	Stricture at the widest part of the urethra.
BXO:
	Also known as balanitis xerotica obliterans. Chronic skin condition that causes scarring and thickening of the skin of the penis.
cancer:
	An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.
caruncle:
	Fleshy growth.
catheter:
	A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.
catheterization:
	Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
cauterize:
	Close a wound or destroy abnormal or infected tissues with a heated instrument, laser or electric current.
chronic:
	Lasting a long time. Chronic diseases develop slowly. Chronic renal (kidney) failure may develop over many years and lead to end-stage renal (kidney) disease.
cyst:
	An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.
cystoscope:
	A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).
cystoscopy:
	Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
cystourethrogram:
	Also called a voiding cystogram. A specific X-ray that examines the urinary tract. A catheter (hollows tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body)and the bladder is filled with a liquid dye. X-ray images are taken as the bladder fills and empties. The X-rays will show if there is any reverse flow of urine into the ureters and kidneys.
cystourethroscopy:
	Also known as cystoscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
cysts:
	Abnormal sacs containing gas, fluid or a semisolid material.
diagnosis:
	The process by which a doctor determines what disease or condition a patient has by studying the patient's symptoms and medical history, and analyzing any tests performed (e.g., blood tets, urine tests, brain scans, etc.).
dilation:
	The stretching or enlargement of a hollow organ or body cavity.
dilator:
	An instrument to stretch body tissues and enlarge an opening, passage or canal.
direct vision internal urethrotomy:
	Also known as DVIU. Surgical procedure using a camera and endoscopic instrument to cut a urethral stricture and fix the abnormal narrowing of the urethra.
DVIU:
	Also known as direct vision internal urethrotomy. Surgical procedure using a camera and endoscopic instrument to cut a urethral stricture and fix the abnormal narrowing of the urethra.
ED:
	Also known as erectile dysfunction or impotence. The inability to get or maintain an erection for satisfactory sexual intercourse.
endoscopic:
	A procedure performed in order to examine the bladder.
estrogen:
	Female hormone produced by the ovaries.
fibrous:
	Consisting of or resembling fibers.
frequency:
	The need to urinate more often than is normal.
gene:
	The basic unit capable of transmitting characteristics from one generation to the next.
general anesthesia:
	Person is put to sleep with muscle relaxation and no pain sensation over the entire body.
gland:
	A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.
gonococcal urethritis:
	Inflammation of the urethra caused by gonorrhea bacteria.
gonorrhea:
	A sexually transmitted disease that causes inflammation of the genital mucous membrane, burning pain when urinating, and a discharge. It is caused by a gonococcus bacterium.
graft:
	Healthy skin, bone or tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body.
hormone:
	A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.
HPV:
	Also known as human papilloma virus. One of the most common causes of sexually transmitted disease.
human papilloma virus:
	Also known as HPV. One of the most common causes of sexually transmitted disease.
incision:
	Surgical cut for entering the body to perform an operation.
infection:
	A condition resulting from the presence of bacteria or other microorganisms.
inflammation:
	Swelling, redness, heat and/or pain produced in the area of the body as a result of irritation, injury or infection.
inflammatory:
	Characterized or caused by swelling, redness, heat and/or pain produced in an area of the body as a result of irritation, injury or infection.
intermittent catheterization:
	Periodic insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
invasive:
	Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.
ions:
	Electrically charged atoms.
laser:
	Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.
lesion:
	A zone of tissue with impaired function as a result of damage by disease or wounding. Examples are scars, abscesses, tumors and ulcers.
membrane:
	A thin sheet or layer of tissue that lines a cavity or separates two parts of the body. A membrane can act as a filter, allowing some particles to pass from one part of the body to another while keeping others where they are.
menopause:
	The time in a woman's life when menstrual periods permanently stop.
paraurethral cysts:
	Cysts affecting the Skene's glands, which are located alongside the urethra.
paraurethral glands:
	Also called Skene's glands. These are singular tubular glands located alongside the urethra.
pelvic:
	Relating to, involving or located in or near the pelvis.
penile shaft:
	The cylindrical body of the penis.
penis:
	The male organ used for urination and sex.
perineum:
	The area between the anus and the scrotum in males and the area between the anus and the vagina in females.
polyp:
	Small, stalk-like growth sticking out from the skin or from a mucous membrane.
prolapse:
	The protrusion or dropping of the uretus (uterine prolapse), rectum (rectocele) or bladder (cystocele) into the vagina.
prostate:
	A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.
pubic bone:
	Also referred to as the pubis. Lower front of the hip bone.
radiographic:
	X-ray.
resectoscope:
	A tube-shaped instrument used by the urologist to scoop a tumor from the bladder lining.
retention:
	In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.
retrograde:
	Backwards.
retrograde urethrogram:
	X-ray diagnostic test to evaluate appearance and integrity of the urethra.
semen:
	Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.
shaft:
	Cylindrical part of the penis.
stent:
	With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.
stone:
	Small hard mass of mineral material formed in an organ.
stricture:
	Abnormal narrowing of a body passage.
stricture disease:
	Condition where there is an abnormal narrowing of a body opening.
suprapubic:
	An area of the central lower abdomen above the bony pelvis and overlying the bladder.
tissue:
	Group of cells in an organism that are similar in form and function.
topical:
	Describes medication applied directly to the surface of the part of the body being treated.
urate:
	A salt of uric acid.
urethra:
	A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.
urethral:
	Relating to the urethra, the tube tha carries urine from the bladder to outside the body.
urethral polyp:
	Non-cancerous growth in the urethra.
urethral prolapse:
	Forward or downward displacement of the urethra.
urethral stricture:
	Scarring of tissue that causes narrowing or blockage of the canal leading from the bladder, discharging the urine externally.
urethral stricture disease:
	Scarring and narrowing at one or more points in the urethra and of variable severity.
urethritis:
	Inflammation of the urethra.
urethrography:
	X-ray examination of the urethra involving radiopaque fluid used to detect any narrowing or other abnormalities.
urethroplasty:
	Surgical repair of the urethra.
urethroscope:
	An instrument consisting of a fine tube fitted with a light and lenses, for examination of the interior of the male urethra, including the prostate region.
urethroscopy:
	Inspection of the urethra with a urethroscope.
urethrotomy:
	Operating of cutting a stricture in the urethra.
urethrovaginal:
	Between the urethra and vagina.
urge:
	Strong desire to urinate.
urgency:
	Strong desire to urinate.
urinal:
	A portable device that is used as a receptacle for urine.
urinalysis:
	A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.
urinary:
	Relating to urine.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinary tract infection:
	Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.
urinate:
	To release urine from the bladder to the outside. Also referred to as void.
urination:
	The passing of urine.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
urologist:
	A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)
vagina:
	The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.
vas:
	Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
VCUG:
	Also referred to as voiding cystourethrogram or voiding cystogram. A catheter is placed in the urethra and the bladder is filled with a contrast dye. X-ray images are taken as the bladder fills and empties to show any blockage or reverse urine flow.
void:
	To urinate, empty the bladder.
voiding:
	Urinating.
voiding cystourethrogram:
	Also referred to as VCUG or voiding cystogram. A specific X-ray that examines the urinary tract. A catheter (hollows tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body)and the bladder is filled with a liquid dye. X-ray images are taken as the bladder fills and empties. The X-rays will show if there is any reverse flow of urine into the ureters and kidneys.

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