Upcoming posts...

My urologist informs me that a software routine is under testing for the DaVinci Robotic Surgical System with regards to the buccal mucosal onlay graft, and penile flap onlay graft urethroplastic procedures. We should see their availability by mid-2012, he stated that it will allow for better positioning of the graft with more precise suturing capabilities, and a shorter O.R. time.

Also, another pharmaceutical company is looking into manufacturing Urised <---LET'S HOPE THIS HAPPENS

That's all folks!  Enjoy your Christmas and New Year holidays!

Still taking time off for the holidays, but an update anyway..

December 7th, 2011: Things have been piling up on both coasts, so we're going to take  a few days off from posting. The Urethral Stricture Support Blog will be monitored daily. Please feel free to post responses, questions or commentary.

Have a wonderful Christmas Season!

December 19th, 2011: A New Jersey licensed urologist has agreed to do two posts (commencing in mid-January). We may try to establish a live chat should the stats stay in an upward direction.

OPINION: How best to proceed with life after receiving the diagnosis of urethral stricture disease PART 2

*"Scott", continued: Our urologist wanted him to undergo an immediate open urethroplasty, and explained that the procedure offered the best chance for cure. Without it, he felt that "Scott" would be looking at a receiving a partial urostomy within a very few years. The family conceded, and he eventually went to Cornell Presbyterian Medical Center in New York City. He underwent several individual "staged" surgeries, the last of which was a plastic reconstructive procedure. I do not know the eventual outcome, however, he did function well for at least three years afterwards.

Optical urethral surgery has only been around since the early 1950's.  Rigid cystoscopes which were pioneered because of WWII had the reputation of causing damage to the urethra when passed past the penile urethra, and into the bulbar aspect of the structure. This damage was often resultant in strictures, and visual procedures were reserved for only penile-area defects, and T.U.R.P. (trans urethral resection of the prostate). In the early 1970's, advances in fiber optics allowed for the development of the flexible cystoscope, and the inception of visual internal urethral procedures as we know them today.

When you combine all of this information, it becomes somewhat apparent that the best way in which to persevere is to know your condition, your body, and your psyche thoroughly. While this disorder/disease/malady is not rare, it is not at the forefront of medical priority, sans a very few research institutions and reconstructive urologists. Education is the key to living with the diagnosis of urethral stricture stenosis.

Per: Moderator Tim

OPINION: How best to proceed with life after receiving the diagnosis of urethral stricture disease PART 1

*In 1992, my urologist asked if I would speak to a 16 year old and his family after they received the news that the young adult had been diagnosed as having a rather severe case of urethral stricture disease. The case was so severe that a cystoscope-guided dilitation with filiform and followers was attempted, and the filiform was unable to thread itself through the stricture, and into the bladder. (*I will elaborate more on this later) "Scott" was only the second person whom I had encountered besides myself who had a stricture. The other was a friend, and the subject of difficult urination came up after he complained of "dreading each and every trip to the bathroom", he then proceeded to tell me what a stricture was, and that he had been diagnosed at age 17. We compared notes, and our experiences were quite similar.

There are no accurate statistics of the percentage of the male population with the malady. The co-moderator of this forum goes to a prominent west-coast urologist, who informed him of two (other) current patients. My urologist, located near Philadelphia, Pennsylvania, once elaborated (after my not needing dilitation for almost three years - post urethrotomy) that he was somewhat out of practice with the filiform and followers. This leads me to believe that far less than a fraction of one percent of a general urologists practice is composed of stricture-related disorders. I know for a fact that he has over 9,000 active patients.

These observations lead me to the conclusion that for our own well-being, we should educate ourselves to the highest degree possible regarding all aspects of urology. You never know when your knowledge of your case will be necessary in procuring adequate treatment while away from home. Dealing with urinary tract infections has always been my key task health-wise. Yet there are some with the problem who have never had trouble with a UTI. We are each individual, with specific traits, requiring different approaches. The fact that there are a total of around twenty urological surgeons who specialize in urethral reconstruction serving an estimated population of 309 million does not lend confidence that there is enough of a market for a surgeon to be proficient in dealing with complex cases.

I cannot speak for all urologists in general, but mine was an advocate of the proactive approach with regards to my condition. I would often leave his office with a copy of the latest urology journal, or other pertinent medical publication (with the agreement that it would be returned within two weeks), and within two years of diagnosis, I had (literal) volumes of photocopied articles, a Tabor's Medical Encyclopedia, a Gray's Anatomy, and two books on urological nursing in the 20th Century. This information helped make sense of the decisions my urologist made. Furthermore, with the help of the nursing publications, I discovered methods for avoiding urinary infections, and methods of care important after each subsequent surgery. What it all boils down to is that we each must develop a system keyed to provide the optimum of care, as this will help minimize hospitalizations, and possibly surgeries.

* Returning to "Scott": When I met him, he had undergone an emergency suprapubic catheter insertion (a catheter and urinary drainage system inserted directly into the bladder) as a result of a stricture which could not be resolved by dilitation. He had the procedure performed in the ER of a local hospital, it was deemed necessary because it was thought that he was about to encounter a urinary reflux (due to the fact his bladder was so full). His stricture was thought to be nearly 4 centimeters in length, which is fairly long. Our urologist wanted him to go to one of the teaching hospitals in Philadelphia, but his parents were apprehensive, as their primary physician informed them that the problem could be dealt with adequately in a local setting. His exact words were "it's not open heart surgery".

I explained that (at that time) eleven years had passed since being diagnosed. I had undergone around forty - plus dilitations, two urethrotomies, a urethroplasty (failing at that very moment), one emergency dilitation (similar to his event), a suprapubic catheter failure, and that if I had it to do over, I would have searched for a specialist in strictures and their care. By that point in time, the scarring to my urethra was already substantial, and had I been given the option to seek out a surgeon/specialist at a teaching hospital, that my outcome would have been far different.

Levaquin, off patent in 2010 - Levofloxacin now has full availablity in the U.S.

Late last year, Janssen's (actually Miles Pharmaceuticals) powerhouse fluroquinolone - LEVAQUIN, had its patent protection expire. What had been a $29.00 USD (per tablet, with a ten-tablet average per script) medication) as of July, 2011, has three generic rivals. Dr.Reddy's Labs (India, Mexico), Teva Pharmaceuticals (Israel, USA), and Greenstone, Ltd (Michigan, USA) each have approved versions of the medication available to the pharmaceutical market.

It has taken almost six months for availability and distribution to "hit every corner" of the U.S., Dr. Reddy's was the first available in my hometown in Pennsylvania. I've had no problems with the quality of any of Reddy Labs' offerings in the past, even though they've had issues .  Teva is a first-rate producer of pharmaceuticals, the "Cadillac" of generic drug makers (IMHO, Mylan is of equivalent stature). My pharmacist, whom I interviewed for this post, has had little experience with Greenstone, so I won't elaborate with regards to them.

Why has levofloxacin been so slow to saturate the market??  Primarily because of the costs involved with product liability insurance coverage borne by the manufacturer, distributor, and the pharmacy's liability carrier. Levofloxacin has a myriad of bad side effects, including effects on the heart, tendons, severe insomnia, and more. At least 50% of the retail cost of the generic med will reflect that liability cost, all of this adds up, and is the main reasoning behind the "slow to market" appearance of this life-saving, powerful anti-infective.

Per: Moderator Tim

Many thanks to MSP, R.Ph. for his help in compiling this info!!

Your urologist is recommending urethrotomy PART 2

The big day is here, you have arrived at the appointed coordinates, signed-in, filled out 739 individual sheets of paper asking everything from your mother's maiden name to your preferred brand of underwear (Hanes). You'll be instructed to disrobe and change into a cotton gown (you know, the famous type where your ass hangs out), told to hop on up into a hospital bed where the nurse will again ask what type of surgery you are having (this is a good thing, a safety procedure which helps assure that you won't receive an incorrect surgery), have your vital's checked (temp, pulse, BP, pulse oximetry), and have an IV started (usually in the hand, one "prick", and it's done). You may be given an IV sedative or other pre-surgical medication at this time, also, an IV antibiotic such as gentamycin may be administered prior to your being wheeled into the surgical theater.

After your surgeon's fifth cup of coffee and a pit-stop in the bathroom, the OR staff will transfer you over to a gurney for transport to the OR. You will again be asked which procedure you are having performed (this is one time when being a smartass doesn't pay), asked to transfer onto the operating table, and placed into the lithotomy (OB/GYN) position, stirrups and all. Your choice of anesthesia will be started and this is what happens next:

THE PROCEDURE:

1. Your urinary meatus will be exposed and cleansed with a Povidone-iodine wipe (Betadine), and approximately 30 cc's (one fluid ounce) of a viscous topical anesthetic containing lidocaine (usually Anestacon) will be instilled into your urethra, then held in the urethra by applying a crown clamp to the base of the head of the penis (the penile corona). Depending upon your choice of anesthesia, your physician may choose to begin immediately (using the viscous anesthetic as a lubricant for the cystoscope), or wait a few minutes for it to take effect.
2. A cystoscope with a trans-urethral injection system will be inserted into the urethra, and the surgeon will inject lidocaine (a local anesthetic) into the length of the stricture at various points using a technique called "infiltration".
3. The cystoscope/injection system will be withdrawn, and a cutting device called a urethrotome will be attached to the cystoscope and inserted.  A safety guide filament will be threaded through the stricture, and into the bladder. This helps the surgeon position the urethrotome in a safe aspect for performing the incisions into the stricture Next, the surgeon will guide the urethrotome to the face of the stricture and a small blade towards the tip of the instrument will be deployed using a trigger mechanism to cut the stricture at locations he or she believes will provide optimum relief. The urethrotome/safety guide/cystoscope will then be withdrawn, and an appropriately sized catheter will be inserted and connected to a urinary drainage system (catheter hose and bag).  
4. You will be instructed on the care and emptying of the catheter/drainage system/bag, and given prescriptions for an antibiotic/systemic antibacterial, a urinary analgesic (pyridium or prosed), a few days of a minor pain medication (there is usually very little pain associated with urethrotomy), and instructed to see the surgeon in three to seven days for removal of the catheter.

Youtube video showing a DVIU, or Direct Visual Internal Urethrotomy

Per: Moderator Tim

Your urologist is recommending urethrotomy PART 1

If you are a novice at the lifestyle routine of the stricture patient, your first urological surgery per se may cause feelings of anxiety in anticipation of your date with the O.R.  Trust me, put your mind at ease, it's not all that bad, in fact, most everyone with whom I've corresponded would rather undergo a urethrotomy than have an office dilitation (with metal sounds).  Minor disclaimer: the in-dwelling catheter afterwards isn't a walk in the park, but the surgery is not all that uncomfortable.

A day-or-two before the procedure, you'll be ordered to report to the hospital or surgery center for a routine pre-surgery workup, which may include a chest x-ray, electrocardiogram (EKG), blood work (chem 36 profile), an evaluation of pulmonary status, and an anesthesia interview. During the anesthesia interview, an anesthesiologist or certified registered nurse anesthetist (CRNA) will ask questions about your health, your knowledge of the procedure, and your preferences of anesthesia.  You will be given the choice of three options:

• Procedural sedation: (once referred to as "conscious sedation"), a method of anesthesia which uses a benzodiazepine such as midazolam or diazepam (both members of the Valium family) to relax you during the initial phase of the procedure. The surgeon or anesthetist may also elect to add a narcotic pain medication, usually fentanyl citrate into the IV established soon after your arrival. These meds are all rapidly metabolized, and will allow you to leave the facility within six hours post-procedure.
• Spinal anesthesia: a method of anesthesia whereby an anesthetic is injected directly into the spinal column for means of blocking the impulses of pain and sensation from the area of the surgical procedure. There are two types of spinal anesthesia, the first is known as an epidural, the second is referred to as a spinal block.  Spinal anesthesia is most often employed in the patient who has contraindications for general anesthesia.
• General anesthesia, "a.k.a. going under, getting knocked out", a method of anesthesia which today most often employs a hypnotic known as propofol. Yes, the same med which contributed to the death of Michael Jackson, but a medication with a stellar safety record. Sometimes a barbiturate may be employed, however, most anesthesiologists prefer to use propofol becaues it is rapidly metabolized, and allows for the almost immediate awakening of the patient. In the event general anesthesia is selected, an endotracheal tube will be inserted to assure a secure airway.

Stay tuned for chapter two....

A little info on antibiotics and systemic anti-bacterials PART 2

Cephalosporins:   a class of oral and parenteral medications first synthesized from penicillin in the latter part of the 1940's in Italy. In the 1960's, Cephalexin, sold by Eli Lilly under the brand-name of "Keflex" became the most widely prescribed form of the medication (a similar medication, Keflin, was a close second). There have been five generations in the evolution and synthesis of this class of antibiotics, and are still a very useful adjunct in the treatment of infections in the world today. Cephtriaxone, (Rocephin, Roche Pharmaceuticals) is one of the most often prescribed intravenous antibiotics used in hospitals and in home-care today. Note: Because of the fact the drug is an analog of penicillin, there is the possibility of cross-allergency with this class of medication. Discuss this with your prescriber and pharmacist if you are penicillin allergic.

Ampicillin and amoxicillin, which are technically cephalosporins but not classified as such are often employed in the treatment of UTI's in children and adolescents (when susceptibility permits). When combined with potassium clavuante to form (Augmentin, GSK Pharmaceuticals), amoxicillin can be used in the treatment of more severe infections and susceptible sexually transmitted diseases.

Tetracyclines:  The most frequently used antibiotic in this class is a second-generation medication known as doxycycline hyclate. It is a semi-synthetic antibiotic, the base material used in its synthesis being oxytetracycline, and was first synthesized by Pfizer Pharmaceuticals in the early 1960's.  Common brand names are Vibramycin, Vibra-tabs, and Doryx (timed-release capsules). Doxycycline provides the benefit of once-daily dosing (in the 100 mg strength) for the treatment of uncomplicated urinary tract infection.  Minocycline, (Minocin, Lederle) a somewhat "cousin" to Doxycycline, has also proven useful in the treatment of UTI's, and is usually prescribed twice daily.  In 2009, the FDA added minocycline to its Adverse Event Reporting System; a list of medications under investigation by the FDA for potential safety issues. It is believed there is a correlation between minocycline and certain pediatric autoimmune disorders.  Tetracycline hydrochloride, the parent of these second generation medications is now seldom used in the treatment of urinary tract infections because of bacterial resistance.  It is still used in the treatment of chlamydia trachomatis.

Note: avoid sunlight when taking any of the tetracycline class antibiotics because of photosensitivity. Also, it is advisable to avoid taking any form of antacid containing aluminum or magnesium, or the consumption of milk within a few hours of taking the medication. Tetracyclines chelate, or bind to minerals very easily, reducing the availability of the medication in your system. Pediatric usage (under 12 years of age) is usually contraindicated because this class of medication can discolor teeth and have adverse effects on bone formation.

Nitrofurantoin:  was specifically developed for use in the treatment of susceptible urinary tract infections. It was discovered in the late 1950's, and came into favor during the latter-part of the 1960's. Common brand names are Furadantin, Macrobid, and Macrodantin.  It is generally a well tolerated medication, and is useful only in non-complicated UTI's. It is of little benefit in the treatment of bacterial prostatitis, or skin-structure infections.

Fluroquinolones:  Ciprofloxacin (Cipro, Miles Pharmaceuticals) was the first widely available second generation fluroquinolone anti-infective marketed in the U.S., beginning in 1986. It is the most commonly prescribed of its class of medications,  and seems to be the go-to drug for most practitioners (it is listed among the $4.00 generics at Wal*Mart).  It was initially marketed for the treatment of both complicated and uncomplicated urinary tract infections and prostatitis, and is well-tolerated by most patients. That said, in the mid-1990's, a correlation between tendon rupture, tendinitis, and ciprofloxacin was discovered, and appropriate precautions were recommended for its prescribing and usage. Concomitant administration of antacids containing aluminum and magnesium within five hours of taking ciprofloxacin is contraindicated. Milk should be avoided when taking this medication.

Norfloxacin (Noroxin, Merck Pharmaceuticals) was the second widely available form of the second generation fluroquinolone class of anti-infectives approved in the United States. It was initially marketed for the treatment of both complicated and uncomplicated urinary tract infections and prostatitis, but has since fallen out of favor because of a myriad of adverse side-effects including tendinitis, tendon rupture, hypersensitivity, hepatic (liver) disorders - including hepatitis. It is rarely prescribed in the United States.

Levofloxacin (Levaquin, Janssen Pharmaceuticals) is the strongest commonly prescribed member of the fluroquinolone family. It comes complete with all of the side effects listed for the rest of this class of medications, and carries two FDA Black Box warnings regarding the danger of prescribing levofloxacin. At $29.00 US per 500 mg tablet, it is cost-prohibitive, and reserved for only the most serious of urinary tract infections. Moxifloxacin (Avalox, Merck Pharmaceuticals) is slightly less expensive than Levaquin, and carries similar side effect liability.

There have been a few misfires among this class of medication, the most notable being Trovafloxacin (Trovan, Pfizer Pharmaceuticals), which was restricted to use in hospitals and long term care facilities shortly after its introduction into the market in 1998. It was implicated in cases of severe liver failure in the U.S., and at least six deaths in Nigeria in the mid-1990's.  Olfloxacin, (Floxin, Janssen Pharmaceuticals) was essentially withdraw from manufacture by Janssen in 2009, and is unavailable in the U.S. at this time. It, too had similar liabilities to the rest of the class of anti-infective medications.

Per: Moderator Tim

**Many thanks to my friend, Dr. R.S.H., D.P.M. for his contribution to the "antibiotics/anti-infectives" posts.

Per Dr. "Rob": IT IS IMPORTANT TO TAKE THE ANTIBIOTICS AS DIRECTED, WHEN DIRECTED, AND FOR THE LENGTH OF TIME DIRECTED BY THE PRESCRIBER. REPORT ANY ADVERSE EFFECTS TO THE PHYSICIAN IMMEDIATELY. IN THE EVENT OF SYMPTOMS OF ANAPHYLAXIS (HIVES, DIFFICULTY BREATHING, SWOLLEN THROAT, LOW BLOOD PRESSURE) SEEK IMMEDIATE EMERGENCY TREATMENT, ACTIVATE 911. FOR LESSER SIDE EFFECTS, CONTACT YOUR PHYSICIAN OR PHARMACIST.

A little info on antibiotics and systemic anti-bacterials PART 1

Most stricture patients will have encounters with urinary tract infections, or UTI's at some point during their lifetime. Here's a little primmer which should help in understanding your practitioner's choice of medication(s) for the treatment of UTI's:

• A "Urine C&S" (is a urinalysis with a culture for bacteria, fungi, or in rare(er) cases, anaerobic organisms and protozoans), which helps the practitioner decide which is the most effective treatment with the least side effect potential. Why shoot a rabbit with a cannon when a pellet gun will suffice.

Sulfonamides: a class of oral and parenteral medications developed in the 1930's, as the first widely available therapy for infections without having the liability of toxicity that arsenicals and mercuricals did. The most common of this class of drug in North America is referred to as an "SMT Combination", a mixture of sulfamethoxazole and trimethoprim. Common brand names are Septra, Septra DS, Bactrim, and Bactrim DS. They are fairly inexpensive, and very, very effective. The main liability of this classification of medication is the fact that allergies to sulfonamides are commonplace.  If prescribed for you, be sure to drink plenty of water during the usual 10-day course of treatment. The oral form of the medication is usually administered twice daily.  Discontinue use, and contact your practitioner should any itching or rash develop. In the event that breathing becomes difficult, seek emergency treatment immediately.

Penicillins:  a class of oral and parenteral medications initially discovered by Alexander Fleming in 1928, and developed in the 1940's,  mostly because of the need for an infection-fighting agent generated by WWII. The perfection of the manufacturing process largely took place in the United States, with priority just below that of the Manhattan Project. Wyeth Pharmaceuticals, of West Chester, Pennsylvania developed the first effective process for the generation of penicillin mold from orange skins in 1942, and in conjunction with the British (with the help of an Australian scientist), who discovered the properties of this, the world's first "miracle drug"

Once the go-to treatment for gram-positive organisms, penicillin, penicillin G, procaine penicillin, and penicillin V-K are now relegated to the category of "mostly ineffective" for use in UTI's, primarily due to their over use in times past, which produced strains of bacteria resistant to the medication. Penicillin was, at one time, the first-line cure for syphilis and gonorrhea.

Per: Moderator Tim

You've gotta laugh!!

 ©Grainger, Inc and Orange County Choppers, Llc

I cannot honestly believe that I am the only person on the face of this earth that sees something "funny" with regards to this motorcycle, unveiled during the 21 November 2011 "Old Rivals" episode of the Discovery Channel series American Chopper: Senior vs. Junior. 

BTW: I believe this discussion to be on topic, sort of.  If not, it's great comic relief!


Per: Moderator Tim

The blessings and curses of Urethrotomy

Today's urologist will very likely consider performing a Direct Visual Internal Urethrotomy (DVIU) very-early on in the progression of your case. Urethrotomy was once thought to be curative in a high percentage of patients, in-fact, as recently as the 1990's it was considered by many urologists as the primary "go-to" after the initial few dilitations with recurrence. There have been no formal studies addressing the recurrence rate of strictures after undergoing DVIU, however, conjecture is that it is around 90%, which leads to the question of cost-effectiveness for the insurer.  **see report on the University of Washington - Seattle, Department of Urology study regarding this hypothesis  HERE.

Medical schools with urology programs in Pennsylvania and New York are now instructing their progeny to perform a urethrotomy at first diagnosis of stricture for two primary reasons:

• First, it is thought to cause less scarring of the urethral wall, allowing for a more patent urethra with which to perform a future urethroplasty.
• Secondly, it is theorized that the stress of undergoing multiple dilitation routines may cloud the judgment of the novice stricture patient (who is most often in his late teens to mid-twenties). Performing a urethrotomy as the first surgical fix is thought to provide time for the patient to emotionally prepare for the eventuality which is urethroplasty, the "gold standard" of urethral repair options.

On average, expect two or three years of relief from strictures after a successful urethrotomy. Many urologists are attempting the extension of this interval by prescribing a regimen of self catheterization (with a Foley catheter) at regular intervals. Personally, I'd bite the bullet (per se), and opt for the "mucho invasive" option of urethroplasty. Catheterization "ain't" exactly a walk in the park...

Per: Moderator Tim

Tips on "psyching up" for that upcoming dilitation

From what my urologist had told me, 90% of the problems with in-office dilitation arise in the patient who is unable to mentally prepare for the procedure. They sometimes delay, and delay (ad infinitum..), to the point where they risk Vesicoureteral reflux (urinary reflux), and that "ain't" fun.

In order to help prepare for the dreaded in-office dilitation, physicians often recommend that you "psych yourself up", much in the same way that a sports team prepares for the big game, here are a few tips:

1.  Tell yourself to remember that after having the dilitation performed, you will be able to "pee like a race horse", literally. It's the truth, and will help you to realize that a few moments of discomfort will be rewarded by at least a few months of normal performance.

2.  After the appointment, treat yourself to that half-gallon of home-made iced tea, consumed "all in-one pop", your bladder will now be able to handle it. Should you choose to rent a beer-or-three, be sure to do it within the confines of safety, where no driving will be necessary.

3. If your urologist is "a cool person, someone with whom you are comfortable", ask them for a written prescription for sex. Hand it to tour wife/girlfriend, or significant other - and say, "see, I have a prescription, I can't fill it myself". <---this maneuver always worked for me!

4.  If you reside in a colder climate, and you are lucky enough to have snow, go out back of your home (where your neighbors won't see you), and "write" your name in the snow! On second thought, throw caution to the wind, let her rip! TO HELL WITH THE NEIGHBORS!!

5.  If you reside in a rural area, populated by dairy farms, pull along side of the road and urinate in-front of a diary cow, make her envious. ADVISORY: this won't work if she's standing near (or on) a flat rock. Note: this scenario is not advised when a bull is in pasture.

6.  If your driveway has a down-hill slope, stand at the top, let 'er fly, see if you can make it to the base of the driveway! Again, screw the neighbors!


7.  Remember, you will now be able to generate "pee foam" in the toilet, screw with your wife's mind by adding a few drops of dish detergent prior to urinating in-order to enhance the effect. Invite your friends and neighbors to admire your handy work!!


8.  Crank up the old piano, and sing this John Valby classic :-)  (this one's a bit on the risqué side)

DISCLAIMER: Should you decide to follow any of the recommendations past recommendation three, you are on your own. Perform them at your own risk! Life's too damn short not to have fun!!

What to expect during your first conscious dilitation

Several months ago, you were diagnosed as having a urethral stricture, and told in these exact words: "they have a tendency to recur".  Well,, it's "x" number of months later, and your stream has diminished to a mere fraction of what it was immediately after your first dilitation (which was probably done under sedation). It's time to head to the urologist, what should you expect?

Don't be afraid, while dilitation is not the  most comfortable thing in the world to have done, it is also far from the worst. You'll go into the office, provide a urine sample (drink a few glasses of water 45-minutes before the appointed time), be lead back to a treatment room, and told to disrobe from the waist down. Your physician will appear, ask you how things have been with regards to the stricture, and if no other complications have arisen, he (or she) will tell you that "maybe it's time that we performed a dilitation.  He (or she) will use a medicated 4x4 containing Povidone iodine (Betadine) to cleanse your urinary meatus (the opening of the urethra), and instill about one fluid ounce of a viscous topical anesthetic containing lidocaine or bupivicaine. You'll feel some pressure as your urethra fills with the anesthetic, and truthfully, for me, I disliked this more than the dilitation itself. A penile crown clamp will then be applied to the "penile corona" a.k.a.  the base of the head of the penis (to keep the medication inside the urethra), and allowed to take effect for at least ten-to-fifteen minutes.

Depending on the location, length of, number of strictures (and their alignment), and the degree of difficulty which you are having establishing a stream, the selection will be made between dilitation using metallic urethral sounds, or a system of woven fibre catheters called "filiform and followers". Better streams usually receive dilitations with the metal sounds, while the more complex dilitations are carried out using the filiform and followers.

Metal sound dilitation:
The clamp will be removed, and sounds (most often Van Buren sounds are employed) of increasingly graduated sizes will first be lubricated with a water-based lubricant (Surgilube or K Y Jelly) and gently passed through the urethra and into the bladder, gradually widening the passage through which the urine flows. Once in the bladder, the penis and sound combination will be manipulated "North, East, South, and West" in order to ensure all sides of the stricture are addressed with equal attention. On average, four different diameters of sounds will have to be used in order to achieve the 24-Fr (Fr = French, a medical unit of measurement similar to the "gauge" terminology commonly used in life) optimum urethral diameter. Once the desired status of your urethra has been re-established, you will be allowed to relax for a few minutes, and asked to urinate.<---this is important! Urination cleanses the urethra, and helps remove any blood, anesthetic, or lubricant from the urethra, thus lessening the possibility of infection.


Filiform and followers dilitation:
The clamp will be removed, and a thread of woven fiber about the diameter of a bass guitar string will first be lubricated with a water-based lubricant (Surgilube or K Y Jelly) then "manipulated" into the opening of the stricture by gently moving the filiform through the narrowed stricture and into the bladder using an in-and-out motion, much in the same way that a needle is threaded. A good portion of the end of the filiform will be allowed to remain in the bladder in order to maintain positioning for the followers, which as the word says, "follow". After application of lubricant, a slightly larger follower is gently threaded onto the exposed end of the filiform, and gently passed through the stricture and into the bladder. This process is repeated four or five times with increasingly wide followers, again, gradually widening the passage through which the urine flows., until the desired 24-Fr urethral diameter is achieved. The maximum diameter sound may be allowed to remain in-place for up to twenty minutes in more complex "multi-stricture" cases. After removal, you will be allowed to relax for a few minutes, and asked to urinate.<---this is important! Urination cleanses the urethra, and helps remove any blood, anesthetic, or lubricant from the urethra, thus lessening the possibility of infection.

I was hesitant about the addition of this link to a Youtube video of a urethral dilitation with metal sounds, as this patient is obviously under general anesthesia, and the physician can be a little less gentle with the dilitation. You may notice that there is a very slight resistance when the first sound is inserted, this is the apparent location of the stricture (it is probably a penile urethral stricture, and not a bulbar urethral stricture, as are most. Note: due to the subject/situation of the video, there is unavoidable nudity contained within. Viewer discretion is advised.

Per: Moderators César  and Tim

Whatever happened to URISED?? a.k.a. What REALLY happened to Urised??

While doing research into which topics to best cover within this blog, I was "wishin" that I had a few Urised tabs around to ward-off some minor burning that I've been encountering. So,,,, I picked up the phone, called my daughter, an M.D. , and asked if one of her associates could call in a script for 30-or-so. "Shure", she replied, only to follow with a phone call ten minutes later stating: "it's not being manufactured anymore, do you want Pyridium instead"? HELL, NO!, I replied, I like to pee "peeeecock blue" (my licensed variant in spelling), not rust-orange,,, I ABSOLUTELY HATE PHENAZOPYRIDINE!!

So, being the intrepid research scientist that I am (seriously, I contracted to NASA for two years), I did some digging. Here's what was discovered:

Interstitial Cystitis (ICN) Bladder Pain Support Forum 


Just wanted to put it out there for those that use it- that Urised has been discontinued by the manufacturer (Amerifit) and according to them it is permanent. I liked Urised the best out of all of the antispasmodics.  This was effective in late 2007

There is a near-substitute, Prosed, which has had it's own problems. So, here's the rest of the story:

CHAPTER ONE 

As mentioned above, Urised was produced by a company called "Amerifit Brands", which apparently purchased it's former manufacturer, American Urological sometime after 1999.  Everything was copasetic until 07 November 2007, when this occurred. (well worth linking to, and they sent it via FEDEX!)

Shortly thereafter, the remaining stock was sold off, and Urised was destined to never be seen again.

Oh - wait, THERE'S MORE!!


CHAPTER TWO 


Anyone having to purchase medications containing pseudoephedrine can tell you of the rigamarole that you now have to go through. A driver's License, passport, birth certificate, iris scan, and third-degree interrogation seem to be commonplace because of the pseudoephedrine controls initiated at the state level. This law has made it more difficult for diversion of the substance, which is a precursor to methamphetamine, to be purchased by clandestine manufacturers of illicit meth, thus making manufacture of meth almost impossible, correct??

Well, it turns out that Urised contained a chemical called methanamine, which metabolizes into formaldehyde in the urinary tract. Methanamine is also a precursor to methamphetmine, and a DEA Schedule C-I Controlled Substance, which made Urised a possible target for meth labs as a source of the base ingredient. It seems the formulation of Urised is easily separated by the backyard chemist. Prosed uses a proprietary process to sequester the methanamine, making its separation darn near impossible. Rumors were, that in order to continue the manufacture of Urised, Amerifit would have been required to also sequester the Methanamine.


YES, THERE'S STILL MORE!!


CHAPTER TWO POINT ONE  

A little more research yielded a treasure-trove of info on Amerifit Brands, and their "alleged" quality control issues. It turns out that Amerifit is/was one of the leading manufacturers of non-prescription (which often contained ephedra) diet pills and programs (can you say "Accutrim"?). Much of this mess started with the push to restrict the sale of ephedra and pseudoephedrine in 2004 (election season), and concluded with the restriction of phenylproponalamine (PPA) and ephedra under the  Combat Methamphetamine Epidemic Act of 2005. Whatever occurred, in 2010 Martek Biosciences Corporation followed through with the purchase of Amerifit Brands.


People who have various lower urinary tract disorders no longer have the peace of mind (without the large out-of-pocket cost) and relief offered by Urised for more than fifty years!



Say thank you to your local meth addict!

That's all she wrote folks, it's ProsedDS® or nothing, and that a damn shame....

BTW: I settled for its more expensive half-brother, ProsedDS®. <---hey, it's better than  nothing!

UPDATE: 22 JULY 2012

The makers of ProsedDS® had a few QC Hiccups in September of 2011, and as of this writing, it has pretty much disappeared from pharmacy stock. Hyophen®, a similar, and slightly less expensive alternative (again, without the atropine liability of Urised®, and at a slightly lesser expense than ProsedDS® appeared in our pharmacies earlier this year. The jury is still out on it's effectiveness, however, Hyophen® provides an alternative to phenazopyridine. A much welcomed alternative.

UPDATE: 30 JULY 2012

The initial information that we received regarding Hyophen® was that it was intended to be a similar performer to ProsedDS® and Urelle®, but would be available at lower pricing; that information was partially in error. To my astonishment, I paid $69.04USD for THIRTY of them. My apologies for not verifying pricing before publishing a post, you have my assurances that this will not happen again. You may have noticed a survey request for information from those taking Hyophen®. This request was made after receiving an email from a urologist who had questions about the performance of the medication. The results were informative, but not sufficient for a conclusion in any direction.  ProsedDS® is off of the market; Urelle® and Hyophen® are both of similar composition and price. Let's just say that you had better have a good third party pharmacy plan should your urologist prescribe either medication.  We are looking for foreign alternatives.

We have also heard that two of the ingredients in the medications have become extremely expensive, and difficult to source.


Per: Moderator Tim

The advantages of in-home uroflowmetry

In the mid-1980's, my urologist urged me to use a device for uroflowmetry which looked like a small rectangular plastic fish-tank prior to commencing each office visit. The urine flowed through small "trap doors" which activated at four stages. The urine measured at each stage was compared to a chart that provided a mean-value which was charted for comparison to a base-line obtained soon after each urethral surgery. Eventually, I was prompted to purchase one of these now-extinct "manual urine flow gauges" (which lasted ten years) to track thrice-weekly measurements which really did help by forcing me to go for a dilitation/urethrotomy, or whatever - while the stricture was in a more open state, allowing for a "kinder instrumentation" or easier urethrotomy.

Ask your urologist if he or she feels this type of tracking would be beneficial in your case, there is a device made in the U.K. known as the Uflow urine meter which is not easily available in North America. With shipping, the cost is around $23.00 U.S.  A base-line (in-office) uroflowmetric study will have to be done for comparison to your initial results.  The savings in discomfort should be well worth the investment!
 
 Per: Moderator Tim

Manufacturer's information page

On a lighter note....

 © Judge-mental Productions, and Fox Television Networks

I absolutely despise Hank Hill, and his "narrow urethra"!

I'd love to know if Mike Judge, or any of the other staff of JUDGE-MENTAL PRODUCTIONS has a urethral stricture, or any idea of the life-long undertaking dealing with urethral stricture disease presents. I doubt very much if anyone at Judge-mental has had the pleasure of  *"pissing through an eye dropper"* day-in, day-out for years on end. I've watched most of the episodes, and never once saw Hank visit an M.D. for treatment of any urinary malady. He didn't "poop" for a week once, and went the colonoscopy route, but I never saw the s.o.b. head to the Arlen Urology Clinic for a "Roto-Rooter ®" tune-up, or to get a "ream-job". Could you imagine the vocal intonations Hank would exude while having a 24-Fr Van Buren sound passed through his most delicate of areas. Never once did Hank say: "Peggy, I'm sorry, you'll have to scratch your own itch tonight, my scratcher's been through a lot today".  ;)    Per: Moderator Tim

The correlation between Urethral Stricture and Prostatitis

From Wikipedia:
After age 40, it is recommended that the prostate of urethral stricture patients be monitored (in males) at intervals as determined by the physician/practitioner overseeing the situation. Although no formal studies are available documenting this, there appears to be a slightly higher incidence of prostatitis in stricture patients versus the general population. Patient education and counseling is an important aspect of the successful resolution, and continued care for the stricture patient.

Per Moderator Tim:
I can attest to this first hand! My prostate began going south around age 34, as I visited my urologist on a bi-monthly basis with symptoms of UTI (Urinary Tract Infection) which would subside after beginning an antibiotic/antibacterial treatment regimen (note: Nitrofurantoin never worked, a symptom which is now known to be a key indicator that prostatitis is the culprit, and not a simple or more complex UTI). Very often, I would present with clouded urine, which showed symptoms of infection - sans bacteria. At one point my urologist postulated that this "probably has something to do with phosphotase".

**After countless courses of antibacterial therapy, at age 51, I am now taking Finasteride and Doxazosin daily, a treatment regimen which has helped (me) immensely, and have come to the realization that my prostate has been sending messages since my early '30s. I now require only one-or-two courses of antibacterial treatment per year. HAVE YOUR UROLOGIST MONITOR YOUR PROSTATE!

Prostatis.org: "Can Urethral Strictures cause Prostatitis?"

What to look for in a Urologist PART 2

Your local, board certified Urologist is most often certified by at least one of two well-recognized organizations: the American College of Surgeons (F.A.C.S. = "Fellow, American College of Surgeons),  and the American Board of Urology (Diplomat, American Board of Urology). INQUIRE AS TO WHETHER THE PHYSICIAN IS IN CURRENT STANDING WITH HIS OR HER BOARD CERTIFICATION, ASK TO SEE THE CERTIFICATE ON THE WALL IN THEIR OFFICE!!! <----IMPORTANT

*Check the track record of the hospital that the physician uses for his or her "base of operations", most often, a physician will have satellite offices spread throughout a specific region. Avoid having your procedure(s) performed at the regional hospitals, as the surgeon will (most often) be more familiar with the method of operations at their base hospital.

CONSIDER EMPLOYING A UROLOGIST BASED AT A "BIG CITY HOSPITAL" OR TEACHING FACILITY.

Research the physician's continuing education records, specifically related to urethral surgery (not related to the prostate). That walnut-sized "little gold mine" often preoccupies most urologists, as roughly 40% of their practice is prostate related.


*ask friends, neighbors, co-workers, etc. about their opinion of the facility in question, very often, the reputation of a hospital will correlate with the standard of care which you receive. Research the archive(s) of local newspapers by using the keyword "malpractice" in the search function. Check to see if there has been a recent change in the command structure of the facility, and consider avoiding having surgery there if "things appear out of place".

Consumers Research Council's AMERICA'S TOP UROLOGISTS:

Consumers Research Council's  TOP UROLOGIST SEARCH FUNCTION

What to look for in a Urologist PART 1

Once a diagnosis of Urethral Stricture Disease has been established by either urethrography or cystoscopy, it is important to credential the urologist whom you are considering to trust with the management of your case. BOARD CERTIFIED DOES NOT MEAN "EXPERT IN URETHRAL SURGERY", most urologists are "one size fits all", and have difficulty treating recurrent strictures successfully. Any of us who have heard the torturous metallic noise of urethral sounds hitting the tray can attest to this. The web will provide access to research written by your intended physician, look for research submitted to the journal UROLOGY, the National Institutes of Health, JAMA, and papers published by medical colleges and universities.

A UROLOGISTS STATEMENT ON THEIR WEBSITE OR CONTAINED WITHIN ADVERTISING DOES NOT AN EXPERT MAKE

Remember, this is a condition which you will carry throughout your life - select only the best surgeon - speak up, stay involved in the management of your case - gather research and documentation for your insurance carrier as proof that sending you to a specialist in urethral surgery will save money for them, and anxiety for you. DO NOT SETTLE FOR DILITATION UPON DILITATION, it's difficult for you, and scars the urethra making surgeries in the future more difficult.