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.