|Year : 2019 | Volume
| Issue : 4 | Page : 118-124
A Review of the epidemiology and management of urethral stricture disease in Sub-Saharan Africa
Irekpita Eshiobo1, Udefiagbon Ernest2
1 Department of Surgery, Ambrose Alli University, Ekpoma, Edo State, Nigeria
2 Department of Surgery, Pediatric Surgery Unit, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
|Date of Submission||04-Sep-2019|
|Date of Decision||07-Sep-2019|
|Date of Acceptance||26-Sep-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Irekpita Eshiobo
Department of Surgery, Ambrose Alli University, Ekpoma, Edo State
Source of Support: None, Conflict of Interest: None
The prevalence of urethral stricture in Sub-Saharan Africa is unknown though a few epidemiological studies show that it constitutes a huge disease burden in the region. Over the years, there has been a global change in the epidemiology and management of urethral stricture the extent of which depends on the differences in the regional and subregional economy. The latter affects the pattern of disease distribution and the available tools and expertise for their management. Sixty-one published reports were obtained from Google for this review which critically analyzed the current epidemiology, treatment of urethral stricture disease, and the challenges associated with its treatment in Sub-Saharan Africa from 2011 to 2019. The review also assessed the subregional capacity to treat urethral stricture, taking into consideration available tools, expertise, standard treatment methods, and guidelines.
Keywords: Epidemiology, Sub-Saharan Africa, tools and expertise, treatment, urethral stricture
|How to cite this article:|
Eshiobo I, Ernest U. A Review of the epidemiology and management of urethral stricture disease in Sub-Saharan Africa. Curr Med Issues 2019;17:118-24
| Introduction|| |
There are references to Sushruta  and Socrates  in relation to treatment of urethral stricture in ancient times. Urethral stricture is a narrowing of the urethral lumen anywhere along its length. Early reports almost completely attributed urethral stricture to gonococcal urethritis as the sole cause. Other known causes have emerged, and they include trauma, iatrogenic, posthypospadias repair, lichen sclerosis, postprostatectomy, radiotherapy, and catheter induced.
There are, similar to the global situation, temporal and regional variations in the epidemiology of urethral stricture disease in Sub-Saharan Africa. This is a consequence of the differences in the level of development of the subregions as indicated by the 2017 per-capita of selected Sub-Saharan African countries. Trauma now predominates as a cause of urethral stricture in the developed world., Authors from most part of the developing world still report urethritis as a leading cause., The incidence has been documented to increase with age in the developed world where many of the strictures now result from medical intervention.
The first known treatment of urethral stricture is dilatation. The management of the disease has evolved all over the world though not uniformly. A good history and physical examination contribute immensely to the diagnostic process. Retrograde urethrography (RUG) remains the gold standard investigation, while ultrasonography, computerized tomography (CT), and magnetic resonant imaging (MRI) are presently seen as adjunct to RUG.,
This article aims to review the epidemiology and management of urethral stricture disease and the factors that influenced them in Sub-Saharan Africa from 2011 to 2019.
| Materials and Methods|| |
Information for this review was obtained from published work done in the region and assessed from Google. Search items used were: Urethral stricture in Sub Saharan Africa, West Africa, Central Africa, East Africa, and Southern Africa. The inclusion criteria were published work and dissertations emanating from the region between 2011 and 2019.
The search item “urethral stricture in sub Saharan Africa” produced 26 publications. Of these, five were published before 2011, four were works done outside the region, two were on hypospadias, one was a book chapter, and one was on prostate cancer, leaving 13 relevant publications. The search term “urethral stricture in West Africa” displayed 33 items. Six of these were not done in Sub-Saharan Africa, five were published before 2011, and 2 were on prostate, while 8 overlapped with those of the previous search item, leaving 12 relevant publications. Of the 16 items produced by the search item “urethral stricture in Central Africa” 7 were works done outside Sub-Saharan Africa, four were published before 2011, while one overlapped with those of the previous search item leaving four relevant works. The search term “urethral stricture in Southern Africa” displayed 59 published works out of which 22 were done outside the region, 12 were published before 2011, 5 overlapped with findings in previous searches, while 20 met the inclusion criteria. Using the same method, 12 publications met the inclusion criteria when the search term 'urethral stricture in East Africa'was used. Overall, 61 publications met the inclusion criteria and were selected.
| Epidemiology of Urethral Stricture in Sub-Saharan Africa|| |
There is a paucity of data on the epidemiology of urethral stricture disease in Sub-Saharan Africa. Yameogo et al. reported the hospital prevalence in Ouagadougou, Burkina Faso, as 4.2% which they said was similar to the finding of Guiriansor. In a study of 558 men with acute urinary retention, Stephan et al. from Southern Africa found that 14.3% of them had urethral stricture as a cause of the retention. This is similar to the 15.4% reported by Udoh and Ukpong  and 20% from Kano, both in Nigeria. A study by Ngaroua et al. in Cameroun showed that urethral stenosis accounted for 0.6% of consultations, 11.36% of surgical hospitalizations, and 6.96% of surgical procedures. The implication is that urethral stricture constitutes a huge disease burden in the region.
A mixed picture of predominant etiology obtains in this part of the world. While published work from the rural and suburban centers report urethritis as the leading cause, the urban centers document trauma as the predominant etiology. For instance, Tijani et al. from Lagos, Nigeria, reported trauma from urethral catheterization as the most common cause of fossa navicularis stricture in their recent work. About the same time, Ibrahim et al. from Maiduguri, Nigeria, reported urethritis as the dominant etiology. South African authors, however, documented trauma as the predominant etiology , within the period. Recently documented predominant etiological factors from other countries in the region are shown in [Table 1].
|Table 1: Predominant etiology of urethral stricture as reported by authors from Sub Saharan Africa between 2011 and 2019|
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Trauma remains a formidable etiology of urethral stricture. It occurs in different forms such as fall astride, urethral catheterization, pelvic fracture, and even rupture of the penis. Recently, Ekeke and Amusan  from Nigeria reported a 19.07% contribution from iatrogenic causes and 55.15% from road traffic crash (RTC) and fall astride injuries. Mugalo et al. from Moi Hospital (East Africa) reported that in cases due to trauma, the causes were distributed almost equally between iatrogenic (28%) and external trauma (25%). Heyns et al. from South Africa documented 36.8% iatrogenic trauma as the cause of urethral stricture within the same period. This differs from the 33% external trauma and 26% iatrogenic trauma reported by van den Heever et al. from the same region. Other recent reports on traumatic urethral stricture are from Dakar (Pelvic trauma, 28.57%); Abakaliki, Nigeria (fall astride, 89.3%); Lagos, Nigeria (RTC 34.9% and iatrogenic trauma 20.5%); and Lusaka, Zambia (external trauma 16.9%, iatrogenic trauma 12.7%). These figures to a large extent, reflect the level of available medical care in these countries and subregions. Iatrogenic trauma as a cause of urethral stricture appears to be more commonly documented in developed communities, while urethral stricture disease following hypospadias repair is at present not common in the region. Similarly, lichen sclerosis has been so scantily documented in Sub-Saharan Africa to the extent that it is considered to be absent, especially in Blacks.,,,
Urethral stricture is predominantly a male disease. However, it has been reported in females worldwide. Bello et al. in their case report indicated that, although urethral stricture is unknown in females, it may complicate traditional female genital mutilation (circumcision) which is a common practice in Sub-Saharan Africa. According to Mugalo, urethral stricture may complicate vesicovaginal fistula which in the subregion, is commonly of obstetric origin. Only a few authors have reported on female urethral stricture in Sub-Saharan Africa, and it appears to be 3% or less of all urethral strictures in the region.,
Urethra stricture most commonly affects the bulbar urethra as a result of the S shape of this segment which slows down the flow of urine, and the presence of abundant periurethral glands which may be infected as a result of this slowed flow. This common location of strictures is also determined by the etiology. For instance, fall astride injuries typically produce a bulbar urethral stricture, while bulbomembranous strictures usually follow pelvic fracture urethral distraction injury. The documented experiences from the region within the review period are shown in [Table 2].
|Table 2: Segmental distribution of urethral stricture disease as reported by authors from the region between 2011 and 2019|
Click here to view
Traditionally, urethral stricture was regarded as a disease of the sexually active young male. Then, gonococcal urethritis was the known cause. The picture has since changed in the developed countries. In urban centers in developing countries and the developed world, the prevalence and incidence of the disease increase with age. [Table 3] shows the mean age and age range reported by authors from the region within the review period. The mean age appears to be low where external trauma and urethritis are mostly responsible for the strictures.,
|Table 3: Mean age and age range reported by some authors from Sub-Saharan African between 2011 and 2019|
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In the past when gonococcal urethritis was the common cause of urethral stricture, it was usual to describe men with the disease as belonging to the lower social class. There is ample evidence that no class is exempted as this depends on the etiology, the level of development, available medical care, the prevalence of medical intervention, and the age under consideration. The author  in his study in suburban Southern Nigeria assessed the social class of men with urethral stricture using their occupation as an index. Fifty-two percent were artisans with poor educational background, while others were businessmen, students, and civil servants. This patient distribution most likely represents the situation in other rural Sub-Saharan Africa. This is in contrast to the findings by Heyns et al. in Cape Town, South Africa, where 55.9% of the patients had up to 6–10 years of schooling, 21.6% had more than 10 years of schooling, and only 61.6% earned less than the mean national income. This is probably what obtains in urban Sub-Saharan Africa where iatrogenic urethral trauma is increasingly being responsible for urethral stricture.
Urethral stricture is a disease of both the young and old because of which it is often associated with comorbidities, and these affect their management. Authors from the region who have reported on this are Salako et al. (38.2% hemiplegia, chronic obstructive airway disease, diabetes mellitus and hypertension), Bello (hypertension 28%, diabetes mellitus 8%), Irekpita (diabetes mellitus 6.5%, hypertension 37%), and Heyns et al. (52% in patients who have had 1–2 previous treatment, 73% in those who have had 3–4 previous treatment and 80% of those who have had 5–6 previous treatment).
| Evaluation of Urethral Stricture Disease in Sub-Saharan Africa|| |
Evaluation of patients with urethral stricture requires a good history, physical examination, and the diagnosis established with a standard investigation. A urinary flow rate and the American Urological Association Symptom Index are useful combination in early diagnosis. There is at present no evidence that the latter approach is used in this region probably because the patients present late and at a time the diagnosis is obvious.
Delayed presentation in the region has been reported by several authors. The implication of it is that patients often present with complications. From West Africa, the complication rate documented by authors from the subregion is Ekeke and Amusan  (fistulae 4.13%), Fall et al. (57.8%), Ibrahim et al. (acute urinary retention 12.1%, watering can perineum 6.6%), and Olajide et al. (urethrocutaneous fistula 6.0%, urinary retention 52.4%, bladder/urethral calculi 9.5%, chronic renal impairment 6%, significant urinary tract infection 60.7%). In his explanation of the reasons for the delay in presentation, the latter author disclosed that “Poverty, ignorance, and superstitious beliefs in diabolical causes of illness make these patients vulnerable…. Late presentation with complications is the rule after several visits to spiritualists and traditional healers.” Reports on complication rate from other subregions of Sub-Saharan Africa are similar and include those of Heyns et al. ([urinary retention in 36.8% of cases], urinary tract infection [14%], paraurethral abscess [4%], urethrocutaneous fistula [4%], necrotizing fasciitis [2.8%], bladder stones [2.8%], and epididymo-orchitis [2.4%]). HIV prevalence among patients with urethral stricture in the region has been variously reported as 8%, 9.7%, and 37%.,
RUG, sometimes along with a micturating cystourethrography (MCUG), remains the gold standard investigation for the diagnosis of urethral stricture. According to Ahidjo et al., conventional imaging of the urethra with a dynamic retrograde urethrocystography is an easy procedure to perform, readily available, reproducible, and cost-effective examination that can detect clinically relevant strictures involving the anterior urethra and those with extension into the membranous urethra making it still the initial imaging of choice for suspected stricture disease in the developing countries. It is, however, incapable of assessing the posterior urethra and associated periurethral complication such as abscesses. It is for the latter reason that ultrasonography has emerged as an adjunct to RUG in the confirmatory investigation of urethral stricture. However, similar to RUG, it is incapable of assessing the posterior urethra, hence the need to request for both RUG and MCUG in circumstances in which information about the posterior urethra will influence the choice of treatment option.
There are evidence that RUG is widely used for diagnosing urethral stricture in Sub-Saharan Africa. Oranusi et al. interviewed 55 board-certified urologists in Nigeria in order to assess their practice with regard to urethral stricture disease. While all the participants admitted that they request for RUG in all patients, only 67.3% said that they request for both RUG and MCUG concurrently. Salako et al. in their work on pendulous urethral stricture indicated that they requested for MCUG and RUG concurrently in 26.5% of patients in order to evaluate the proximal urethral segment due to complete obstruction or involvement of the external meatus and fossa navicularis. Ekeke and Amusan, Obi, Olajide et al., and Ibrahim et al. documented that they commonly use MCUG, RUG, and urethroscopy for diagnosis but did not state when and how they request these modalities in order to reach a firm preoperative diagnosis. In contrast to this, Yameogo et al. documented MCUG as their investigation for confirmation of urethral stricture, while van den Heever et al. reported that he relies on MCUG and intraoperative finding. Overall, there appears to be subregional and individual practice variations in this aspect of urethral stricture care. In practice, RUG and MCUG are required if the stricture is obliterative.
Ultrasonography is useful in defining the degree of spongiofibrosis and can more precisely diagnose anterior urethral stricture. There is no documented evidence at present to show that ultrasonography, CT scan, and MRI are used commonly in the evaluation for the diagnosis of urethral stricture in Sub-Saharan Africa probably because of the need to reduce the cost of managing the disease in this predominantly low-resource environment.
| Treatment of Urethral Stricture Disease in Sub-Saharan Africa|| |
The first method of treatment of urethral stricture is dilatation. Over the decades, urologists have ingeniously developed different treatment methods ranging from direct vision internal urethrotomy (DVIU) to various urethroplasty techniques. The challenge at present is how to streamline these methods of treatment in order to achieve maximum cost-effectiveness, reduce complications, and give to the patients the maximum quality of life possible. The extent of this refinement of the treatment varies from one region to another depending mainly on available tools and expertise.
Heyns et al. studied the reasons patients repeatedly have dilatation and or urethrotomy in South Africa in spite of their often poor outcome. The factors were limited theater time, increased patient age, and the presence of underlying comorbidities, according to the study. In a similar vein, Olajide et al. from Nigeria reported the lack of funds to pay for treatment, delay in getting investigations performed due to large patient load with limited facility, industrial actions by health-care providers, and a high load of patients requiring surgical treatment with limited operating rooms, as some of the challenges that militate against the effective treatment of urethral stricture disease in the region. According to Mensah et al., “although urethrotomy and dilatation are not curative, patients who otherwise would have benefited from urethroplasty are still offered repeated urethrotomy because of lack of theater space and trained surgeons to perform urethroplasty. For the same reason, many patients in the subregion spend many months to years with a suprapubic catheter.”
In Central and East Africa, different treatment methods have been reported as used for urethral stricture disease with varying success rates claimed. However, DVIU appears to be the predominantly used technique. Nyongole et al. in their study of 100 and 11 males in Tanzania, DVIU was done in 73 (65.8%), primary urethroplasty in 31 (27.9%), and multistage urethroplasty in 7 (6.3%). The success rate for DVIU was 93%, and along with excision and primary anastomosis, it was done, according to the authors, with the intent to cure. Similarly, Ngaroua et al. from Cameroon analyzed 57 patients, out of which, 58% had DVIU with a success rate of 87.73%. A number of centers and authors have, contrary to the above, documented successes in urethroplasty which is currently the gold standard in the treatment of urethral stricture. Kaggwa et al. from Uganda reported on 72 men for whom urethroplasty was done. Thirty-two (44.4%) had ventral onlay buccal mucosa graft (BMG) with a success rate of 84%, while 40 (55.6%) had dorsal onlay BMG with success rate of 80%. This is similar to that of Makanga and Agbo  in terms of urethroplasty rate though, the documented complication rate in the latter was 39%. Igenge et al. reported doing more of anastomotic urethroplasty, BMG, and occasionally, Orandy technique. Urethral dilatation, however, constituted 73% of the treatment offered in the work of Labib et al. The largest series on urethral stricture treatment in East Africa is the study in KCMC hospital, Tanzania, in which 648 cases were analyzed. Three hundred and sixty-five of them (56.3%) had DVIU with a recurrence of 44.93% within 6 months. Of the 283 (43.7%) who had urethroplasty, 191 (67.5%) were anastomotic, 64 (22.6%) were multistage, while 28 (9.9%) had substitution urethroplasty. The type of substitution urethroplasty was, however, not stated.
A fairly large pool of analyzed data, although not as large as the above, is available from Southern Africa, and there is evidence that appreciable progress has been made in the treatment of urethral stricture disease in the subregion. For instance, van den Heever  in 2012 published a retrospective outcome analysis of 69 patients who had urethroplasty in a single center in South Africa. Surgeries performed included 12 bulbar and 8 membranous anastomotic urethroplasty, 13 ventral and 22 dorsal buccal mucosa onlay grafts (BMG), and 14 two-stage urethroplasty. The recurrence rates were 5% in the dorsal onlay group and 8% in the ventral onlay BMG urethroplasty. Claassen and Wentzel  in 2011 reported on 35 men who had either ventral onlay penile skin island flap urethroplasty or ventral onlay BMG urethroplasty with a success rate of 64.7% for the penile skin island flap and 72.2% for the BMG urethroplasty. Ashmawy and Magama  in 2017 recorded a recurrence rate of 5% at 3–18 months using tunica vaginalis for repair. Claassen  in a recent report documented a 7-year success rate of dorsal buccal mucosa onlay urethroplasty as 65%, being significantly higher than the 27% success rate of ventral buccal mucosa onlay urethroplasty. The double-layer continuous running suture reanastomosis had a success rate of 90%, significantly higher than the 71% success rate of the interrupted suture reanastomosis. In spite of this record from the subregion, according to Heyns et al. “less than one-third of men who should have had a urethroplasty do in fact undergo the procedure.”
In the West African subregion, several published reports on the treatment of urethral stricture disease abound in the literature. Oranusi et al. survey of board-certified urologist in Nigeria, for instance, reported that 23 (41.8%) of the respondents had between 5 and 9 years of experience as reconstructive urologists, while their most common complication after urethroplasty was recurrence of the stricture and fistula. Currently in the region, there is a mix of anastomotic and substitution urethroplasty, the latter either with pedicle penile skin or BMG. Salako et al. in 2013 published their experience with 34 men who had single-stage urethroplasty using longitudinal distal penile island flap technique for pendulous urethral stricture with a complication rate of 11.8%. He encouraged the use of the technique since it obviates the need for two teams and the additional morbidity from oral trauma in BMG urethroplasty. This opinion is also expressed by Olajide et al. who in their work justified its use because according to them, a vascularized flap is still preferred by some urologists where the conditions of the recipient site may interfere with graft survival. The approach in the author's view is justifiable considering the fact that lichen sclerosis LS, the major reason because of which the use of BMG urethroplasty was facilitated, is at present considered to be rare in Sub-Saharan Africa, especially in Blacks. Other workers in the region who reported on the use of skin for urethral substitution within the review period are, Bello (36.1% of 36 patients), Tijani et al. (21 patients), Ibrahim et al. (BMG and penile skin flap in 48 [52.7%]), and Fall et al. (Quartey and Blandy technique). Overall, workers in the region appear to use anastomotic urethroplasty technique, penile skin flap technique, and BMG urethroplasty technique equally, while DVIU is scantily mentioned. It may be that the tools or expertise or both for DVIU are not readily available in the subregion. Many authors ,, in the region still use dilatation frequently in the treatment of urethral stricture. Similar to the experience of Heyns etal. in South Africa, some patients cannot have urethroplasty for varying but avoidable reasons.
| Conclusion|| |
The Sub-Saharan Africa has a large burden of urethral stricture disease. Presentation with complication is rife due to ignorance and poverty. It is predominantly a male disease with a mixed picture of predominant etiology in the region. The patients present late, often with complications. RUG and MCUG are the mainstay in the confirmatory diagnosis in the region. Urethroplasty has gained ground though the extent of its application and the type differ between the subregions. This borders mainly on the availability of tools and expertise which on the overall, are in short supply. Consequently, there is delay in clinical presentation, diagnosis, and treatment.
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[Table 1], [Table 2], [Table 3]