Diagnostic Assessment — Urethral Stricture
Example 1 of 1 · fictitious patient (Veteran CM)
Diagnostic Assessment
Urethral Stricture
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CM, date of birth 02 March 1985, Australian Army, Cavalry Scout (armoured vehicle crewman, later Corporal), enlisted 14 July 2004, medically discharged 11 October 2018. Operational service: Afghanistan, 05 March 2011 to 28 October 2011 (warlike); Iraq, 15 January 2016 to 20 July 2016 (warlike).
Occupational History
Cavalry scouts crew light armoured vehicles as drivers, gunners and crew commanders, conducting reconnaissance, convoy escort and security tasks. The work involves climbing on and off vehicles and in and out of hatches with sharp steel edges, prolonged sitting in cramped turret and hull positions over rough terrain, and long periods in the field with limited hygiene, heat, sweat and occlusive clothing.
On operations, armoured vehicle crews are at high risk of improvised explosive device strikes, which characteristically cause pelvic, perineal and lower limb injuries through upward blast and vehicle deformation. Field and deployed conditions also limit access to timely sexual health care, urology services and continence supplies.
History
Veteran CM, a cavalry scout in the Australian Army, sustained a straddle injury in 2009, gonococcal and chlamydial urethritis in 2010 and lichen sclerosus, and in July 2011, on warlike service in Afghanistan, a pelvic fracture with posterior urethral disruption when his vehicle struck an improvised explosive device. He developed a post-traumatic urethral stricture on 20 February 2012, after traumatic catheterisation, endoscopic realignment and six weeks of urethral catheterisation, and it worsened on warlike service in Iraq in 2016.
Timeline
- 17 Sep 2009 — During a peacetime field exercise in northern Australia the veteran slipped while climbing out of the turret of his armoured vehicle and fell astride the hatch rim. He had perineal bruising, a perineal haematoma and frank haematuria at the next void. A medical officer recorded a probable bulbar urethral contusion. He voided spontaneously and the haematuria settled over five days. "straddle injury, perineal haematoma, haematuria"
- 08 Jun 2010 — After three weeks of purulent urethral discharge and dysuria that began during a bilateral exercise in Southeast Asia, where no sexual health testing was available in the field, urethral swabs were positive for Neisseria gonorrhoeae and Chlamydia trachomatis on PCR. He was treated with ceftriaxone and azithromycin. The prolonged untreated urethritis was noted as a risk for later stricture. "gonorrhoea and chlamydia, delayed treatment"
- 03 Nov 2010 — A dermatologist diagnosed genital lichen sclerosus, with white sclerotic plaques of the glans and foreskin and early narrowing of the urethral meatus, after recurrent balanitis during long field exercises in heat and occlusive clothing. Biopsy confirmed lichen sclerosus. Potent topical corticosteroid was commenced. "genital lichen sclerosus, meatal narrowing"
- 14 Jul 2011 — On warlike service in Afghanistan his armoured vehicle struck an improvised explosive device. He sustained an open-book pelvic fracture with symphyseal diastasis and blood at the urethral meatus. At the point of injury a urethral catheter was attempted and passed with resistance and fresh bleeding. At the role 3 hospital a retrograde urethrogram showed extravasation from a partial posterior urethral disruption, and a suprapubic catheter was placed. "pelvic fracture, posterior urethral disruption"
- 16 Jul 2011 — At a coalition role 4 hospital the pelvic fracture was fixed and a urologist performed cystoscopy and primary endoscopic realignment of the urethra, noting a false passage at the bulbomembranous junction from the attempted catheterisation. A urethral catheter was left across the realignment and removed after six weeks, on 27 August 2011. Uroflowmetry on 15 December 2011 showed a normal maximum flow rate of 18 mL/s. "endoscopic realignment, false passage"
- 27 Feb 2012 — He presented with a week of weak stream, straining, a split and spraying stream and incomplete emptying, beginning on 20 February 2012. Maximum flow rate was 7 mL/s with a post-void residual of 140 mL. On 12 April 2012 a retrograde urethrogram showed a 2 cm stricture at the bulbomembranous urethra, and a urologist diagnosed post-traumatic urethral stricture. "weak stream, Qmax 7 mL/s"
- 05 Mar 2013 — The stricture recurred after optical urethrotomy on 18 June 2012 and a second urethrotomy was performed on 05 March 2013, followed by intermittent self-dilatation with hydrophilic catheters twice weekly. Maximum flow rate improved to 14 mL/s. He had three urinary tract infections with Escherichia coli during 2013 to 2015. "repeat urethrotomy, self-dilatation"
- 08 Jun 2016 — On warlike service in Iraq, after his self-dilatation catheters ran out in April 2016 with no resupply and no urologist in theatre, and after he fell astride a concrete barrier during a rocket attack alarm on 02 May 2016, he developed acute urinary retention with fever. A urethral catheter could not be passed and a suprapubic catheter was placed. Urine grew Escherichia coli. On 15 August 2016 a retrograde urethrogram showed the stricture lengthened to 4.5 cm with near-obliteration of the lumen. "acute retention, stricture 4.5 cm"
Symptoms
At onset the veteran had a weak, split and spraying urinary stream, straining to void, hesitancy, a sensation of incomplete emptying and post-void dribbling, with nocturia twice a night. Symptoms improved after each urethrotomy and then recurred within months.
After the worsening in 2016 he had acute urinary retention and then very poor flow, recurrent infections and pain on voiding. Since buccal mucosa graft urethroplasty in 2017 he has a reduced but adequate stream, post-void dribbling, urgency, nocturia three times a night and occasional urinary tract infections, and he must plan outings around access to toilets.
Imaging
- 14 Jul 2011 — CT abdomen and pelvis: "Open-book pelvic fracture with 4 cm pubic symphyseal diastasis and left sacroiliac joint widening. Perivesical and perineal haematoma."
- 14 Jul 2011 — Retrograde urethrogram: "Contrast extravasation at the bulbomembranous junction with some contrast reaching the bladder, consistent with partial posterior urethral disruption."
- 12 Apr 2012 — Retrograde and voiding urethrogram: "2 cm stricture of the bulbomembranous urethra with proximal dilatation and a small diverticulum at the site of the previous false passage."
- 15 Aug 2016 — Retrograde and antegrade urethrogram: "4.5 cm dense stricture of the bulbomembranous and proximal bulbar urethra with near-obliteration of the lumen. Healed pelvic fixation."
Onset Date
The most likely date of onset of this condition is 20 Feb 2012.
At that date the veteran was serving full time with a cavalry regiment in Australia, on restricted duties during rehabilitation from the pelvic fracture and urethral disruption sustained on warlike service in Afghanistan on 14 July 2011. His urethral catheter had been removed on 27 August 2011. On 20 February 2012 he noticed a weak, spraying stream and straining to void.
This date is appropriate because uroflowmetry on 15 December 2011 showed a normal maximum flow rate of 18 mL/s, and he presented on 27 February 2012 with a maximum flow rate of 7 mL/s, one week after the symptoms began. Strictures after urethral disruption and realignment typically become symptomatic within months of catheter removal. The date falls within uninterrupted full-time service.
For the catheterisation and instrumentation causes, the 5 years before onset run from 20 Feb 2007 to 20 Feb 2012; they contain the traumatic catheterisation and suprapubic catheter of 14 July 2011, the cystoscopy and endoscopic realignment of 16 July 2011 and urethral catheterisation for 42 days, from 16 July to 27 August 2011. The straddle injury of September 2009, the gonococcal and chlamydial urethritis of 2010, the lichen sclerosus diagnosed in November 2010 and the pelvic fracture with urethral disruption of July 2011 all preceded onset.
For the worsening causes, the period after onset runs from 20 Feb 2012 to the documented worsening on 08 Jun 2016, during which he had two urethrotomies and regular self-dilatation, recurrent urinary tract infections, the perineal fall of 02 May 2016 and urethral and suprapubic catheterisation on 08 June 2016. The inability to obtain appropriate management ran from April 2016, when his self-dilatation catheters ran out on warlike service in Iraq, to the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Urethral Stricture, post-traumatic, of the bulbomembranous urethra (ICD-10-AM N35.0). No Statement of Principles has been determined for urethral stricture.
A urethral stricture is a narrowing of the urethra caused by scarring of the urethral lining and the surrounding spongy tissue, which obstructs the flow of urine. It causes a weak or split stream, straining, incomplete emptying and post-void dribbling, and it can lead to urinary retention, infection, bladder damage and kidney impairment. In men most strictures are caused by trauma, including pelvic fracture and straddle injury, by instrumentation and catheterisation, by sexually transmitted urethritis and by lichen sclerosus. Strictures commonly recur after urethrotomy and dilatation, and repeated instrumentation lengthens and densifies the scar.
The diagnosis followed a straddle injury in 2009, gonococcal and chlamydial urethritis and lichen sclerosus in 2010, and a pelvic fracture with posterior urethral disruption on warlike service in Afghanistan in 2011, treated with catheterisation and endoscopic realignment. It began on 20 February 2012, was confirmed on urethrography on 12 April 2012 and worsened on warlike service in Iraq in 2016.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 February 2012.
When did the veteran first present to a health / medical provider for this condition?
27 February 2012.
When was the condition confirmed / formally diagnosed?
12 April 2012.
When did the veteran first present to you (or your practice) for this condition?
29 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by retrograde and voiding urethrography on 12 April 2012, which showed a 2 cm stricture of the bulbomembranous urethra with proximal dilatation, in a man with obstructive voiding symptoms and a maximum flow rate of 7 mL/s with a post-void residual of 140 mL. A urologist confirmed the diagnosis and the stricture was visualised directly at optical urethrotomy on 18 June 2012.
The worsening was confirmed by acute urinary retention on 08 June 2016 with failure to pass a urethral catheter, and by urethrography on 15 August 2016 showing the stricture lengthened from 2 cm to 4.5 cm with near-obliteration of the lumen. Buccal mucosa graft urethroplasty was required in 2017.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for urethral stricture, so the Statements of Principles do not limit the factors that can be considered. The claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, applied to the veteran's service. The recognised causes below are drawn from the urology literature and are set out in Statement of Principles style.
Legislation: the clinical onset of this condition was on 20 February 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The principal injury occurred on warlike service in Afghanistan in 2011 and the worsening on warlike service in Iraq in 2016; the straddle injury, urethritis and lichen sclerosus arose during peacetime service. For conditions with Statements of Principles, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service, and the same beneficial approach is applied here.
Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: sustaining a pelvic fracture with injury to or disruption of the urethra before the clinical onset of urethral stricture; — MET
- On 14 July 2011, on warlike service in Afghanistan, the veteran's armoured vehicle struck an improvised explosive device and he sustained an open-book pelvic fracture with a 4 cm symphyseal diastasis, blood at the meatus and a partial posterior urethral disruption shown by contrast extravasation on retrograde urethrography. The stricture developed at the site of this disruption seven months later.
Cause 2: sustaining blunt trauma to the perineum, including a straddle injury, before the clinical onset of urethral stricture; — MET
- On 17 September 2009, during a peacetime field exercise, he fell astride the hatch rim of his armoured vehicle, with a perineal haematoma and frank haematuria recorded as a probable bulbar urethral contusion. This straddle injury to the bulbar urethra preceded onset by more than two years, and the 2016 urethrogram showed the stricture extending into the bulbar segment.
Cause 3: undergoing urethral catheterisation for a cumulative period of at least 7 days within the 5 years before the clinical onset of urethral stricture; — MET
- After the endoscopic realignment of 16 July 2011 a urethral catheter remained in place for 42 days, until 27 August 2011, as part of his treatment for the injury sustained on warlike service. This was within the 5 years before onset, from 20 February 2007 to 20 February 2012.
Cause 4: undergoing traumatic urethral catheterisation, with urethral bleeding or the creation of a false passage, before the clinical onset of urethral stricture; — MET
- At the point of injury on 14 July 2011, on warlike service, a urethral catheter was attempted despite blood at the meatus and passed with resistance and fresh bleeding. Cystoscopy on 16 July 2011 confirmed a false passage at the bulbomembranous junction, and the 2012 urethrogram showed a small diverticulum at that site within the stricture.
Cause 5: undergoing transurethral instrumentation, including cystoscopy or endoscopic urethral realignment, within the 5 years before the clinical onset of urethral stricture; — MET
- On 16 July 2011 a urologist at a coalition role 4 hospital performed cystoscopy and primary endoscopic realignment of the disrupted urethra, seven months before onset and within the 5-year window, as treatment of his warlike service injury.
Cause 6: having gonococcal urethritis before the clinical onset of urethral stricture; — MET
- Urethral swabs on 08 June 2010 were positive for Neisseria gonorrhoeae. The urethritis began during a peacetime bilateral exercise in Southeast Asia and went untreated for three weeks because no sexual health testing or treatment was available in the field, prolonging the urethral inflammation. It preceded onset by 20 months.
Cause 7: having non-gonococcal urethritis, including chlamydial urethritis, before the clinical onset of urethral stricture; — MET
- Chlamydia trachomatis was detected on urethral swab PCR on 08 June 2010 together with the gonococcal infection, and the combined urethritis went untreated for three weeks in the field before onset.
Cause 8: having lichen sclerosus of the genital skin involving the foreskin, glans or urethral meatus before the clinical onset of urethral stricture; — MET
- Genital lichen sclerosus with early meatal narrowing was diagnosed on biopsy on 03 November 2010, after recurrent balanitis during long field exercises in heat and occlusive clothing, and it was present before onset. Lichen sclerosus is a recognised cause of anterior urethral and meatal stricture and impairs healing of the urethral lining after injury.
Worsening factors
Worsening 1: undergoing repeated urethral dilatation or urethrotomy after the clinical onset of urethral stricture; — MET
- After onset the veteran underwent optical urethrotomy on 18 June 2012 and again on 05 March 2013, followed by twice-weekly self-dilatation, all provided through Defence health services. Repeated incision and dilatation of the scar is recognised to lengthen and densify a stricture, and the stricture lengthened from 2 cm to 4.5 cm by 15 August 2016.
Worsening 2: having a urinary tract infection or urethritis after the clinical onset of urethral stricture; — MET
- He had three Escherichia coli urinary tract infections from 2013 to 2015 and a febrile Escherichia coli infection with acute retention on 08 June 2016 on warlike service in Iraq, where the heat, dehydration and lack of clean self-dilatation supplies increased his infection risk. Infection of the strictured urethra promotes further fibrosis.
Worsening 3: undergoing urethral catheterisation, including traumatic or failed catheterisation, after the clinical onset of urethral stricture; — MET
- On 08 June 2016, on warlike service in Iraq, a urethral catheter was attempted for acute urinary retention and could not be passed, causing bleeding, before a suprapubic catheter was placed. The urethrogram on 15 August 2016 showed the stricture lengthened and almost obliterated.
Worsening 4: sustaining blunt trauma to the perineum after the clinical onset of urethral stricture; — MET
- On 02 May 2016, on warlike service in Iraq, he fell astride a concrete barrier while running to a bunker during a rocket attack alarm, with perineal bruising and haematuria recorded by the deployed medical officer. Acute retention followed five weeks later, on 08 June 2016.
Worsening 5: inability to obtain appropriate clinical management for urethral stricture. — MET
- On warlike service in Iraq his prescribed self-dilatation catheters ran out in April 2016 and could not be resupplied, and there was no urologist in theatre, so the dilatation regimen that was keeping his stricture open stopped for two months. The stricture closed down, with acute retention on 08 June 2016 and lengthening to 4.5 cm. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The urethral stricture is a sequela of the pelvic fracture with posterior urethral disruption sustained on warlike service in Afghanistan, and of the urethral instrumentation and catheterisation required to treat it. In turn, the stricture has caused recurrent urinary tract infections, acute urinary retention and post-void dribbling, urgency and nocturia that persist after urethroplasty.
Unintended Consequence
Met. The traumatic urethral catheterisation at the point of injury, which created a false passage, the endoscopic realignment and prolonged catheterisation, and the repeated urethrotomies and dilatations, all provided and paid for by the Commonwealth, contributed to the onset and worsening of the stricture (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From April to June 2016, on warlike service in Iraq, the veteran's prescribed self-dilatation catheters ran out and were not resupplied, and no urologist was available, so the regimen maintaining his urethral calibre stopped. The stricture closed down, causing acute urinary retention with infection on 08 June 2016, failed urethral catheterisation and lengthening of the stricture from 2 cm to 4.5 cm, which required buccal mucosa graft urethroplasty. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that interrupt prescribed treatment and specialist access amount to an inability to obtain appropriate clinical management. The three-week delay in treating his urethritis in the field in 2010 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 17 Sep 2009, Field health record, Medical Officer
- 08 Jun 2010, Outpatient health record and sexual health pathology, Medical Officer, Garrison health centre
- 03 Nov 2010, Dermatology consultation and biopsy report, Dermatologist
- 14 Jul 2011, Casualty report, CT and retrograde urethrogram, Role 3 hospital, Afghanistan
- 16 Jul 2011, Operation report, Urologist, Coalition role 4 hospital
- 27 Aug 2011, Urology outpatient record, Urologist
- 15 Dec 2011, Uroflowmetry report, Urology nurse
- 27 Feb 2012, Outpatient health record, Medical Officer, Garrison health centre
- 12 Apr 2012, Retrograde urethrogram and urology consultation, Radiologist and Urologist
- 18 Jun 2012, Operation report, Urologist
- 05 Mar 2013, Operation report, Urologist
- 02 May 2016, Deployed health record, Medical Officer, Iraq
- 08 Jun 2016, Deployed health record and aeromedical evacuation summary, Medical Officer, Iraq
- 15 Aug 2016, Urethrogram and urology consultation, Radiologist and Urologist
