Guidelines
Guidelines Summary
In 2016, the American Urology Association (AUA) released guidelines for the diagnosis and treatment of male urethral strictures. Key recommendations for diagnosis include [33] :
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Urethral stricture should be considered in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection (UTI), and after rising post void residual.
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Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to make a diagnosis of urethral stricture.
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Perform biopsy for suspected lichen sclerosus (LS), or if urethral cancer is suspected.
Treatment
Recommendations for treatment with dilation, internal urethrotomy, and urethroplasty include [33] :
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Offer urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty for the initial treatment of a short (< 2 cm) bulbar urethral stricture.
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Either dilation or DVIU may be performed when endoscopic treatment is utilized.
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The urethral catheter can be safely removed within 72 hours following uncomplicated dilation or DVIU.
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Self-catheterization after DVIU to maintain urethral patency for patients who are not candidates for urethroplasty.
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Offer urethroplasty, instead of repeated endoscopic management, for recurrent anterior urethral strictures following failed dilation or DVIU.
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Monitor urethral stricture patients to identify symptomatic recurrence following dilation, DVIU or urethroplasty.
Major recommendations for anterior urethral reconstruction are as follows [33] :
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Initially treat meatal or fossa navicularis strictures with either dilation or meatotomy.
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Offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures.
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Urethroplasty for patients with penile urethral strictures, given the expected high recurrence rates with endoscopic treatments.
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Initially treat patients with long (≥2 cm) bulbar urethral strictures with urethroplasty
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Reconstruct long multi-segment strictures with one stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps or a combination of these techniques.
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Offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty.
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Oral mucosa is preferred when using grafts for urethroplasty.
For patients with pelvic fracture urethral injury, UAU guidelines recommendations include [33] :
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Use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury (PFUI).
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Perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to PFUI.
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Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.
Media Gallery
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Urethral strictures. Cross-sectional diagram of the penis.
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Urethral strictures. Schematic of penile anatomy.
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Retrograde urethrogram demonstrating bulbar urethral stricture.
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Urethral strictures. Retrograde urethrogram demonstrating complete obliteration of the bulbous urethra.
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Retrograde urethrogram demonstrating pan-urethral stricture disease.
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Urethral strictures. Retrograde urethrogram demonstrating patent urethra after buccal mucosa urethroplasty.
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Urethral strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary anastomosis.
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Urethral strictures. Photograph of a permanent urethral stent.
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Urethral strictures. A buccal mouth graft has been harvested from the inner aspect of the cheek. The graft size is measured to accommodate the length of urethra involved in the onlay.
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Urethral strictures. The buccal mucosal grafts have been secured to the corpora cavernosa. The anastomosis will run along either side of the dorsum of the urethral edges to complete the dorsal onlay. The glans penis (distal) is at the top of the picture. The catheterized urethra with a dorsal urethrotomy is on the left.
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Urethral strictures. Photograph of open urethroplasty depicting the pedicled flap.
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Urethral strictures. Photograph depicting pedicled flap anastomosed to the left side of the urethra. Suturing of the right side of the pedicled flap to the urethra completes the anastomosis.
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Urethral strictures. The anastomosis of the pedicled flap is complete. The pedicle of the flap (left side) originates from the dorsolateral aspect of the penis. The glans penis (distal) is at the top of the photograph.
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