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 [35] :
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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 rising post-void residual urine volume.
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Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to diagnose 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 [35] :
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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 [35] :
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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 [35] :
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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.
European Association of Urology Guidelines
In 2021, the European Association of Urology (EAU) released new guidelines addressing management of urethral strictures in males, females, and transgender patients. [36, 37]
Diagnosis
The guidelines offer the following diagnostic algorithm for males with suspected urethral strictures [36] :
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Initial testing consists of uroflowmetry and estimation of post-void residual urine volume.
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Combine retrograde urethrography with voiding cystourethrography to assess nearly-obliterative strictures, stenoses, and pelvic fracture urethral injuries.
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Perform cystourethroscopy if further information is required.
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Combine retrograde urethroscopy and antegrade cystoscopy to evaluate pelvic fracture urethral injuries.
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Consider MRI urethrography as an ancillary test in posterior urethral stenosis.
In men considering surgery, retrograde urethrography is required to assess stricture location and length. Assessment of patient-derived benefit from surgery should considered. Validated patient-reported outcome measures (PROM) should be administered to assess symptom severity and impact on quality of life, and to assess sexual function.
Treatment
The EAU guidelines recommend against treatment for asymptomatic small-caliber (≤ 10 Fr) strictures. Long-term suprapubic catheterization should be considered for the treatment of radiation-induced strictures. Key recommendations for first-line treatment with direct vision internal urethrotomy (DVIU) include the following [36] :
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DVIU should not be used to treat penile strictures.
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DVIU/dilatation should be used to treat a primary, single, short (< 2 cm) and non-obliterative stricture at the bulbar urethra.
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DVIU/dilatation can be used to treat a short recurrent stricture after prior bulbar urethroplasty.
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Do not use DVIU/dilatation as solitary treatment for long (> 2 cm) segment strictures.
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Do not perform repetitive (> 2) DVIU/dilatations if urethroplasty is a viable option.
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Do not use permanent urethral stents or urethral stents for penile strictures.
Key recommendations for urethroplasty include the following [36, 37] :
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Do not perform urethroplasty within three months of any form of urethral manipulation.
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Administer prophylactic antibiotics at time of surgery.
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Offer open meatoplasty or distal urethroplasty in cases with meatal stenosis or fossa navicularis/distal urethral strictures.
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Use free graft urethroplasty for bulbar strictures not amendable to excision and primary anastomosis (EPA).
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Warn patients about the risk of de novo incontinence and new onset erectile dysfunction after urethroplasty for radiation-induced strictures.
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Failed hypospadias repair (FHR) should be considered complex cases and referred to specialist centers.
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Offer psychological and/or psychosexual counselling to men with unsatisfactory cosmesis and sexual or urinary dysfunction following FHR.
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Following failed FHR, do not use penile skin grafts or flaps in patients with lichen sclerosus or scarred skin.
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Do not use genital skin in augmentation penile urethroplasty in men with lichen sclerosus–related stricture.
Following surgical intervention, the guidelines recommend the followiing [37] :
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After urethroplasty and prior to removal of the catheter, perform urethrography to assess for urinary extravasation
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Remove the catheter within 72 hours after uncomplicated DVIU/dilatation
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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.
