Urethral Strictures in Males 

Updated: Oct 04, 2021
Author: Joshua A Broghammer, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Practice Essentials

Urethral strictures can result from inflammatory, ischemic, or traumatic processes. These processes lead to scar tissue formation; scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance to the antegrade flow of urine.

The term urethral stricture generally refers to the anterior urethra and is secondary to scarring in the spongy erectile tissue of the corpus spongiosum. A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and usually results from a distraction injury secondary to trauma or surgery, such as radical prostatectomy.[1]  The focus of this article is anterior urethral stricture disease.

Urethral strictures arise from various causes and can result in a range of manifestations, from an asymptomatic presentation to severe discomfort secondary to urinary retention. Retrograde urethrogram (RUG) is the main diagnostic method to find anterior urethra stricture and help find the length of the stricture.

Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential. See the images below.

Urethral strictures. Cross-sectional diagram of th Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy. Urethral strictures. Schematic of penile anatomy.

Many techniques are available for the treatment of urethral stricture disease. Based on the literature, no technique can be applied successfully to every situation. Each technique has advantages and disadvantages.[2, 3, 4]  

The role of tissue engineering and stem cells in urethral reconstruction

Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering with the objective of creating functional replacement tissue. El Kassaby et al published a randomized comparative study of buccal mucosal and acellular bladder matrix grafts. An off-the-shelf matrix derived from the bladder was used. This biomaterial was obtained from donors and prepared via a multistep process, resulting in the removal of all cellular components. The tissue matrix that remains consists of collagen, elastin, growth factors, and macromolecules. Predicated on biocompatibility and the ability to recruit urethral tissue growth in several experimental and clinical studies, this matrix was used.

With a mean follow-up period of 25 months in patients with a healthy urethral bed, the success rates for the acellular bladder matrix were similar to those using buccal mucosa. In patients who had undergone two or more prior urethral surgeries with significant spongiofibrosis, the success rate significantly deteriorated for the acellular matrix relative to buccal mucosa. This study demonstrates promise for the use of acellular matrices as a viable option for urethral repair in patients with a healthy urethral bed, no fibrosis of the corpora spongiosis, and good urethral mucosa.[5]

 

Relevant Anatomy

The urethra is divided into anterior and posterior segments. The anterior urethra (from distal to proximal) includes the meatus, fossa navicularis, penile or pendulous urethra, and bulbar urethra. The posterior urethra (from distal to proximal) includes the membranous urethra and the prostatic urethra.

The urethra lies within the corpus spongiosum, beginning at the level of the bulbous urethra and extending distally through the length of the penile urethra. The bulbar urethra begins at the root of the penis and ends at the urogenital diaphragm. The penile urethra has a more central position within the corpus spongiosum in contrast to the bulbous urethra, which is more dorsally positioned.

The membranous urethra involves the segment extending from the urogenital diaphragm to the verumontanum.

The prostatic urethra extends proximally from the verumontanum to the bladder neck. The soft-tissue layers of the penis, from external to internal, include the skin, superficial (dartos) fascia, deep (Buck) fascia, and the tunica albuginea surrounding the corpora cavernosa and corpus spongiosum.

The superficial vascular supply to the penis comes from the external pudendal vessels, which arise from the femoral vessels. The external pudendal vessels give rise to the superficial dorsal penile vessels that run dorsolaterally and ventrolaterally along the penile shaft, providing a rich vascular supply to the dartos fascia and skin. The deep penile structures receive their arterial supply from the common penile artery, which arises from the internal pudendal artery. The common penile artery gives off several branches, including the bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus spongiosum receives a dual blood supply via anastomoses between dorsal and urethral artery branches in the glans.

The scrotum receives its vascular supply via branches from both the external and internal pudendal arteries. See the images below.

Urethral strictures. Cross-sectional diagram of th Urethral strictures. Cross-sectional diagram of the penis.
Urethral strictures. Schematic of penile anatomy. Urethral strictures. Schematic of penile anatomy.

Pathophysiology

Anterior urethral injury most often results from a blunt force blow to the perineum, producing a crushing effect on the tissues of the urethra. The initial injuries are often ignored by the patient, and urethral injury manifests years later as a stricture. The stricture results from scarring induced by ischemia at the site of the injury. 

A congenital stricture results from inadequate fusion of the anterior and posterior urethra, is short in length, and is not associated with an inflammatory process. This is an extremely rare cause.

Etiology

The most common causes of urethral stricture today are traumatic or iatrogenic. Inflammatory or infectious, malignant, and congenital etiologies are less common. Approximately 30% of urethral strictures are idiopathic.

Iatrogenic urethral trauma usually results from improper or prolonged catheterization and accounts for 32% of strictures.[6]  The size and type of catheter used have an important impact on urethral stricture formation. Silicone catheters and small-calibre Foley catheters are associated with less urethral morbidity. 

Urethral stricture after radiation therapy for prostate cancer is a late complication usually observed 1–3 years after radiation. The overall reported incidence of urethral stricture after radiation therapy for prostate cancer varies between 0%–18%. Urethral stricture occurs in about 2% of patients undergoing external beam (EBRT), 4% for brachytherapy (BT) and 11% of EBRT-BT combination therapy. Several risk factors for the development of a urethral stricture have been identified. Previous transurethral resection of the prostate (TURP) increases the stricture rates up to 15% compared to 6% without prior resection. History of arterial hypertension in combination with diabetes mellitus is also a predictive factor, as this may lead to reduced blood supply due to changes in microcirculation.[7]  

Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral strictures.[8]

Infectious urethral strictures are secondary typically to gonococcal urethritis, which remains common in certain high-risk populations.

 

Epidemiology

The narrowing of the urethra is estimated between 200 and 1200 cases per 100 thousand people, and it will be dramatically increased within people over 55 years. In estimation, the prevalence of urethral stricture in industrial countries is around 0.9%.[9]

Prognosis

The outcomes of urethral reconstruction for lichen sclerosus (LS) urethral strictures are poor, with reported stricture recurrence rates ranging from 20% to 50%. LS strictures are generally longer and have a penile urethral location, both of which independently increase the risk of recurrence. In contrast, non-LS strictures is usually shorter and located in the bulbar urethra.[8]

For patients with RT-induced strictures, radiation damage may result in vasculare atrophy, poorly oxygenated tissue and/or collagen deposition with eventual tissue scarring. The decreased availability of tissue healing and the close relation to the sphincter complicates any surgical approach. Dilatation and/or direct vision internal urethrotomy (DVIU) results are poor with success rates ranging from 0%-20%.[7]

In the largest study examining the outcome of men treated for RT-induced strictures, Hofer et al. examined 72 patients (42% received BT, 42% received EBRT and 14% combination EBRT-BT) with a mean stricture length of 2.3 cm. The majority of the patients (n=66) were treated with stricture excision and primary anastomosis (EPA). Intervention was successful in 70% of the patients. The median time to recurrence was 10,2 months. New onset incontinence was reported by 12 men (18.5%) but the rate of erectile dysfunction remained stable (preoperative, 45.6%; postoperative, 50.9%.[10]  

Urethral dilation and internal urethrotomy

A prospective randomized comparison of internal urethrotomy and urethral dilation for male urethral strictures found no significant difference in efficacy between the two procedures when used as initial treatment.[11]  Recurrence rates increased as the length of the stricture increased. Recurrence rates at 12 months were 40%, 50%, and 80% for stricture lengths of less than 2 cm, 2-4 cm, and greater than 4 cm, respectively. The recurrence rate for strictures 2-4 cm long increased to 75% at 48 months of follow-up.

Permanent urethral stents

Five-year follow-up data demonstrated a long-term success rate of 84% and high level of patient satisfaction.[12]  Failures typically occurred in patients with extensive stricture disease. The North American Study Group 11-year data demonstrated an overall success rate of less than 30%.[13]  A European group reported 2 out of 15 satisfied patients 10 years postimplantation.[14]  An Italian multicenter study following 94 cases reported on the short- and long-term complications.[15]  Short-term complications (7-28 d following the procedure) included perineal discomfort (86%) and dribbling (14%). Long-term complications included painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%). Additionally, some unique complications are associated with permanently implantable stents. The stents are designed for placement within the bulbous urethra. If they are placed distally, there is a risk of pain upon sitting and intercourse.

Excision with primary anastomosis

This form of repair for anterior urethral strictures is considered to be the criterion standard. Historically, this technique has been reserved for strictures shorter than 2 cm. Better understanding of the anatomy has led to successful application of this repair to longer strictures. Jordan and Schlossberg (2007) reported 3 recurrences among 220 patients undergoing primary repair, with a mean follow-up period of 44 months.[16]  Mundy (2006) performed an analysis of a large series of urethral reconstructions and described a durable rate after primary repair that does not deteriorate with time.[17]

Free graft repair

These procedures have an overall success rate of 84.3%. Mundy's analysis demonstrated a 95% success rate with graft reconstructions when the follow-up was limited to 1 year. Longer follow-up showed deterioration over time.[17]

Pedicled skin flaps

The overall success rate is 85.5%. Skin island onlay flap with preservation of the urethral plate provides better success rates than the tubularized flap. Tubularized island flaps have lower success rates than skin island onlay flaps secondary to stricture formation at the site of anastomosis with the native urethra.[18]

A meta-analysis showed equivalent results when comparing graft versus flap reconstruction.[19]  Many authors believe grafts are better suited for proximal reconstruction than flaps for distal reconstruction when all other variables are equivalent.[20]

Postoperative erectile dysfunction

Overall, the rates of erectile dysfunction after urethral reconstruction are low. Reported rates are as low as 2%.[16]  Patients with severe straddle injuries were particularly at risk. A series of 200 patients who underwent anterior urethroplasties demonstrated that the rate of erectile dysfunction was comparable to that after circumcision. Patients who had longer segments of their urethra reconstructed were at higher risk. In this analysis, erectile dysfunction did improve over time.[21]

A study to evaluate whether the type of one-stage urethroplasty has any influence on recovery from erectile dysfunction found that although the procedure has a probability of causing erectile dysfunction in as many as 20% of patients, the type of urethroplasty has no bearing on recovery, which generally occurs within 6 months.[22]

 

Presentation

History

The most common presentation includes obstructive voiding symptoms, urinary retention, or urinary tract infections. Obstructive voiding symptoms are characterized by a decreased force of stream, incomplete emptying of the bladder, urinary terminal dribbling, and urinary intermittency. These symptoms are progressive in many patients.

 

 

Workup

Approach Considerations

Urethral strictures are diagnosed based on a suggestive history, findings on physical examination, and radiographic or endoscopic techniques. The entire urethra, both proximal and distal to the strictured area, must be evaluated endoscopically and/or radiographically prior to any surgical intervention.[23]

Imaging Studies

Radiographic evaluation of the urethra with contrast studies is best achieved by retrograde urethrogram or antegrade cystourethrogram if the patient has an existing suprapubic catheter. Retrograde urethrograms (RUG) and antegrade cystourethrograms are usually obtained through the radiology department, although the urologist can perform them directly. These studies can be used to diagnose and define the extent of the urethral stricture. Accurately documenting the extent and location of the stricture is important so that the most effective treatment options can be offered to the patient.

The technical aspects of a retrograde urethrogram involve placing a nonlubricated 8F or 10F urethral catheter into the fossa navicularis and inflating the balloon with 1-3 mL of sterile water until the balloon occludes the urethral lumen. A scout film is obtained. Approximately 10 mL of iodinated contrast media is then injected into the catheter under fluoroscopy, and images of the anterior urethra are taken. Extreme pressure during the injection phase can lead to extravasation and should be avoided. Do not mistake the membranous urethra for a stricture. On a retrograde urethrogram, the membranous urethra lies between the distal end of the verumontanum and the conical tip of the bulbous urethra. See the images below.

Retrograde urethrogram demonstrating bulbar urethr Retrograde urethrogram demonstrating bulbar urethral stricture.
Urethral strictures. Retrograde urethrogram demons Urethral strictures. Retrograde urethrogram demonstrating complete obliteration of the bulbous urethra.
Retrograde urethrogram demonstrating pan-urethral Retrograde urethrogram demonstrating pan-urethral stricture disease.
Urethral strictures. Retrograde urethrogram demons Urethral strictures. Retrograde urethrogram demonstrating patent urethra after buccal mucosa urethroplasty.
Urethral strictures. Retrograde urethrogram demons Urethral strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary anastomosis.

An antegrade cystourethrogram involves distending the bladder with water-soluble contrast media via a suprapubic tube or urethral catheter. A scout film is taken before administration of contrast material. Once the bladder is fully distended with contrast media, the suprapubic tube is clamped or the urethral catheter is removed and the patient is asked to void. Spot films are taken before, during, and after the voiding phase. This study can help delineate the posterior urethral anatomy.

Ultrasonography of the male urethra can be useful in evaluating urethral strictures. A transducer can be placed longitudinally along the phallus, within the lumen of the urethra or along the perineum. Ultrasonography can be used to evaluate the stricture length and the degree and depth of spongiofibrosis. Several authors have described techniques that involve distension of the urethra with normal saline instilled in a retrograde fashion prior to ultrasonography. Ultrasonography demonstrates thicker periurethral tissues at the level of the stenosis compared to unaffected areas of the urethra.

Ouattara et al showed that urethral strictures identified on perineal sonograms were significantly longer than those identified on retrograde urethrography and voiding cystourethrography.[24]  However, in a series of 92 patients, Shahsavari et al found the estimated lengths of strictures were significantly shorter using sonography compared to RUG.[9]

A study by Zhang et al evaluated patients with conventional voiding and retrograde urethrography and 64-row multidetector CT (64-MDCT) urethrography and found that 64-MDCT urethrography is a useful alternative to traditional radiographic methods for defining male urethral strictures.[25, 23]

Diagnostic Procedures

Endoscopic evaluation can be conducted by flexible or rigid cystourethroscopy. Flexible cystourethroscopy can be performed with little discomfort to the patient using only local anesthesia, such as 2% lidocaine jelly intraurethrally.M alignancy should be ruled out with an endoscopic biopsy.

 

Treatment

Approach Considerations

There is no medical therapy to treat urethral stricture disease, however, urinary tract infections (UTIs) should be adequately treated prior to surgical intervention. Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when conservative management fails.

The patient should be evaluated and deemed medically stable for the selected procedure. Urine culture should be sterile. Urethral stricture disease should be thoroughly evaluated with radiographic and/or endoscopic techniques. The procedure selection should be discussed thoroughly with the patient in advance, and the discussion should include information on the risks and benefits of the procedure and postoperative care. Risks include, but are not limited to, bleeding, infection, recurrence of stricture, and urethrocutaneous fistula formation.

Surgical Therapy

Urethral dilation

Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial strictures (no involvement of corpus spongiosum).

Internal urethrotomy

Internal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision allows for release of scar tissue. Success depends on the epithelialization process finishing before wound contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the 12 o'clock position, either with a “cold” knife or urethrotome or a “hot” knife that uses electrocautery to cut through the scar tissue. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction.

Complications include recurrence of stricture, which is the most common complication, bleeding, or extravasation of irrigation fluid into perispongial tissues, thus increasing the fibrotic response. The curative success rate is reported as 20%-35%, with no increase in the success rate with a second internal urethrotomy procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen. However, strictures typically return once the patient stops.[11]

Permanent urethral stents

Permanent urethral stents are placed endoscopically. Stents are designed to be incorporated into the wall of the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated in patients with dense strictures and in patients with prior substitution urethral reconstruction because it elicits a hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo lengthy open urethral reconstruction procedures.[12] See the image below.

Urethral strictures. Photograph of a permanent ure Urethral strictures. Photograph of a permanent urethral stent.

Open Reconstruction

Primary repair

Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis. The key technical points that must be followed include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. Primary repair is typically used for stricture lengths of 1-2 cm. With extensive mobilization of the corpus spongiosum, strictures 3-4 cm in length can be repaired using this technique. Morey et al (2004) reported on a series of patients who underwent excision with anastomosis for strictures up to 5 cm.[26] Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter.

Free graft repair

For free graft repair success depends on the blood supply of local tissues at the site of placement. Pendulous urethral strictures may be repaired with the patient in the supine or split-legged position. Bulbar or membranous urethral strictures are repaired with the patient in the exaggerated lithotomy position.

The urethra is exposed through a penile or perineal incision. The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from the desired non–hair-bearing location. For example, bladder, buccal, or rectal mucosa are potential options. The graft is sutured to the edges of the urethrotomy. The graft is covered by the dartos fascia of the pendulous or bulbous urethra. Incisions are closed in 2 layers with an absorbable suture, and a Penrose drain is placed through a separate incision in the suprapubic or perineal areas.

Full-thickness skin graft is most successful in the area of the bulbar urethra. 

Split-thickness skin graft is not preferred with a single-stage repair because of the contraction characteristics of the graft. It is typically reserved for use in patients for whom multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is conducted as a 2-stage procedure.

First stage

The urethra is opened via a ventral midline incision down to the level of healthy urethra. The scarred urethra is excised completely. The dartos fascia is mobilized bilaterally and then closed in the midline over the scarred urethral bed. A split-thickness skin graft is harvested from a desired non–hair-bearing location. The graft is transferred to the ventrum of the penis and sutured to the dartos-covered urethral bed, and the proximal aspect is anastomosed in a spatulated fashion to the proximal urethral stump. Xeroform gauze and Dacron padding are used to cover the graft and are secured with supporting sutures. A 14F soft silicone catheter is placed into the urethra and bladder for stenting. Urine is diverted with a suprapubic tube. The Dacron and Xeroform padding is removed after 5-6 days. The suprapubic tube is removed after 2 weeks.

Second stage

Closure takes place in 6-9 months if the graft has succeeded. A 3-cm–wide strip of skin is marked along the ventrum of the penis, which is to be used as the neourethra. A superficial, skin-deep incision is made along the marked lines. Care must be taken to spare the underlying dartos fascia. The skin strip is developed using the tissue plane between the penile skin and dartos fascia. The skin strip is fashioned into a neourethra as it is inverted using interrupted absorbable sutures. This is followed by a watertight closure using absorbable sutures in a running fashion. A small suction drain is left in the periurethral area, and the skin is closed. The drain is removed on postoperative day 3. A 14F soft silicone catheter is passed through the reconstructed urethra for stenting purposes. Urinary diversion is accomplished via a suprapubic tube for 3 weeks.

Buccal mucosal graft

This tissue is resistant to infection and trauma. The epithelium is thick, making it easy to handle. The lamina propria is thin and highly vascular, thus allowing for efficient imbibition and inosculation. Harvesting is easier than with other free grafts or pedicled flaps. A 15- to 20-mm graft is harvested from the oral mucosa. Larger grafts can be harvested depending on the length of the stricture. Most surgeons prefer to close the buccal harvest site primarily. Care is taken to avoid the opening of the duct originating from the parotid gland. The duct for this salivary gland is also known as Stensen duct.

The graft is sutured to the edge of the urethra. A Penrose drain is left in the incision bed for 24 hours to allow drainage. A 16F urethral catheter is left for 7 days. Suprapubic urinary drainage is continued for 2 weeks. The suprapubic tube is removed in 2 weeks, after voiding cystourethrogram demonstrates no extravasation of urine. The graft may be placed as a ventral, dorsal, or lateral onlay. Dorsal and lateral onlay procedures allow for the advantage of securing the graft to the corpora cavernosa (dorsal) or the ischiocavernosus muscle (lateral). This technique is performed with the hope of improving graft host bed immobilization and approximation.

If a ventral urethrotomy and onlay are to be used, then a spongioplasty maneuver should be used to facilitate graft immobilization. This requires a relatively normal corpus spongiosum without fibrosis. Some reports have demonstrated superiority of the dorsal onlay technique, whereas some data do not demonstrate a difference.[27] See the images below.

Urethral strictures. A buccal mouth graft has been 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.
Urethral strictures. The buccal mucosal grafts hav 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.

Bladder mucosal grafts are not as popular as other free tissue grafts because of difficulty in harvesting and handling the tissue.

Pedicled skin flaps

These procedures are based on the principal of mobilizing an island of epithelium-bearing tissue with a pedicle of fascia to provide its own blood supply. Penile skin represents an ideal tissue substitute because it is thin and mobile and has an excellent blood supply. Moreover, the distal penile skin is typically non–hair-bearing.

Skin island onlay flaps

Transverse, longitudinal, and circumferential island flaps refer to the type of skin incision made to fashion the tissue flap. Dorsal and ventral onlay refer to the position in which the flap is sutured to the edge of the incised urethra, as in the dorsal or ventral position with respect to the urethra and corpora cavernosa. Penile incision is carried out through the skin, dartos fascia, and down to Buck fascia. A skin island flap is elevated on the penile dartos fascia, which serves as the vascular supply. A lateral urethrotomy is made along the course of the strictured area. The skin island flap is then transposed to the incised strictured area, oriented into proper position, and sutured to the edges of the urethrotomy incision with an absorbable monofilament suture. A watertight subepithelial suture line should complete the flap placement. The skin is closed with interrupted sutures.

Hairless scrotal island flap

A non–hair bearing area of skin in the midline of the scrotum is used. The tunica dartos of the scrotum is used as the vascular pedicle. This procedure typically is used in complex urethroplasty procedures and is combined with penile skin island flaps to provide additional vascularized tissue for reconstruction.

Skin island tubularized flap

It can be used in combination with onlay flap when a large obliterated segment of urethra is present. It involves tubularizing the pedicled skin flap over a sound and anastomosing the tubularized edge to the native urethral stump. See the images below.

Urethral strictures. Photograph of open urethropla Urethral strictures. Photograph of open urethroplasty depicting the pedicled flap.
Urethral strictures. Photograph depicting pedicled 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.
Urethral strictures. The anastomosis of the pedicl 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.

Postoperative Care

Patients are placed on bedrest for 24-48 hours, depending on the extent of the procedure. Intravenous antibiotics are continued for 24 hours and then followed with oral culture-specific antibiotics or antibiotics with good gram-negative coverage. When all tubes are removed and no evidence of infection is present, antibiotics may be discontinued. Antimuscarinic agents are often used to prevent bladder spasms.

Drains, if necessary, are typically removed on postoperative day 1-3. Wounds should be washed with soap and water daily after drains are removed. 

The patient may be discharged when afebrile, ambulatory, tolerant of a regular diet, and competent in managing drains, catheters, and wound care.

Patients undergoing internal urethrotomy should return to the outpatient clinic for catheter removal on postoperative day 3-5. Patients undergoing open repair should return to the outpatient clinic on postoperative day 3 for wound evaluation and removal of drains.

Prior to removal of the suprapubic catheter, a voiding cystourethrogram is conducted with contrast, instilled through the suprapubic tube. If contrast extravasation is not evident and the suture line is intact, the urethral catheter is removed and the suprapubic tube capped. If the patient continues to void well, the suprapubic catheter is removed after 1 week.

Urethral evaluation should be conducted with retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively.

Complications

Postoperative urinary tract infection and wound infections are rare complications of surgery to repair urethral strictures. Although there is no universal protocol for prescribing antibiotics postoperatively, most surgeons provide a short course of antimicrobials to minimize infections. Importantly, a sterile culture should be documented prior to bringing the patient to the operating room. In the event that a urine culture is positive for bacterial growth, culture-specific antibiotics should be prescribed prior to the procedure.

Urethral dilation

Recurrence of the urethral stricture is the most common complication. Dilation of a urethral stricture is appropriate for patients with isolated epithelial strictures without scarring of the corpus spongiosum. Although rare, dilations can lead to urethral trauma caused by passage of the instrument through the urothelium into the corpus spongiosum or perispongial tissues. This risk can be minimized with careful technique and appropriate selection of patients for dilation.

Internal urethrotomy

Recurrence of the stricture is the most common complication, with up to 80% of strictures recurring after an internal urethrotomy. Persistent postoperative bleeding can occur. The placement of a urinary catheter postoperatively provides intraluminal tamponade of superficial blood vessels. Extravasation of irrigation can precipitate a fibrotic response within the perispongial tissues.

Permanent urethral stents

Distal migration of a urethral stent can lead to the complications of pain while sitting or during intercourse. Large multicenter studies have identified short-term risks of perineal discomfort and dribbling. Long-term risks include painful erections, mucous hyperplasia, recurring strictures, and urinary incontinence.

Open reconstructive techniques[28]

Large series describing the use of an end-to-end anastomosis after excision of the strictured urethral segment report high success rates. Barbagli et al (2007) reported on a series of 153 patients undergoing this repair for bulbar urethral strictures. Most of the strictures were less than 2 cm in length. Ninety-one percent of patients responded after the single repair.[29, 30]

Postoperative chordee and penile shortening after an excision and primary anastomosis is a concern. Appropriate patient selection and mobilization of the distal urethra may minimize these risks. Younger patients are less likely to experience these complications, as they have more compliant urethral tissue.

Recent reports assert that sparing periurethral musculature such as the bulbospongiosus muscle can minimize postoperative ejaculatory dysfunction. Less commonly, decreased penile glans sensitivity, coldness of the glans during erection, and a glans that is not swollen during erection have been documented.

Onlay procedures use tissue transfer techniques, including skin flaps, rather than a graft, such as buccal mucosa. Complications include postvoid dribbling caused by postoperative diverticulum, retraction of the ventral skin of the penis, and urethrocutaneous fistula. Most experts agree that surgical technique and experience with tissue transfer techniques play a large role in maximizing outcomes and minimizing complications.

Oral complications after buccal mucosal harvesting

Buccal mucosal harvesting is an important tool in the urologist’s armamentarium in treating urethral stricture disease. The harvesting procedure is considered well-tolerated but does carry a risk of long-term complications. Several authors have monitored patients postoperatively after a buccal mucosal harvesting procedure. Oral pain over the harvest site resolves within the first month postoperatively. Persistent numbness, tightness, or coarseness over the harvest site has been reported in patients as late as 2 years postoperatively. Dublin and Stewart (2004) reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported that they would undergo the same procedure again.[31] Most experts agree that the potential for long-term complications such as persistent neurosensory deficits and tightness, albeit rare, should be discussed with the patient preoperatively.[32]

Consultations

Consultation with a urologist should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease. 

 

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] :

  • 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. 
  • Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to diagnose urethral stricture. 
  • 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] :

  • Offer urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty for the initial treatment of a short (< 2 cm) bulbar urethral stricture. 
  • Either dilation or DVIU may be performed when endoscopic treatment is utilized. 
  • The urethral catheter can be safely removed within 72 hours following uncomplicated dilation or DVIU. 
  • Self-catheterization after DVIU to maintain urethral patency for patients who are not candidates for urethroplasty. 
  • Offer urethroplasty, instead of repeated endoscopic management, for recurrent anterior urethral strictures following failed dilation or DVIU. 
  • Monitor urethral stricture patients to identify symptomatic recurrence following dilation, DVIU or urethroplasty. 

Major recommendations for anterior urethral reconstruction are as follows[33] :

  • Initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. 
  • Offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. 
  • Urethroplasty for patients with penile urethral strictures, given the expected high recurrence rates with endoscopic treatments. 
  • Initially treat patients with long (≥2 cm) bulbar urethral strictures with urethroplasty 
  • 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.
  • Offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty.
  • Oral mucosa is preferred when using grafts for urethroplasty. 

For patients with pelvic fracture urethral injury, UAU guidelines recommendations include[33] :

  • Use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury (PFUI). 
  • Perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to PFUI. 
  • 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.[34, 35]   

Diagnosis

The guidelines offer the following diagnostic algorithm for males with suspected urethral strictures[34] :

  • Initial testing consists of uroflowmetry and estimation of post-void residual urine volume.
  • Combine retrograde urethrography with voiding cystourethrography to assess nearly-obliterative strictures, stenoses, and pelvic fracture urethral injuries.
  • Perform cystourethroscopy if further information is required.
  • Combine retrograde urethroscopy and antegrade cystoscopy to evaluate pelvic fracture urethral injuries.
  • 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[34] :

  • DVIU should not be used to treat penile strictures.
  • DVIU/dilatation should be used to treat a primary, single, short (< 2 cm) and non-obliterative stricture at the bulbar urethra.
  • DVIU/dilatation can be used to treat a short recurrent stricture after prior bulbar urethroplasty.
  • Do not use DVIU/dilatation as solitary treatment for long (> 2 cm) segment strictures.
  • Do not perform repetitive (> 2) DVIU/dilatations if urethroplasty is a viable option.
  • Do not use permanent urethral stents or urethral stents for penile strictures.

Key recommendations for urethroplasty include the following[34, 35] :

  • Do not perform urethroplasty within three months of any form of urethral manipulation.
  • Administer prophylactic antibiotics at time of surgery.
  • Offer open meatoplasty or distal urethroplasty in cases with meatal stenosis or fossa navicularis/distal urethral strictures.
  • Use free graft urethroplasty for bulbar strictures not amendable to excision and primary anastomosis (EPA).
  • Warn patients about the risk of de novo incontinence and new onset erectile dysfunction after urethroplasty for radiation-induced strictures.
  • Failed hypospadias repair (FHR) should be considered complex cases and referred to specialist centers.
  • Offer psychological and/or psychosexual counselling to men with unsatisfactory cosmesis and sexual or urinary dysfunction following FHR.
  • Following failed FHR, do not use penile skin grafts or flaps in patients with lichen sclerosus or scarred skin.
  • Do not use genital skin in augmentation penile urethroplasty in men with lichen sclerosus–related stricture.

Following surgical intervention, the guidelines recommend the followiing[35] :

  • After urethroplasty and prior to removal of the catheter, perform urethrography to assess for urinary extravasation 
  • Remove the catheter within 72 hours after uncomplicated DVIU/dilatation