Urethral Strictures in Males

Updated: Aug 05, 2022
Author: Wesley R Baas, 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; the scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance to the antegrade flow of urine. Many cases are idiopathic, but patients may have a history of genitourinary tract infection or trauma, including iatrogenic trauma.

The term urethral stricture generally refers to the anterior urethra. These cases are 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 may be asymptomatic. Clinical manifestations include obstructive voiding symptoms, urinary retention, and urinary tract infection (see Presentation). Retrograde urethrography (see the image below) is the main diagnostic method for finding anterior urethra strictures and determining their length (see Workup).

Retrograde urethrogram demonstrating bulbar urethr Retrograde urethrogram demonstrating bulbar urethral stricture.

Many techniques are available for the treatment of urethral stricture disease, including dilation, urethrotomy, and open reconstruction (see Treatment). No single technique can be applied successfully to every situation; each technique has advantages and disadvantages.[2, 3, 4] Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential.

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 are thought to most often result 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. 

It is also not uncommon to encounter strictures from iatrogenic causes including prior instrumentation of the urethra with scopes or urethral catheters.

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 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.[5]  The size and type of catheter used have an important impact on urethral stricture formation. Silicone catheters and small-caliber 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.[6]  

Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral strictures.[7]

Infectious urethral strictures are most often secondary to gonococcal or nongonococcal urethritis, which remains common in certain high-risk populations.

 

Epidemiology

The annual incidence rate of narrowing of the urethra is estimated to be from 200 to 1200 cases per 100,000 population, with dramatically higher rates in persons older than 55 years. The prevalence of urethral stricture in industrial countries is estimated at around 0.9%.[8]

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.[7]

For patients with RT-induced strictures, radiation damage may result in vascular 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%.[6]

In the largest study examining the outcome of men treated for RT-induced strictures, Hofer et al examined 72 patients (42% received brachytherapy [BT], 42% received external beam radiation therapy [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%.[9]  

Urethral dilation and internal urethrotomy

A prospective randomized comparison of internal urethrotomy (DVIU) and urethral dilation for male urethral strictures found no significant difference in efficacy between the two procedures when used as initial treatment.[10]  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. The success rate of DVIU/dilation also goes down with each subsequent attempt, with a success rate of 0% for dilation of strictures that have recurred twice previously.  

Permanent urethral stents

In the first study of urethral stenting, in 50 patients, five-year follow-up data demonstrated a success rate of 84% and high level of patient satisfaction.[11]  Failures typically occurred in patients with extensive stricture disease. In contrast, the North American Study Group 11-year data demonstrated an overall success rate of less than 30%.[12]  A European group reported 2 out of 15 satisfied patients 10 years postimplantation.[13]  An Italian multicenter study in 94 cases reported that short-term complications (7-28 d following the procedure) included perineal discomfort (86%) and dribbling (14%), while long-term complications included painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%).[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 (EPA)

This form of repair for anterior urethral strictures is considered to be the "gold standard" and was the first type of surgical repair of described. EPA, as the name suggests, consists of completely excising the scarred urethral stricture then spatulating the distal and proximal healthy ends and bringing them together. 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 in 220 patients undergoing primary repair, with a mean follow-up period of 44 months.[15]  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.[16]

Free graft repair

Free graft repair consists of harvesting tissue from elsewhere in the body (usually the buccal mucosa of the mouth) and using that tissue to augment the strictured segement of urethra.  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.[16]

Pedicled skin flaps

The overall success rate of pedicled skin flap grafts 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.[17]

A meta-analysis showed equivalent results with graft versus flap reconstruction.[18]  Many authors believe grafts are better suited for proximal reconstruction and flaps are better suited for distal reconstruction, when all other variables are equivalent.[19]

Postoperative erectile dysfunction

Overall, reported rates of erectile dysfunction after urethral reconstruction are as low as 2%.[15]  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.[20]

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.[21]

 

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 (post-void dribbling), straining to void, and urinary intermittency. These symptoms are progressive in many patients.

 

Physical Examination

Physical examination in patients with urethral stricture is often normal unless they have involvement of the urethral meatus. This is most commonly seen in men with lichen sclerosus/balanitis xerotica obliterans, in which scarring starts at the urethral meatus and progresses proximally down the urethra. In severe cases, spongiofibrosis of the penile urethra may be palpable on physical exam.  

 

DDx

 

Workup

Approach Considerations

The diagnosis of urethral strictures is based on a suggestive history, findings on physical examination, and radiographic or endoscopic visualization. The entire urethra, both proximal and distal to the strictured area, must be evaluated endoscopically and/or radiographically prior to any surgical intervention.[22]

Imaging Studies

Radiographic evaluation of the urethra with contrast studies is best achieved by retrograde urethrogram (RUG), or antegrade cystourethrogram if the patient has an existing suprapubic catheter. Oftentimes strictures are initially diagnosed with cystoscopy. However, cystoscopy can usually only determine the presence of stricture but cannot accurately delineate the length of the stricture because the proximal extent of stricture cannot be visualized through the small lumen.  

Retrograde urethrograms 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. This is done with the patient in an obliqued position. Adequate positioning is known when the obturator foramen on the patient's inferior side cannot be seen.  Doing the imaging without the patient in the proper position can result in underestimation of stricture length.

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 (seen as a "bird's beak" at about the level of the inferior magin of the obturator foramen).  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 medium 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 medium, 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 with 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.[23]  However, in a series of 92 patients, Shahsavari et al found the estimated lengths of strictures were significantly shorter using sonography compared with retrograde urethrography.[8]

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.[24, 22]

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. Malignancy should be ruled out with an endoscopic biopsy when appropriate. Again, cystoscopy can usually only determine the presence of stricture but cannot accurately delineate the length of the stricture because the proximal extent of stricture cannot be visualized through the small lumen. Because of this, imaging such as retrograde urothrography should be performed before any surgical intervention on urethral stricture.

 

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, 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). Urethral dilation is more likely to be successful in short, first-time, bulbar urethral strictures. Penile urethral strictures are unlikely to respond to dilation. The likelihood of success decreases with each subsequent dilation.  

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. Lasers (eg, Holmium) have also been used for the incision. There is no evidence that one modality is better than another. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction and increased blood loss.

Complications include recurrence of stricture, which is the most common complication; bleeding; and 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 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterization have been shown to increase failure rates. Counterintuitively, larger-caliber catheters have also been shown to increase recurrence rate, presumably because they incude ischemia induced by pressing against the mucosa. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen but it has been shown to worsen quality of life, and strictures typically return once the patient stops catheterizing.[10]

Permanent urethral stents

Permanent urethral stents (see the image below) 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.

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

Complications include pain while sitting or during intercourse, due to placement or migration of a stent distal to the bulbous urethra. 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. Because of complications, permanent urethral stents have been taken off the market in the United States.

Stent placement 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.[11]

Open Reconstruction

Primary repair

Primary repair (excision and primary anastomosis [EPA]) involves complete excision of the fibrotic urethral segment with reanastomosis. EPA should not be done distal to the penoscrotal junction, as this will induce chordee.  

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 and Kizer reported success in 10 of 11 procedures for strictures ranging from 2.6 to 5.0 cm in young men with proximal bulbar strictures.[25] Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair.

The key technical points in EPA include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. 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. Most commonly buccal mucosa from the mouth is used but other options include lingual, bladder, or rectal mucosa. A urethrotomy is made either on the ventral or dorsal side of the urethra at the level of the scar, per surgeon preference. 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.

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 or buccal mucosa graft is harvested. 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.   The skin s closed. A 16F 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

Buccal mucosa offers several advantages as grafting source. This tissue is adapted to a moist environment and 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. Care is taken to avoid the opening of the duct originating from the parotid gland (also known as Stensen's duct). Most surgeons prefer to close the buccal harvest site primarily, though it is becoming increasingly popular to leave the harvest site open.

The graft is sutured to the edge of the urethra. A 16F urethral catheter is left in place for 7-21 days. 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.[26] 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

A skin island tubularized flap can be used in combination with an 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.

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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.

Tissue engineering of grafts

Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering with the objective of creating functional replacement tissue. Tissue engineering of grafts for urethral strictures offers the potential benefit of eliminating the need for autologous tissue; this would be particularly useful in patients with long strictures, who would otherwise require harvesting of lengthy mucosal grafts.[27]

One tissue engineering approach is the use of acellular matrix bioscaffolds. El Kassaby et al reported successful treatment of urethral stricture with acellular bladder matrix grafts.[28] This biomaterial was obtained from cadaveric donors and prepared via a multistep process, resulting in the removal of all cellular components. The tissue matrix that remained consisted of collagen, elastin, growth factors, and macromolecules. In patients with a healthy urethral bed (those with less than 2 prior operations), the success rate for the acellular bladder matrix (8 of 9) was similar to that with buccal mucosa (10 of 10). In patients who had undergone two or more prior urethral surgeries with significant spongiofibrosis, the success rate was significantly inferior with the acellular matrix relative to buccal mucosa (2 of 6, versus 5 of 5).[28]

Another approach is the use of a bioscaffold seeded with stem cells, which is currently in the experimental stage.[27] For example, in vitro studies of human stem cells harvested from urine have demonstrated promising results. In a rabbit model, autologous urine-derived stem cells were shown to repair urethral defects.[29] None of those methods are close to clinical use, however.[27]

Postoperative Care

Patients typically spend one night in the hospital depending on the extent of the procedure.  Intravenous antibiotics are now usually only given at the time of surgery and then followed with oral culture-specific antibiotics or antibiotics with good gram-negative coverage.  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. 

Patients may be discharged when they meet the following criteria:

  • Afebrile
  • Ambulatory
  • Tolerant of a regular diet
  • 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. Patients undergoing open repair typically return at the time of catheter removal, with length of time being determined by type of repair.

Postoperative urethral evaluation is not standardized and physician dependent. One popular method is to perform retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively. Patients are usually followed subjectively after 1 year, as the highest risk of recurrence is within the first year.

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 complications

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.  Dilations can also rarely injure the rectum.This risk can be minimized with careful technique and appropriate selection of patients for dilation.

Internal urethrotomy complications

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.

Complications of open reconstructive techniques

Large series describing the use of an end-to-end anastomosis after excision of the strictured urethral segment report high success rates.[30] Barbagli et al 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.[31, 32]

Postoperative chordee and penile shortening after an excision and primary anastomosis is a concern. Appropriate patient selection, avoiding dissection distal to the penoscrotal junction, 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.

Sparing periurethral musculature such as the bulbospongiosus muscle may 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; for example, Dublin and Stewart reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported that they would undergo the same procedure again.[33]

Nevertheless, buccal mucosal harvesting does carry a risk of long-term complications. 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. 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.[34]

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[35] :

  • 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[35] :

  • 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[35] :

  • 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[35] :

  • 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.[36, 37]   

Diagnosis

The guidelines offer the following diagnostic algorithm for males with suspected urethral strictures[36] :

  • 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[36] :

  • 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[36, 37] :

  • 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[37] :

  • 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