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INTRODUCTION — Urethral strictures are relatively common in men. The most common etiology is idiopathic in developed countries and trauma in developing countries . Iatrogenic injuries, such as oversized resectoscope at the time of transurethral surgery and traumatic placement of indwelling urinary catheters, account for 45 percent of all cases . Other causes of urethral strictures include infection (including sexually transmitted disease), hypospadias, skin conditions (most commonly lichen sclerosus), trauma (most commonly pelvic fracture), and radiation therapy (table 1).
The clinical manifestations, diagnosis, and management of urethral strictures in men are discussed here. The diagnosis and treatment of other lower urinary tract diseases are discussed in other topics. (See "Lower urinary tract symptoms in men" and "Clinical manifestations and diagnosis of urinary tract obstruction and hydronephrosis" and "Acute urinary retention" and "Approach to infectious causes of dysuria in the adult man".)
ANATOMY AND PATHOPHYSIOLOGY — The urethra conveys urine from the bladder to the exterior of the body. The anatomy is important here because male urethral strictures differ in etiology, diagnosis, and management based upon stricture locations.
The male urethra is divided into two major segments: the anterior urethra and the posterior urethra (figure 1). By convention, the surfaces of the penis are defined with the penis extended cranially and the urethra located ventrally.
●The anterior urethra begins at the meatus of the penis and includes the fossa navicularis, the pendulous urethra, and the bulbar urethra. The suspensory ligament of the penis delineates the pendulous and bulbar urethra. The anterior urethra consists of an epithelial layer that is surrounded by the corpus spongiosum. The spongiosum is concentrically located around the urethra in the distal pendulous urethra. In the bulbar urethra, it becomes eccentrically located with a larger component on the ventral surface.
●The posterior urethra includes the membranous urethra, the prostatic urethra, and the bladder neck. The spongiosum is absent around the posterior urethra.
Iatrogenic injuries may affect any segment of the urethra. Pelvic fractures can cause distraction defects in the posterior urethra, whereas blunt perineal trauma injures the bulbar urethra. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Anatomy, physiology, and mechanism' and "Blunt genitourinary trauma: Initial evaluation and management", section on 'Clinical features'.)
The male urethra is supplied proximally by the bulbar arteries, which are branches of the penile artery, whereas the distal urethra is perfused by retrograde flow from the dorsal penile artery (figure 2).
Spongiofibrosis — Spongiofibrosis refers to the deposition of collagen and fibrous tissue deep to the urethral mucosa in an injured area. In urethral strictures, spongiofibrosis can be more extensive than mucosal involvement, rendering the effective stricture length longer than that seen on imaging or endoscopic studies. Thus, some experts advocate including areas of spongiofibrosis in the surgical repair to improve outcomes, although doing so would likely lead to a more extensive repair.
Most patients with a urethral stricture present with chronic obstructive voiding symptoms, such as decreased urinary stream and incomplete bladder emptying. Although some patients are able to relate a definitive history of prior instrumentation, injury, or infection, the etiology of the stricture often remains unknown due to the lag time between an inciting event and the development of symptoms .
In other patients, acute urinary obstruction can occur without significant warning, requiring emergency transurethral or suprapubic catheter placement to facilitate urinary drainage.
Besides decreased force of urinary stream, some patients also present with recurrent urinary tract infections, urinary spraying, dysuria, or decreased force of the ejaculate during orgasm, causing sexual dysfunction .
If left untreated, urethral strictures can result in further complications such as elevated postvoid residual urine volumes, bladder stones, or, more rarely, hydronephrosis, urethral fistula, or periurethral abscess [1,3].
In a study of 214 men with anterior urethral strictures, the most common presenting complaints were weak stream (49 percent) and incomplete bladder emptying (27 percent) . However, 21 percent did not present with voiding symptoms addressed by the American Urological Association symptom index (table 2) but instead complained of spraying of urinary stream (13 percent), dysuria (10 percent), or no symptoms (10 percent).
The clinical features, diagnosis, and differential diagnosis of lower urinary tract diseases are further discussed in other topics. (See "Lower urinary tract symptoms in men" and "Clinical manifestations and diagnosis of urinary tract obstruction and hydronephrosis" and "Acute urinary retention" and "Approach to infectious causes of dysuria in the adult man".)
DIAGNOSIS — A urethral stricture should be suspected in men with chronic obstructive voiding symptoms, especially if noninvasive studies (eg, uroflowmetry, ultrasound postvoid residual [PVR] measurement) demonstrate poor bladder emptying with low peak rate of urine flow . (See "Lower urinary tract symptoms in men", section on 'Noninvasive studies'.)
Patients suspected of having a urethral stricture should undergo cystourethroscopy, retrograde urethrogram (RUG), voiding cystourethrogram (VCUG), or ultrasound urethrography to establish the diagnosis . The same studies, especially RUG, also help define the location and length of the stricture to guide treatment. (See 'Defining the stricture' below.)
DIFFERENTIAL DIAGNOSIS — Other urological conditions below can present with similar symptoms to those of urethral stricture, making the diagnosis difficult (see "Lower urinary tract symptoms in men", section on 'Symptoms' and "Lower urinary tract symptoms in men", section on 'Diagnostic testing'):
●Benign prostatic enlargement and/or bladder outlet obstruction – Patients with benign prostatic enlargement and/or bladder outlet obstruction have a predominance of "voiding" symptoms, such as slow stream, intermittent stream or intermittency, hesitancy, straining to void, terminal dribble, or dysuria. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia", section on 'Clinical manifestations' and "Lower urinary tract symptoms in men", section on 'Voiding symptoms'.)
By noninvasive studies, such as uroflowmetry and postvoid residual (PVR) measurements, both urethral stricture and benign prostatic enlargement/bladder outlet obstruction show a pattern of low peak urine flow rate and a high PVR. Bladder outlet obstruction is unlikely when the maximal urinary flow rate is greater than 15 mL/second. Maximal flow rates less than 15 mL/second are compatible with obstruction due to prostatic or urethral disease; however, this finding is not diagnostic since a low flow rate can also result from poor detrusor function (see "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia"). Furthermore, prostatic and urethral disease need to be differentiated from one another by a diagnostic test (eg, retrograde urethrogram [RUG], voiding cystourethrogram [VCUG], cystourethroscopy, or ultrasound urethrography).
●Abnormal detrusor function – Patients with abnormal detrusor function are more likely to have "storage"-type lower urinary tract symptoms such as urgency, daytime frequency, nocturia, or urgency incontinence. Abnormal detrusor function is empirically diagnosed in patients with a history of such symptoms and an absence of urethral/prostate/bladder outlet obstruction and better characterized with urodynamic studies. (See "Lower urinary tract symptoms in men", section on 'Storage symptoms' and "Lower urinary tract symptoms in men", section on 'Invasive diagnostic studies'.)
MANAGEMENT — Treatment is indicated for patients with a urethral stricture that results in bothersome voiding symptoms, acute urinary retention, bladder stones, high postvoid residuals, or recurrent urinary tract infections . In many cases, we feel that asymptomatic patients may not require treatment as long as they are followed clinically, as they may be at risk of developing long-term complications.
There is no absolute contraindication to treating urethral strictures. Patients who are not candidates for open surgical intervention can often be managed with minimally invasive techniques, and if the stricture no longer responds to therapy, urinary diversion is always an option.
The approach to the treatment of urethral stricture disease depends upon the length, location, severity, and etiology of the stricture. The available data to guide the treatment of urethral stricture disease come primarily from observational studies in generally heterogenous populations with a variety of etiologies, locations, and severities of stricture. The approach to the treatment of urethral stricture disease that is presented below (except that due to lichen sclerosus) is based upon the available observational data and expert opinion . The treatment of penile disease due to lichen sclerosus is discussed elsewhere. (See "Balanitis in adults".)
Treatment options — Treatment options for urethral stricture include several minimally invasive therapies (dilation, endoscopic urethrotomy), urinary diversion procedures (suprapubic tube, perineal urethrostomy), and surgical reconstruction of the urethra. No single procedure is appropriate to manage all strictures, and multiple techniques may be used in the same patient if the stricture recurs.
●Urethral dilation and urethrotomy, which are minimally invasive techniques, continue to be the most commonly employed initial treatments [5,6]. Endoscopic urethrotomy is quick, widely available, and safe. Long-term success rates are overall poor but are improved for strictures <1 cm, those located in the bulbar urethra, and those with at least 5 mm of preserved luminal diameter. However, most patients develop recurrent strictures after endoscopic treatment, many of whom eventually progress to surgical repair .
Given the high rate of recurrence with minimally invasive techniques and the overall superior outcomes of surgical reconstruction, we attempt endoscopic urethrotomy only once and, if unsuccessful, progress directly to surgical reconstruction (urethroplasty) in appropriately selected men, rather than multiple repeated endoscopic procedures (see 'Endoscopic techniques' below). Repeated endoscopic treatment should be avoided when possible as it is ineffective and counterproductive, often leading to longer, more complex strictures that ultimately require more involved reconstructive techniques .
●Urethral reconstruction (urethroplasty) involves varying degrees of stricture incision or excision with or without augmentation using a flap or graft of autologous tissue. The potential effects of the chosen surgical technique on erectile function are important to consider. Penile elongation during erection requires that surgical repairs of the penile urethra be elastic and mobile. Similarly, anastomotic urethroplasty, which is useful for repairing the bulbar urethra, can result in penile curvature or tethering with erection when used in the penile urethra. Specific surgical techniques that are most appropriate for each of the segments of the urethra are described in detail below. (See 'Urethroplasty techniques by location' below.)
●Some patients are not candidates for, or will elect not to undergo, surgical reconstruction of the urethra. For these patients, several options for urinary diversion are available, including suprapubic tube placement, perineal urethrostomy, and permanent urinary diversion. (See 'Noncandidates for urethroplasty treated with diversion' below.)
Prior to any instrumentation, the absence of active urinary tract infection must be verified with a urine culture. Whenever possible, patients with symptomatic urinary tract infection or bacterial colonization should be treated with broad-spectrum oral antibiotics, and instrumentation or surgery should be delayed until the urine culture has been cleared. Positive urine cultures were associated with a higher rate of complications .
Bladder decompression — Patients with long-standing symptoms who have maintained urine flow are generally able to decompress their bladder adequately. However, patients who present with acute urinary obstruction may require retrograde serial dilation and catheter placement or placement of a suprapubic tube emergently for complete bladder decompression . At times when urologic expertise to open the stricture is not immediately available, a percutaneous suprapubic tube may be placed by an appropriately trained provider. (See "Acute urinary retention", section on 'Acute management' and "Placement and management of urinary bladder catheters in adults", section on 'Suprapubic catheter placement'.)
Defining the stricture — Prior to treatment, the location, length, and severity of the strictured segment must be defined by radiographic and endoscopic studies.
The initial diagnosis of urethral stricture is often made with a retrograde urethrogram (RUG) (image 1A-C) performed in a setting of trauma or inability to pass a urinary catheter. RUG alone is often all that is needed to define the extent of the stricture disease.
Prior to treatment and regardless of the findings of the initial study that established a diagnosis of urethral stricture, cystourethroscopy should be performed to define the caliber and extent of the urethral stricture and the extent of urethral mucosal involvement .
In patients with acute urinary retention requiring suprapubic tube placement, a voiding cystourethrogram (VCUG) can be performed through the tube to better define the urethral stricture. Alternatively, antegrade cystourethroscopy can also be performed through the suprapubic tract. The bladder should also be examined for calculi, which can be associated with long-term bladder outlet obstruction.
In patients for whom the etiology of the stricture is a pelvic fracture urethral distraction defect, it is important to evaluate the bladder outlet for evidence of concomitant injury.
Some clinicians have advocated the adjunctive use of ultrasound to define the extent of spongiofibrosis and thus determine the absolute length of the urethra that needs to be repaired. Specially designed probes are available for intraurethral ultrasound examination . (See 'Spongiofibrosis' above.)
Endoscopic management of bulbar or meatal strictures — Several endoscopic (ie, minimally invasive) techniques, including dilation with balloons or serial axial dilators (filiforms and followers), cold knife incision, incision with electrocautery or laser, and self-catheterization (ie, self-calibration), can be attempted as the initial treatment of short (<1 cm) bulbar or meatal urethral strictures.
However, the entire group of endoscopic options should only be considered as a single initial therapy and not repeated; patients who fail one endoscopic treatment should be offered surgical reconstruction, rather than repeated endoscopic interventions. Additionally, endoscopic management should not be offered for any other types of strictures such as those in the pendulous urethra (algorithm 1).
Endoscopic techniques may be performed safely in the clinic (self-calibration is performed by the patient at home) using local anesthesia consisting of viscous lidocaine jelly instilled into the urethra and a mild sedative. Various local blocks have been described, including penile blocks and periurethral spongiosum blocks. To perform a spongiosum block, 1 or 2% lidocaine without epinephrine is injected directly into the glans penis to provide anesthesia for instrumentation .
Endoscopic techniques — The choice of endoscopic techniques to initially open a stricture is left to the urologist's experience and the availability of urologic tools because none of the following techniques has been proven superior to any other (see 'Outcomes of endoscopic therapies' below):
Urethral dilation — Axial dilation of urethral strictures in the office or clinic setting is most commonly performed using filiforms and followers or coaxially after endoscopic placement of a guidewire across the stricture. Urethral dilation is an appropriate initial treatment when the history and imaging evaluation have found a bulbar stricture <1 cm with no associated spongiofibrosis and no complex features such as a fistula or a diverticulum. (See 'Spongiofibrosis' above.)
Following successful dilation, the patient can be taught self-calibration with a soft 14- to 16-French catheter to maintain urethral patency. The patient typically performs self-calibration once a day for a week after the initial dilation and then at decreasing intervals over time. Few patients are compliant with self-calibration in the long term, and some patients will present for urethral reconstruction specifically because they are not satisfied with the quality-of-life impact of self-calibration .
Endoscopic urethrotomy — We prefer to use direct vision internal urethrotomy (DVIU), a form of endoscopic urethrotomy after axial dilation for the initial treatment of simple bulbar strictures. Longer strictures, strictures involving the pendulous urethra, or strictures associated with significant spongiofibrosis are associated with high failure rates and therefore are not suitable for endoscopic intervention .
Urethrotomy can be performed safely in the office setting using a penile block or in an ambulatory setting with local, spinal, or general anesthetic [11,13,16]. The procedure is aided by a guidewire placed through the stricture. The urethrotomy incision is made at the 12 o'clock or at the 3 and 9 o'clock positions with a cold knife urethrotome. The method to perform the incision (cold knife, electrocautery, laser) and location of incision(s) are a surgeon preference since outcomes are similar regardless of method. (See 'Outcomes of endoscopic therapies' below.)
Steroid injection in conjunction with internal urethrotomy has been used to treat urethral strictures. Although the time to stricture recurrence may be longer, the overall rate of recurrent stricture does not appear to be affected . (See 'Spongiofibrosis' above and 'Outcomes of endoscopic therapies' below.)
Outcomes of endoscopic therapies — The advantage of endoscopic methods is that they are quick, widely available, and safe.
No endoscopic technique has proven superior to any other. In one study that compared urethral dilation with urethrotomy, equivalent long-term success rates were found for the treatment of short (<2 cm) urethral strictures .
The endoscopic treatment of urethral stricture is associated with high recurrence rates that range from 30 to 80 percent [19,20]. The wide variability of reported recurrence rates is due to the heterogeneity within the patient populations that are studied.
The likelihood of success (defined as no need for further intervention) of initial treatment of urethral strictures using endoscopic treatment (urethrotomy) depends upon stricture length, degree of luminal narrowing, and the urethral segment that is treated . Strictures that are <1 cm, are located in the bulbar urethra, and have at least 5 mm of preserved luminal diameter are most likely to be successfully treated with endoscopic urethrotomy [15,19-21].
Thus, short (<1 cm), bulbar strictures should be offered one endoscopic attempt to open the stricture prior to embarking on definitive surgical repair [1,22]. A single initial endoscopic urethrotomy appears to be cost effective and, in general, should be included in the initial treatment algorithm for an appropriate urethral stricture in men [23-25]. Because of high recurrence rates, some clinicians argue that an initial urethrotomy is not cost effective or beneficial in the long-term care of these patients [21,26,27].
Although it has also been suggested that multiple endoscopic treatments may predispose to a more difficult definitive open repair and reduced overall success rates [28-30], our experiences, as well as those of the others, have shown that a failed urethrotomy does not predict the outcomes of a future urethroplasty but could render the procedure more complex [7,8].
Surgical management of other strictures — For men with long strictures (>2 cm), an obliterated urethral lumen, or strictures involving the posterior or pendulous urethra, urethroplasty provides superior outcomes compared with endoscopic management.
Thus, patients with such strictures who are medically fit for extensive surgery should undergo urethral reconstruction. Techniques vary primarily according to the location and length of the stricture. Patients who are medically unfit for extensive surgery, wish to avoid urethral reconstruction, or have failed multiple prior attempts of urethral reconstruction may choose one of the urinary diversion options (algorithm 1).
Candidates for urethroplasty
Penile flaps and grafts — Surgical reconstruction of the penile urethra may require the use of a flap or graft. The optimal source and best position of such a flap or graft remain controversial.
The ideal urethral graft has a thick epithelial layer, has a thin lamina propria, is easy to harvest with minimal donor site problems, has adequate tissue availability, and has minimal primary contracture . Oral mucosal grafts (from either the buccal, labial, or lingual surface) have all these qualities and are naturally resistant to infection and skin diseases such as lichen sclerosus . The mouth donor site heals quickly with minimal morbidity and complications, and thus oral grafts are the graft tissue of choice for urethral reconstruction [33,34]. The risk of oral donor site complications is increased in smokers, tobacco chewers, and others with poor oral hygiene .
Penile or scrotal skin can be used as flap tissue for onlay reconstruction but are less desirable when used as a urethral graft due to failure rates of 20 to 30 percent [31,36]. Bladder mucosa is another alternative, but harvest requires laparotomy and more prolonged recovery . Other free graft tissues harvested from the rectum, bladder, thigh, or postauricular area can be used but should be reserved for cases where more optimal tissues are not available for the reconstruction, which is rare.
Whether a urethral graft should be placed in a ventral or dorsal position remains controversial. We prefer dorsal graft placement [38,39]. The dorsal graft bed is well vascularized (from the corporal bodies) and inelastic, which prevents pseudodiverticulum formation . Spread fixation, in which the graft is attached to the corporal body with fine absorbable stitches, may preserve dorsal graft width and, thus, urethral caliber . On the other hand, ventral grafts have the advantage of ease of exposure while still maintaining the ability to excise the stricture, if needed. Some studies have reported stricture-free outcomes for ventral grafts that are equal to those of dorsal grafts [9,41-43].
Urethroplasty techniques by location — Techniques for urethroplasty include excision with primary anastomosis (anastomotic urethroplasty), incision with onlay graft or flap repair, and stricture excision with an anastomosis that is augmented with a graft (excisional augmented anastomotic urethroplasty). Repairs can be performed in multiple stages, if needed. The chosen surgical technique depends upon the segment of urethra that is affected and length of the stricture (algorithm 1):
Meatus — Meatal strictures in adults most commonly arise from instrumentation injury, skin disorders, or failed hypospadias repair. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation".)
Meatal strictures often initially respond well to minimally invasive techniques such as dilation or urethrotomy/meatotomy. When minimally invasive techniques fail, we use extended meatoplasty as a definitive treatment of most meatal strictures . Other surgical techniques include flap-based repairs, various plastic operations of the glans of the penis, and staged grafting repairs using buccal mucosa.
To perform an extended meatoplasty, an incision is made on the ventral surface of the penis and the meatus opened as far proximal as needed to identify normal urethral tissue, which essentially creates a hypospadiac meatus (picture 1). A triangle of tissue is removed, and fine interrupted absorbable sutures are used to attach the urethral edges to the skin.
Patients with failed hypospadias repair generally require staged reconstructive surgical operations. In the first stage, the prior reconstructed neourethra is excised and replaced with a buccal mucosa graft that is sutured to the corpora cavernosa to construct a urethral plate. In six months to a year, when the first-stage repair has healed, the graft is tubularized in a second operation to form a new urethra.
Pendulous urethra — The preferred management of strictures of the pendulous urethra (other than those due to lichen sclerosus) is urethroplasty with an onlay flap of penile skin, or with free grafts of penile skin, buccal mucosa, bladder mucosa, or rectal mucosa [44-51]. Endoscopic management in the pendulous urethra should be avoided because of poor outcomes, including high recurrence rate .
The urethroplasty procedure entails incising the stricture along its entire length, extending into normal urethral tissue proximally and distally for an additional centimeter each. The scar tissue is generally left in place but can be excised. The urethral lumen is augmented with the penile skin flap, which is rolled over and sutured into place.
Circumcised men usually have ample penile skin that allows harvesting of a longitudinal flap of sufficient width to lay over the stricture . In uncircumcised men, a transverse flap of foreskin is an alternative source of onlay tissue, but the technique is more complicated. Other flaps harvested from the prepuce or the shaft of the penis (J flaps) allow repair of pendulous urethral strictures up to 15 cm in length.
Optimal results are achieved with excision of narrowed segments prior to placing the onlay graft, but the risk of penile chordee during erection is increased with urethral excision in the pendulous urethra. If excision is performed, a lengthy mobilization of the penoscrotal urethra may be needed, which relies on adequate proximal and distal blood supply. If the blood supply is normal, this technique works well.
Bulbar urethra — Bulbar urethral strictures are preferably managed with excision of the tightest segment of the stricture, when possible; removal of the majority of the associated spongiofibrosis; and, if needed, onlay coverage with a buccal graft. (See 'Spongiofibrosis' above.)
The graft augments the anastomosis or the stricture in its entirety. Prior to the development of this technique, flap-based repairs (using pedicled islands of penile skin or even scrotal skin) and tubularized graft urethroplasties were used to repair bulbar urethral strictures; however, these repairs failed in up to 56 percent of patients [36,53].
Stricture length is not a strict determinant for the use of this technique since larger genitalia may allow lengthier urethral mobilization or a greater tolerance for penile shortening. In general, based upon the length of the stricture, management is as follows (lengths given are approximations, and intraoperative findings dictate the choice of procedure):
●For strictures <2 cm in length (including adjacent spongiofibrosis) (image 1A), stricture excision and primary reanastomosis (anastomotic urethroplasty) (figure 3) are ideal and have excellent long-term results .
●For strictures measuring 2 to 4 cm (image 1B), excisional augmented anastomotic urethroplasty is used (figure 4) . The narrowest portion of the stricture is segmentally excised. The ventral urethra is reanastomosed while the dorsal urethra is spatulated and augmented with an onlay graft (usually buccal) applied with a spread-fixed technique to the corporal body.
●Longer strictures (image 1C) that are not amenable to repair with segmental resection alone can be managed with a variety of techniques, including dorsal onlay repair (figure 5) or excisional augmented anastomotic urethroplasty, which requires excision of the tightest part of the stricture and augmented anastomosis utilizing penile skin or buccal tissue graft . In our experience, the excisional augmented anastomotic urethroplasty has more favorable long-term results compared with dorsal onlay alone. In a study involving 250 men, excisional augmented anastomotic urethroplasty was used to manage long strictures in 11 men, which remained successful in 10 at 22-month follow-up without resulting in the chordee with erection [53,55].
The steps outlined above are our preferred approach to bulbar urethral strictures . Other centers only perform onlay repairs and avoid transecting the urethra or removing any spongiofibrosis out of concerns for an increased risk of erectile dysfunction. However, studies, including a meta-analysis, failed to demonstrate any correlation between erectile dysfunction and any of the urethroplasty techniques used to treat bulbar urethra strictures [56,57].
Posterior urethra — Strictures of the posterior urethra include those of the bladder neck, prostatic urethra, and membranous urethra. Bladder neck and prostatic strictures, which can be the result of radiation therapy for prostate cancer, are managed primarily with urethral dilation or transurethral tissue resection. (See 'Urethral dilation' above.)
Stricture of the membranous urethra is due to iatrogenic or traumatic injury. The remainder of the discussion focuses on traumatic injury, which occurs in approximately 10 percent of pelvic fractures .
The severity of the traumatic injury determines the severity of the urethral defect, ranging from elongation without disruption of the urethra to complete transection. The resulting "stricture" is technically a distraction defect characterized by separation of the disrupted urethral ends and subsequent obliteration of the resulting space that no longer contains a true urethral lumen.
When urethral injury is suspected (blood at the meatus, high-riding prostate) in the patient with pelvic trauma, a retrograde urethrogram should be performed. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)
If no extravasation is seen, a Foley catheter is inserted and a cystogram is performed. An upper urinary tract study to evaluate the ureters, such as a computed tomographic urogram or intravenous pyelogram, can also be performed as indicated.
If a posterior urethral injury is present and a urethral catheter cannot be placed across the defect, the conservative option for management is placement of a suprapubic drainage catheter and delayed definitive urethroplasty three to six months later. The interval period allows resolution of hematoma and descent of the prostate, thus shortening the length of the defect. In certain situations, however, attempted primary realignment of the urethra may be appropriate.
Primary realignment — Acute surgical intervention is indicated if the posterior urethral distraction defect is very long, such as in the uncommon situation when pelvic fracture is associated with rectal injury, large pelvic hematoma, or concomitant bladder or bladder neck injury. When immediate repair is indicated, the urethra can be realigned immediately or after a short delay of two to three days after the patient has been stabilized:
●Immediate realignment – Immediate realignment of urethral injury has been performed with good success using a variety of techniques. In patients with urethral continuity on retrograde urethrogram but with extravasation (partial disruption), endoscopic guidance is used to position a guidewire over which a stenting catheter is placed. Other techniques use magnetic guides, interlocking urethral sounds, and a combination of endoscopic or fluoroscopic guidance to position the stenting catheter. Recurrent stricture occurs in 50 to 100 percent of patients who undergo immediate realignment [59,60]. Additional procedures are often needed.
●Delayed realignment – Delayed realignment is an alternative for selected patients who are medically stable and who can be taken to the operating room within 5 to 10 days after the injury. Urethral realignment is accomplished using two flexible endoscopes. The antegrade endoscope is passed through the suprapubic tube tract and through the bladder neck into the injury hematoma. The suprapubic tube would have been placed for bladder decompression percutaneously or during an associated open surgical procedure at the time of the injury. A retrograde endoscope provides irrigation that helps in identifying the urethral defect. A linking guidewire is passed antegrade, over which the stenting catheter is passed.
Delayed secondary repair — Delayed secondary repair is undertaken three or more months after injury and acute placement of a suprapubic catheter. Prior to surgery, a combined retrograde urethrogram and antegrade cystogram ("up and down-o-gram") is performed to identify the length of the defect and any associated pathology, such as bladder neck incompetence, fistula to the rectum or skin, or bladder stones .
The majority of posterior urethral distraction defects are reconstructed with a one-stage perineal anastomotic urethroplasty. This procedure can manage long obliterative strictures. An abdominoperineal approach may be required to manage complex strictures using substitution urethroplasty in fewer than 5 percent of cases [61,62].
The perineal anastomotic repair involves mobilization of the urethra as a distally based urethral flap. The urethra is transected at the proximal point of its obliteration by cutting down onto the tip of a sound passed through the suprapubic catheter tract into the proximal urethral stump. The bulbar urethra is then anastomosed to the prostatomembranous urethra proximal to the obliteration. We spatulate the bulbar urethra dorsally and the prostatic urethra posteriorly and perform the anastomosis with interrupted 4–0 polyglycolic acid sutures over a supporting 12-French fenestrated silastic catheter.
A tension-free anastomosis can be accomplished by mobilizing an adequate length of urethra using a combination of techniques . In our series of 40 patients, circumferential mobilization of the distal urethra to the suspensory ligament of the penis provided 2 to 3 cm of length sufficient for anastomosis in 8 percent of patients. Separation of the proximal corporal bodies shortened the defect by 1 to 2 cm and was sufficient for anastomosis in 41 percent. Inferior pubectomy, which is performed by resecting a 1.5- to 2-cm wide wedge of bone from the inferior surface of the pubis, further shortened the defect by 1 to 2 cm and was used to facilitate anastomosis in 28 percent. Rerouting the urethra around the lateral surface of a corporal body provided another 1 to 2 cm of length and was needed in the remaining 23 percent.
Outcomes of urethroplasty — Despite the fact that urethroplasty can be a challenging and difficult procedure, patient satisfaction is high . How we define failure or success of urethroplasty is evolving. The international conference on urethral disease originally defined success as the ability to pass a flexible cystoscope through the stricture without manipulation . This is a very strict definition of success because many strictures can be smaller than a cystoscope (16 French) and still remain asymptomatic. Some authors have also defined success as not requiring another surgical or endoscopic intervention.
Other authors argue that success should be judged by symptomatic as well as anatomic criteria. This led to the development of several patient-reported outcome measures, many of which are still being validated. Many groups have proposed follow-up algorithms for urethroplasty patients that include a combination of noninvasive uroflow tests, patient-reported outcome measures, and cystoscopy when indicated. One such algorithm, which we follow, includes a patient-reported outcomes questionnaire, uroflow test, and cystoscopy at three to six months after surgery, followed by patient-reported questionnaire and uroflow test at 12 to 15 months, and then annually. After the three-month visit, cystoscopy is performed when there is a change in the flow or other new symptoms . Other validated symptom scores have been developed specifically for urethral stricture patients after a definitive urethroplasty .
The overall failure rate was 15 percent in a study involving 252 males (median follow-up 37 months) . Failure rates were lowest for anastomotic urethroplasty (12 percent), intermediate for free graft repairs (16 percent), and highest for flap and more complicated repairs (20 percent). In a study with 15-year follow-up, anastomotic urethroplasty was found to be durable, whereas substitution urethroplasty (graft or flap) was associated with increasing rates of recurrent stricture over time . The management of recurrent disease after a primary urethroplasty can be very complex; however, these are amenable to a repeat repair. In a review of 130 patients who underwent redo urethroplasty, 78 percent were successfully treated (median follow-up 55 months) .
Representative outcomes are presented below for each segment of the urethra:
●Meatal stricture repairs are associated with complications in up to 50 percent of cases, including the development of fistula, recurrent stenosis, and breakdown of the repair .
●Pendulous urethral stricture repairs with onlay flaps have recurrence rates between 20 and 30 percent. Fistula, penile curvature with erection (chordee), penile paresthesias, and penile urethral diverticulum can also complicate these repairs [44-48].
●Bulbar urethral strictures using anastomotic urethroplasty and augmented anastomotic urethroplasty with buccal tissue have overall success rates greater than 90 percent when performed by an experienced surgeon [20,26,53,54,67,70,71]. Patients undergoing bulbar urethral reconstruction uniformly report significant improvement in urinary symptoms and quality-of-life scores while maintaining or improving their erectile function [72,73].
●Posterior urethroplasty similarly has high success rates (>90 percent). Failed posterior urethral repairs can generally be salvaged by repeating the same procedure while using additional steps for urethral mobilization. Urinary continence is preserved if the patient has a competent bladder neck and de novo erectile dysfunction is low [74,75], although preexisting erectile dysfunction is common (most likely a result of the original trauma).
Noncandidates for urethroplasty treated with diversion — For patients who are medically unfit for extensive surgery, who refuse urethroplasty, or who have failed multiple prior repairs, urinary diversion is the solution. From least to most invasive, options of urinary diversion include suprapubic catheter placement, perineal urethrostomy, and supravesical urinary diversion (eg, ileal loop urinary diversion, continent right colon pouch urinary diversion, continent small bowel urinary diversion). For those who are unfit for surgery, chronic suprapubic tube management may be the only option. Many men who elect to not undergo complex or staged repairs may benefit greatly from placement of a perineal urethrostomy (algorithm 1) :
Suprapubic catheter — A suprapubic catheter can be used for temporary or permanent urinary diversion and may be used in emergency situations such as acute urinary retention . The catheter will need to be replaced monthly to avoid calcification and chronic infection. The main disadvantages of a suprapubic catheter are the need to frequently empty the urinary bag, daily care for the ostomy site, and the potential for recurrent urinary tract infections. (See "Placement and management of urinary bladder catheters in adults", section on 'Suprapubic catheter placement'.)
Perineal urethrotomy — For men who wish to avoid urethral reconstruction, an alternative solution to a permanent suprapubic catheter is urinary diversion using a perineal urethrostomy (picture 2). Perineal urethrostomy is an appealing solution, particularly in the older adult population, since it offers a simple solution that improves the quality of life . Perineal urethrostomy is a good option for patients with extensive or recurrent strictures or for men who are already accustomed to voiding while seated .
A perineal urethrostomy is created by making a flap in the perineal skin with an inverted U-incision and suturing the bulbar urethra proximal to the stricture to the perineal skin with interrupted, absorbable suture. This flap-based technique decreases the likelihood of stenosis compared with a "puncture" technique for which the urethrostomy is created by direct cut-down onto the bulbar urethra.
Permanent urinary diversion — As a last resort for refractory, recurrent, or nonreconstructible severe urethral stricture disease, permanent urinary diversion can be performed with supravesical urinary diversion (eg, ileal loop urinary diversion, continent right colon pouch urinary diversion, continent small bowel urinary diversion). The procedure is performed in a similar manner as following cystectomy. (See "Urinary diversion and reconstruction following cystectomy".)
POSTOPERATIVE CARE — Over the last decade, the duration of hospitalization for patients undergoing urethroplasty has progressively shortened. Outpatient surgery for urethral stricture disease has lowered cost and increased patient satisfaction without compromising patient care . We plan same-day surgery for most patients; only those who undergo posterior urethroplasty are admitted for overnight observation.
A small, 12- to 14-French Foley catheter is left in place following urethroplasty. The patient is discharged with no activity restrictions. The catheter is maintained for 10 days following primary anastomotic urethroplasty or three weeks after augmented or posterior repairs .
At follow-up, patients who have had a straightforward anastomotic repair can have the Foley catheter removed with voiding trial without any further imaging. Patients who have had an augmented repair utilizing flaps or grafts should undergo a pericatheter retrograde urethrogram or postoperative voiding cystourethrogram. The Foley catheter is removed if no extravasation is seen; the catheter is left in place for another week and the urethrogram repeated if extravasation is noted .
The patient should again be seen at three months after surgery, and then yearly thereafter, for a physical examination, a uroflow test, and an American Urological Association (AUA) symptom score (table 2) .
SUMMARY AND RECOMMENDATIONS
●Urethral strictures in men are common and are most often due to trauma or instrumentation of the urethra. Other frequent causes of urethral stricture include idiopathy and infection (table 1). (See 'Introduction' above.)
●The male urethra is divided into two major segments, the anterior urethra and the posterior urethra. The anterior urethra begins at the meatus of the penis and includes the fossa navicularis, the pendulous urethra, and the bulbar urethra. The posterior urethra includes the membranous urethra, the prostatic urethra, and the bladder neck. (See 'Anatomy and pathophysiology' above.)
●Most patients with a urethral stricture present with chronic obstructive voiding symptoms, such as decreased urinary stream and incomplete bladder emptying. Other patients present with recurrent urinary tract infections, urinary spraying, dysuria, or ejaculatory dysfunction. (See 'Clinical manifestations' above.)
●A urethral stricture should be suspected in men with chronic obstructive voiding symptoms, especially if noninvasive studies (eg, uroflowmetry, ultrasound postvoid residual [PVR] measurement) demonstrate poor bladder emptying with low peak rate of urine flow. Patients suspected of having a urethral stricture should undergo cystourethroscopy, retrograde urethrogram (RUG), voiding cystourethrogram (VCUG), or ultrasound urethrography to establish the diagnosis. (See 'Diagnosis' above.)
●We recommend antibiotic prophylaxis prior to cystourethroscopy or surgery for the treatment of urethral strictures (Grade 1A). Antibiotics for routine cystoscopy without urinary tract manipulation (eg, dilation) are not necessary. Patients with colonization or symptomatic urinary tract infection should be treated and instrumentation or surgery delayed until the urine is clear. Sterile urine should be verified prior to the procedure. (See 'Preparation' above.)
●Several endoscopic (ie, minimally invasive) techniques, including dilation with balloons or serial axial dilators (filiforms and followers), cold knife incision, incision with electrocautery or laser, and self-catheterization (ie, self-calibration), can be attempted as the initial treatment of short (<1 cm) bulbar or meatal urethral strictures (algorithm 1). (See 'Urethral dilation' above.)
●For patients with a short (<1 cm) bulbar or meatal urethral stricture, we suggest a single endoscopic intervention prior to surgical reconstruction, rather than no endoscopic intervention (Grade 2C). Patients who fail the endoscopic intervention or have strictures in any part of the urethra other than bulbar should undergo surgical reconstruction (algorithm 1). (See 'Endoscopic management of bulbar or meatal strictures' above.)
●For men with long strictures, an obliterated urethral lumen, or strictures involving the posterior or pendulous urethra, urethral reconstruction provides superior outcomes. The choice of surgical technique is based upon the length of the stricture and anatomic segment of the urethra that is affected (algorithm 1). (See 'Surgical management of other strictures' above.)
●For patients who are medically unfit for extensive surgery, who refuse urethroplasty, or who have failed multiple prior repairs, suprapubic catheter and perineal urethrostomy are options of urinary diversion (algorithm 1). (See 'Noncandidates for urethroplasty treated with diversion' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge George Webster, MD, who contributed to earlier versions of this topic review.
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