INTRODUCTION — Strictures of the adult male urethra are relatively common. The clinical manifestations, diagnosis, and management of male urethral strictures are discussed here. The diagnosis and treatment of other lower urinary tract diseases are discussed in other topics. (See "Lower urinary tract symptoms in males" and "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis" and "Acute urinary retention" and "Approach to infectious causes of dysuria in the adult man".)
Traumatic posterior urethral injury is briefly mentioned here but is discussed in much more detail in another topic. (See "Posterior urethral injuries and management".)
Urethral strictures as a complication of female-to-male transgender surgery are reviewed separately. (See "Gender-affirming surgery: Female to male", section on 'Urologic complications'.)
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 typically causes injuries to the bulbar and penile 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 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.
ETIOLOGY — The most common etiology of male urethral strictures is idiopathic in resource-abundant countries and trauma in resource-limited countries [1]. Iatrogenic injuries, such as oversized rigid endoscope at the time of transurethral surgery, previously performed endoscopic intervention for bladder outlet obstruction and enlarged prostate [2,3], sexually induced trauma such as penile fractures [4], and traumatic placement of indwelling urinary catheters, account for 45 percent of all cases [5]. Other causes of urethral strictures include infection (including sexually transmitted disease), hypospadias, inflammatory skin conditions (most commonly lichen sclerosus), and radiation therapy (table 1) [6,7].
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 [5].
CLINICAL MANIFESTATIONS — Most patients with a urethral stricture present with chronic obstructive voiding symptoms, such as decreased urinary stream and incomplete bladder emptying. In other patients, urinary obstruction can occur acutely without significant warning, requiring emergency urinary drainage procedures. 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 [8].
In a study of 214 males with anterior urethral strictures, the most common presenting complaints were weak stream (49 percent) and incomplete bladder emptying (27 percent) [9]. 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 American Urological Association symptom scores have been validated for some conditions (eg, prostatic hypertrophy, lower urinary tract symptoms) but not specifically for urethral stricture disease. Newer questionnaires are currently in validation studies, and the initial indications show that these may significantly help in the diagnosis of male urethral strictures [10-12].
The Trauma and Urethral Reconstruction Network of Surgeons (TURNS) has developed the Urethral Stricture Symptom Impact Measure (USSIM) [13] based upon qualitative interviews to evaluate the most important symptoms to patients who had urethral stricture disease. The initial tool contained 40 questions, but once validated, the final USSIM short form will only have 13 questions.
The clinical features, diagnosis, and differential diagnosis of lower urinary tract diseases are further discussed in other topics. (See "Lower urinary tract symptoms in males" and "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis" and "Acute urinary retention" and "Approach to infectious causes of dysuria in the adult man".)
DIAGNOSIS — Urethral stricture should be suspected in patients 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 [1]. (See "Lower urinary tract symptoms in males", section on 'Noninvasive studies'.)
Patients suspected of having a urethral stricture should undergo cystourethroscopy, retrograde urethrogram (RUG), voiding cystourethrogram (VCUG), and/or ultrasound urethrography to establish the diagnosis [1]. The same studies, especially RUG, also help define the location and length of the stricture to guide treatment. (See 'Diagnostic evaluation' below.)
Diagnostic evaluation — Noninvasive studies, such as uroflowmetry and PVR, can narrow down the differential diagnosis but cannot definitively diagnose a urethral stricture. Imaging and/or endoscopic studies are required for the diagnosis and to define the location, length, and severity of the strictured segment for the treatment.
●Noninvasive studies – With noninvasive studies, such as uroflowmetry and 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 specific, since a low flow rate can also result from poor detrusor function. Furthermore, prostatic and urethral disease need to be differentiated from one another by a diagnostic test (eg, RUG, VCUG, cystourethroscopy, or ultrasound urethrography). (See "Lower urinary tract symptoms in males", section on 'Noninvasive studies'.)
●Imaging – The initial diagnosis of urethral stricture is often made with an RUG (image 1A-C). RUG alone is often all that is needed to define the extent of the stricture disease. For patients in whom a suprapubic tube was placed for urinary retention, a VCUG can be performed through the tube to better define the urethral stricture.
Some authors have advocated the adjunctive use of ultrasound and magnetic resonance imaging (MRI) 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 [14,15]. However, we have not found ultrasound and MRI to be of significant value in diagnosis or preoperative surgical planning.
●Cystourethroscopy – 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 [1]. Alternatively, antegrade cystourethroscopy can also be performed through the suprapubic tract. In that case, the bladder should also be examined for calculi, which can be associated with long-term bladder outlet obstruction.
DIFFERENTIAL DIAGNOSIS — Other urological conditions can present with similar symptoms to those of urethral stricture, making the diagnosis difficult (see "Lower urinary tract symptoms in males", section on 'Symptoms' and "Lower urinary tract symptoms in males", 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 "Lower urinary tract symptoms in males", section on 'Voiding'.)
●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 males", section on 'Storage' and "Lower urinary tract symptoms in males", section on 'Invasive diagnostic studies'.)
MANAGEMENT
Indications for treatment — 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 [1].
Asymptomatic patients may not require treatment but should be followed clinically, as strictures may progress and/or potentiate long-term complications such as urinary retention, bladder stones, urinary tract infections, or, more rarely, hydronephrosis, urethral fistula, or periurethral abscess [1,8,16].
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. Thus, we advocate timely intervention for symptomatic male urethral strictures; studies show that up to 16 percent may develop complications (eg, urinary retention, infection) while waiting for a urethroplasty [17].
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 (ie, urethroplasty). No single procedure is appropriate to manage all strictures, and multiple techniques may be used in the same patient if the stricture recurs.
The approach to the treatment of urethral stricture disease depends upon the number of presenting symptoms and the length, location, severity, and etiology of the stricture (algorithm 1) [1]:
●For short (<1 cm) bulbar or meatal urethral strictures, initial endoscopic treatments may be attempted once but are rarely repeated. (See 'Endoscopic management of bulbar or meatal strictures' below.)
●For long strictures (>2 cm), an obliterated urethral lumen, or strictures involving the posterior or pendulous urethra, urethroplasty provides superior outcomes compared with endoscopic management. (See 'Urethroplasty' below.)
●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. (See 'Urinary diversion' below.)
The treatment of penile disease due to lichen sclerosus is discussed elsewhere. (See "Balanitis in adults".)
Preparation
Antibiotics — For most patients undergoing urethroplasty, we suggest antibiotic prophylaxis with a single dose of cefazolin to minimize the risk of postprocedure infection (table 3). Other antibiotics that cover mostly gram-negative enteric pathogens and enterococci, including cefoxitin, cefotetan, and ampicillin-sulbactam, are reasonable alternatives. Antibiotic prophylaxis is administered as a single dose within one hour of the procedure. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
This approach is not based on high-quality evidence but rather indirect evidence from the use of antibiotic prophylaxis for other genitourinary procedures. The incidence of perioperative infectious complications (eg, urinary tract infections and surgical site infections) associated with urethroplasty is unknown. Thus, the use of a single dose of prophylactic antibiotics is based on a desire to reduce perioperative complications and to limit antimicrobial exposure.
Patients with symptoms suggestive of a urinary tract infection should be tested prior to the procedure and treated if appropriate [18]. Our approach to antimicrobial prophylaxis is consistent with recommendations by the American Urological Association [19].
Bladder decompression — Patients with long-standing symptoms who have maintained urine flow are generally able to decompress their bladders adequately. However, patients who present with acute urinary retention may require retrograde stricture dilation and catheter placement or placement of a suprapubic tube for complete bladder decompression [1]. At times when urologic expertise to treat the urinary retention 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'.)
Diversion with a suprapubic tube promotes "urethral rest" to let the stricture attain its natural position and length. This allows the most appropriate surgical management and ensures treating the entire length of the stricture and therefore possibly reducing recurrence rates. While some authors argue that this should be done in every patient with initial presentation of urethral stricture prior to definitive repair, others utilize this approach only for patients with chronic indwelling urethral catheters or those who undergo periodic self-catheterization per urethra [20].
Defining the stricture — Prior to treatment, the location, length, and severity of the strictured segment must be defined by radiographic and endoscopic studies. (See 'Diagnostic evaluation' above.)
Several scoring systems are available to grade urethral strictures based on the retrograde urethrogram [21,22]. One such system developed and validated by the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) grades urethral strictures on their length, location, and etiology and may contribute to the surgeon's ability to not only direct the type of treatment required but also predict treatment outcomes and recurrences [23].
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. (See "Posterior urethral injuries and management".)
Endoscopic management of bulbar or meatal strictures — Several 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 [24,25].
However, the entire group of endoscopic options should mainly be considered as a single initial therapy and rarely repeated; some urologists will attempt a second endoscopic procedure with local steroid injection. Patients who fail one endoscopic treatment should be offered surgical reconstruction, rather than repeated endoscopic interventions, as the latter option is ineffective and can be counterproductive, often leading to longer, more complex strictures that ultimately require more involved reconstructive techniques [1,26,27]. 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 [28].
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 [29,30].
●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.
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 [31].
●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 [32].
Urethrotomy can be performed safely in the office setting using a penile block or in an ambulatory setting with local, spinal, or general anesthetic [28,33,34]. 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 up to surgeon preference since outcomes are similar regardless of method. (See 'Endoscopic outcomes' 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 [35]. Mitomycin injection after direct vision internal urethrotomy did not appear to have a significant effect on recurrence stricture rate either [36-38]. Furthermore, this technique has been associated with significant side effects such as worsening stricture, extravasation with necrosis of urethra, and pain issues [39].
●Investigational techniques – One group from Russia described a urethral nickel titanium stent for managing stricture disease after failed urethroplasty. While the results may be encouraging, this has only been used in a small number of patients to date with very short-term follow-up [40]. Other groups have developed a paclitaxel-coated balloon system used to dilate strictures and deliver medication directly to the diseased area to prevent recurrence. Initial experience with this treatment modality seems to be safe, and it may offer a promising alternative to other endoscopic and open surgical reconstructive techniques, especially for patients who are not fit for or decline to undergo open reconstructive surgery. However, results of randomized controlled trials as well as long-term follow-up are still required [41-43].
Endoscopic outcomes — The advantage of endoscopic methods is that they are quick, widely available, and safe. However, such methods are associated with high recurrence rates that range from 30 to 80 percent [44-46]. 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 [45]. 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 [32,44,45,47].
It is generally accepted that for short (<1 cm) bulbar strictures, a single initial endoscopic urethrotomy is cost effective and should be included in the initial treatment algorithm for an appropriate male urethral stricture (algorithm 1) [1,46,48-53]. Although it has also been suggested that multiple endoscopic treatments may predispose to a more difficult definitive open repair and reduced overall success rates [54-56], our experiences, as well as those of others, have shown that a failed urethrotomy does not predict the outcomes of a future urethroplasty but could render the procedure more complex [26,27].
Urethroplasty — For long strictures (>2 cm), 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).
Surgical reconstruction or repair of the urethra (ie, urethroplasty) involves varying degrees of stricture incision or excision with or without augmentation using a flap or graft of autologous tissue. Specific surgical techniques that are most appropriate for each of the segments of the urethra are described in detail below.
The potential effects of the chosen surgical technique on erectile function are important to consider. Penile elongation during erection requires surgical repairs of the penile urethra to 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.
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 [57]. 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 [58]. The mouth donor site heals quickly with minimal morbidity and complications, and thus oral grafts are the graft tissue of choice for urethral reconstruction [59,60]. The risk of oral donor site complications is increased in smokers, tobacco chewers, and others with poor oral hygiene [61].
Various techniques are described to harvest buccal mucosal grafts with either a closure of the harvest site or leaving it open to heal by secondary intention. Both techniques have similar outcomes for pain and overall functionality as well as complication rates. A randomized controlled trial comparing the two techniques showed no overall difference between leaving the harvest site open or closing it [62].
Penile or scrotal skin can be used as flap tissue for onlay reconstruction but is less desirable when used as a urethral graft due to failure rates of 20 to 30 percent [57,63]. Bladder mucosa is another alternative, but harvest requires laparotomy and more prolonged recovery [64]. 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 [65,66]. The dorsal graft bed is well vascularized (from the corporal bodies) and inelastic, which prevents pseudodiverticulum formation [67]. 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 [67]. 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 [68-71].
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 (figure 1) 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 [72]. 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 [73-80]. The flap-based repair has fallen out of favor because of the increased utilization of free buccal grafts for this type of repair. However, both techniques have good outcomes with minimal morbidity and can be employed at the surgeon's discretion [81]. Endoscopic management in the pendulous urethra should be avoided because of poor outcomes, including high recurrence rate [1].
Penile urethroplasty 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.
Males with a circumcised penis usually have ample penile skin that allows harvesting of a longitudinal flap of sufficient width to lay over the stricture [82]. In uncircumcised men, a transverse flap of foreskin is an alternative source of onlay tissue, but the dissection is more challenging. 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.
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 [63,83].
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 [84]. A newer technique of a nontransecting urethroplasty removes just the scarred mucosa but leaves the sponge tissue connected to maintain antegrade and retrograde blood flow for better healing and preservation of erectile function. While the initial results of this newer technique are good [85], long-term follow-up data are needed for it to be compared with the conventional technique [86].
●For strictures measuring 2 to 4 cm (image 1B), excisional augmented anastomotic urethroplasty is used (figure 4) [83]. 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 (figure 3), which requires excision of the tightest part of the stricture and augmented anastomosis utilizing penile skin or buccal tissue graft [57]. In our experience, the excisional augmented anastomotic urethroplasty has excellent long-term results. 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 chordee with erection [83,87].
The steps outlined above are our preferred approach to bulbar urethral strictures [88]. Other centers only perform onlay repairs and avoid transecting the urethra or removing any spongiofibrosis out of concern 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 [88-90].
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 'Endoscopic management of bulbar or meatal strictures' above.)
●Stricture of the membranous urethra is due to iatrogenic or traumatic injury. Traumatic injury to the posterior (prostatomembranous) urethra occurs in approximately 10 percent of pelvic fractures [91]. The severity of the traumatic injury determines the severity of the urethral defect, ranging from elongation without disruption of the urethra to complete transection (table 4 and picture 2). 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. The management of a posterior urethra injury is further discussed in a dedicated topic. (See "Posterior urethral injuries and management", section on 'Our approach'.)
Urethroplasty 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 [92]. 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 [93].
At follow-up, patients who have had a straightforward anastomotic repair can have the Foley catheter removed with voiding trial without any further imaging [93]. Patients who have had an augmented repair using 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 in these patients, who should be followed closely for possible recurrence [93-95].
The patient should again be seen at three to six months after surgery for a patient-reported outcomes questionnaire (American Urological Association symptom score (table 2)), physical examination, uroflow test, and cystoscopy, followed by patient-reported questionnaire and uroflow test at 12 to 15 months, and then annually [1,10,96,97]. After the three- to six-month visit, cystoscopy is performed when there is a change in the flow or other new symptoms.
Urethroplasty outcomes
●Patient satisfaction – Despite the fact that urethroplasty can be a challenging and difficult procedure, patient satisfaction is high [98]. Following urethroplasty, there is generally an improvement in patient-reported genitourinary pain and urinary symptoms [99-102] with either preserved or improved erectile function [103,104]. In one study, urethroplasty has also been associated with improvement in patients' anxiety and depression symptoms [105].
●Failed repairs – The definition of a failed urethroplasty has evolved from being purely anatomic [106] to being based on a combination of anatomical and symptomatic indices [11-13,96,107].
The overall failure rate was 15 percent in a study involving 252 males (median follow-up 37 months) [108]. By techniques, 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 [109].
By stricture locations, representative failure rates 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 [72].
•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 [73-77].
•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 [45,83,84,108,110-112].
•Posterior urethroplasty has similarly high success rates (>90 percent).
Complication rates for definitive surgical urethral stricture repair are low. The most common complications include urinary leak, urinary tract infections, and wound issues [113].
●Recurrences – 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) [114].
In a retrospective review of 258 urethroplasties performed in 11 institutions, patients older than 60 did not have more recurrent strictures or require more repeat procedures than patients younger than 60 [115]. Stricture length was the only independent predictor of surgical success. Thus, older age alone should not be used to exclude patients from urethroplasty.
Urinary 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 (algorithm 1) [111]:
●Suprapubic catheter – For those who are unfit for surgery, chronic suprapubic tube management may be the only option. A suprapubic catheter can be used for temporary or permanent urinary diversion and may be used in emergency situations such as acute urinary retention [1]. 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 patients who wish to avoid complex or staged urethral reconstruction (especially older males), an alternative solution to a permanent suprapubic catheter is urinary diversion using a perineal urethrostomy.
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 (picture 3). 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.
Perineal urethrostomy is a good option for patients with extensive or recurrent strictures [116] and/or those who are already accustomed to voiding while seated [1]. It is a simple solution that may improve quality of life [111]. In a study of perineal urethrostomy as the first stage of a planned urethroplasty, half of the patients were satisfied and chose to forego further reconstruction [117].
Long-term studies show that perineal urethrotomy has similar long-term success rates as multistage and complicated reconstruction without negatively impacting sexual function [118]. Many international groups have verified patient satisfaction with the perineal urethrotomy as a definitive treatment for complex urethral stricture [111,119].
●Supravesical 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".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Genitourinary tract trauma in adults".)
SUMMARY AND RECOMMENDATIONS
●Strictures of the male urethra are common and are most often due to trauma or instrumentation of the urethra. Other frequent causes of urethral stricture are idiopathic and infectious (table 1). (See 'Introduction' above and 'Etiology' above.)
●The male urethra is divided into two major segments, the anterior urethra and the posterior urethra (figure 1). 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.)
●Stricture of the male urethra should be suspected in patients 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.)
●For most patients undergoing urethroplasty for urethral strictures, we suggest antimicrobial prophylaxis with a single dose of cefazolin (Grade 2C). Patients with symptomatic urinary tract infection should be treated prior to endoscopic or open surgery. (See 'Preparation' above.)
●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; there is no absolute contraindication to treating urethral strictures. Asymptomatic patients who do not require treatment should be followed clinically, as the strictures may progress and/or potentiate long-term complications. (See 'Indications for treatment' above.)
●No single procedure is appropriate to manage all strictures, and multiple techniques may be used in the same patient if the stricture recurs. The approach to the treatment of urethral stricture disease depends upon the number of presenting symptoms and the length, location, severity, and etiology of the stricture (algorithm 1) (see 'Treatment options' above):
•For short (<1 cm) bulbar or meatal urethral strictures, 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 urethroplasty. (See 'Endoscopic management of bulbar or meatal strictures' above.)
•For long strictures (>2 cm), an obliterated urethral lumen, or strictures involving the posterior or pendulous urethra, we suggest surgical reconstruction rather than endoscopic intervention (Grade 2C). (See 'Urethroplasty' above.)
•Patients who are medically unfit for extensive surgery, wish to avoid complex or staged urethral reconstruction, or have failed multiple prior attempts of urethral reconstruction may choose one of the urinary diversion options. (See 'Urinary diversion' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges George Webster, MD, who contributed to earlier versions of this topic review.
