Brad Figler, MD
Hunter Wessells, MD, FACS
BASICS
DESCRIPTION
• A urethral stricture is a narrowing of the caliber of the anterior or posterior urethra. Progressive scarring can cause voiding symptoms possibly urethral obstruction.
• True stricture of the female urethra is very rare.
EPIDEMIOLOGY
Incidence
Unknown
Prevalence
• Urethral strictures in Medicare: 4.5k/100k men
• Urethral strictures in VA: 274/100k men
• Posterior urethral injury in 6% of pelvic fractures and 15% of severe pelvic fractures
RISK FACTORS
• Sexually transmitted infections (STIs) (sexually transmitted diseases [STDs]), particularly gonorrhea
• Increasing age
• Some data from Medicare suggests black Americans may have higher stricture rates
• Recurrent infection
• Previous TURP or radical prostatectomy
• Catheterization (usually prolonged)
• Urethral instrumentation
• Trauma (straddle injury or pelvic fracture)
• Lichen sclerosis/balanitis xerotica obliterans (BXO)
– A chronic skin disease that shows a predilection for the anogenital area and may cause anterior urethral stenosis (1)
– Reported as the most common cause of meatal stenosis.
• Hypospadias, with or without prior repair
Genetics
No known associations
PATHOPHYSIOLOGY
• Anterior urethral strictures
– Compromised viability of corpus spongiosum secondary to trauma, inflammation or ischemia
• Posterior urethral strictures
– Pelvic fracture-associated urethral injury and related distraction defects
– Scarring following TURP or radical prostatectomy
ASSOCIATED CONDITIONS
• Trauma
• STD/STI
• Urethral instrumentation
• BPH
• Prostate cancer
• Lichen sclerosis/BXO
GENERAL PREVENTION
• Limited urethral instrumentation
• Appropriately sized instruments for transurethral procedures
• STD/STI prevention and early treatment (gonorrhea most common)
DIAGNOSIS
HISTORY
• Voiding symptoms
– Hesitancy
– Reduced stream
– Post void dribbling
– Spraying or split stream
– Incontinence
– Retention
• Prior surgery
– Transurethral surgery or manipulation
– Hypospadias repair
• Trauma
• STD/STI
– Urethral discharge
• Recent or remote urinary tract infection
• Prostatitis
• Lichen sclerosis/BXO
• Urinary retention
PHYSICAL EXAM
• Palpable bladder with retention
• Lichen sclerosis/BXO
– Hyperkeratosis, meatal stenosis
– Thickened foreskin with glandular adhesion
• Examination of foreskin
• Abundance and quality of penile skin
• Palpable fibrosis of corpus spongiosum
• Evidence of discharge
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis, urinary culture
• Gonorrhea swab
• Uroflowmetry
– Significant strictures will have flow rates <10 mL/s (normal, >20 mL/s)
• Post void residual urine to evaluate for retention
Imaging
• RUG (anterior urethra)
• VCUG or antegrade urethrography through suprapubic catheter (posterior urethra)
• Sonography
Diagnostic Procedures/Surgery
Urethroscopy with flexible cystoscope or hysteroscope may be helpful
Pathologic Findings
• Fibrotic narrowing composed of dense collagen and fibroblasts.
• Squamous metaplasia is common
DIFFERENTIAL DIAGNOSIS
• Benign or malignant prostatic obstruction
• Urethral carcinoma
• Urethral abscess
• Functional bladder disorder
TREATMENT
GENERAL MEASURES
• Often detected with episodic urinary retention or with the inability to pass a catheter
• Treatment depends on stricture location, length, caliber, and whether previous treatment was attempted
• No role for primary medical management of urethral stricture disease
MEDICATION
First Line
Urinary tract infections should be treated before any intervention
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Dilation and direct vision internal urethrotomy (DVIU)
– Dilation, cold DVIU, laser DVIU equivalent results
– Minimally invasive and easy to perform
– Effective for short (<1 cm), large caliber (>15 Fr) strictures in which dilation or DVIU have not been previously attempted
– Use sparingly in long, narrow or refractory strictures; these will not be cured with DVIU
– Techniques
Dilation: Balloon, sounds, filiform, and followers
DVIU: Incise at 12:00 to limit bleeding
For balloon and DVIU, wire helpful
18-French Foley catheter for 48–72 h
– Urethroplasty: Anterior
Short strictures (≤2 cm) amenable to excision and primary anastomosis
Long strictures (>2 cm) require substitution with flap or graft
Long strictures with narrow segment may need combination of resection and substitution (augmented anastomosis)
Long strictures that are diffusely narrow may need staged urethroplasty with substitution (Johanson urethroplasty)
• Urethroplasty: Posterior
– Typically, excision and reapproximation required
– Techniques used to bridge defect:
Urethral mobilization
Corporal separation
Inferior pubectomy
Supracrural rerouting
• Grafts
– Buccal mucosa widely used; favorable outcomes
– No difference in success rates with ventral/dorsal graft position
• Lichen sclerosis urethral reconstruction
– One-stage or staged repairs using oral mucosa grafts are the most recommended
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Intermittent catheterization for 3–6 mo in select cases may improve patency rates
• Suprapubic placement is selected cases with inability to pass catheter or postoperatively following open repair
• UrolumeTM stent approved for short bulbar urethral strictures; no longer manufactured
• MemokathTM stent may be useful after dilation or DVIU; not currently approved in the United States (2).
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Dilation/DVIU:
– 75% long-term success rate for short (<1 cm), wide-caliber (>15-French) and non-refractory stricture
– Minimal long-term efficacy for long, narrow or refractory stricture
• Urethroplasty
– 90–95% long-term success rate for excision and primary anastomosis
– 85% long-term success rate for substitution urethroplasty
COMPLICATIONS
• Immediate
– UTI
– Bleeding
– Urinary leak and/or fistula
– Lower extremity compartment syndrome
• Delayed
– Postoperative erectile dysfunction may occur, but recovers by 3 mo
– Stress incontinence is rare, but can occur if internal and external sphincters are damaged—either prior to or at time of urethroplasty
– Post-void dribbling
– Bleeding
– Urethrocutaneous fistula
– Penile curvature
FOLLOW-UP
Patient Monitoring
• Recurrence most likely within 1 yr
• Uroflowmetry, PVR, and AUA-SS sufficient to monitor for recurrence; cystoscopy optional
Patient Resources
• MedlinePlus: Urethral Stricture.http://www.nlm.nih.gov/medlineplus/ency/article/001271.htm
REFERENCES
1. Palminteri E, Brandes SB, Djordjevic M. Urethral reconstruction in lichen sclerosus. Curr Opin Urol. 2012;22(6):478–483.
2. Jordan GH, Wessells H, Secrest C, et al. ; United States Study Group. Effect of a temporary thermo-expandable stent on urethral patency after dilation or internal urethrotomy for recurrent bulbar urethral stricture: results from a 1-year randomized trial. J Urol. 2013;190(1):130–136.
ADDITIONAL READING
• Jordan GH, McCammon KA. Surgery of the penis and urethra. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 36.
• Lumen N, Oosterlinck W, Hoebeke P, et al. Urethral reconstruction using buccal mucosa or penile skin grafts: Systematic review and meta-analysis. Urol Int. 2012;89(4):387–394.
See Also (Topic, Algorithm, Media)
• Balanitis Xerotica Obliterans/Lichen Sclerosis et Atrophicus
• Lower Urinary Tract Symptoms (LUTS)
• Sexually Transmitted Infections (STIs) (Sexually Transmitted Diseases [STDs])
• Urethra, Trauma (Anterior and Posterior)
• Urethral Stenosis/Stricture, Female
CODES
ICD9
• 598.00 Urethral structure due to unspecified infection
• 598.1 Traumatic urethral stricture
• 598.9 Urethral stricture, unspecified
ICD10
• N35.9 Urethral stricture, unspecified
• N35.014 Post-traumatic urethral stricture, male, unspecified
• N35.119 Postinfective urethral stricture, NEC, male, unsp
CLINICAL/SURGICAL PEARLS
• Direct vision internal urethrotomy (DVIU) is effective for short, wide-caliber, non-refractory strictures; otherwise non-curative.
• Excision and primary anastomosis for strictures <2 cm.
• Buccal mucosa is excellent graft; success rate similar for dorsal or ventral graft position.
• Recurrences most likely within 1 yr.
• Flow/PVR and AUA-SS sufficient for monitoring postoperatively.