Continuing Education Activity

Urethral strictures represent a common yet often overlooked urological condition characterized by the narrowing of the urethra, which can lead to various urinary symptoms and complications. This condition is caused by many etiologies and can vary in severity. Urethral strictures can have a significant impact on patients' quality of life. Understanding the basics of urethral strictures is essential for health care professionals to diagnose, treat, and manage this condition effectively. The latest insights, best practices, and multidisciplinary approaches are vital to improving patient outcomes and safety. Public education and prevention efforts regarding urethral strictures are crucial to raise awareness and reduce the incidence. This activity describes the most current information on the etiology, evaluation, and management of urethral strictures. It also highlights the role of the interprofessional team in providing comprehensive and high-quality care for patients with this challenging condition.

Objectives:

• Differentiate between types of urethral strictures, including anterior and posterior strictures, based on clinical presentation, etiology, and anatomical location.

• Screen patients at risk for urethral strictures by evaluating relevant medical history, symptoms, and risk factors, such as prior urethral trauma, urinary tract infections, or instrumentation.

• Apply evidenced-based non-surgical interventions and surgical approaches for the management of urethral strictures.

• Collaborate with an interprofessional team to facilitate accurate diagnosis and comprehensive treatment planning for patients with urethral strictures.

Introduction

A urethral stricture is a narrowing of the urethra, causing obstructive symptoms. These strictures usually result from injury to the urethral mucosa and tissues around it. It is a common condition resulting in many office appointments, emergency room visits, and hospital admissions.[1] Urethral strictures can occur in both sexes but are rare in women, so guidelines are lacking with regard to diagnosing and treating female strictures.[2] 

In males, strictures can develop anywhere along the length of the urethra but are most often found in the bulbar urethra and can be due to many etiologies.[3] The male urethra is divided into anterior (from the external urethral meatus to the distal membranous urethra) and posterior (from the distal membranous urethra to the bladder neck) portions.[4][5] The urethra is contained within the corpus spongiosum, which lies in a groove below the two corpora cavernosa. The inside of the urethra is lined with stratified squamous epithelium[5][6]. Anterior strictures comprise 92.2%, with most occurring in the bulbar urethra (46.9%), followed by the penile urethra (30.5%), a combination of the bulbar and penile urethras (9.9%), and finally, panurethral strictures (4.9%).[7]

The 2002 World Health Organization Conference recommended a more specific descriptive nomenclature in which the urethra is broken up into 7 segments; the urethral meatus, followed by the fossa navicularis, penile (or pendulous), bulbar, membranous, and prostatic urethra, and lastly, the bladder neck.[8]

Etiology

The etiology of urethral strictures is divided into 4 major groups; idiopathic, iatrogenic, inflammatory, and traumatic, with idiopathic and iatrogenic being the most common at 33% each. Next are the traumatic causes comprising 19%, and inflammatory, producing 15%, although infection may account for up to 26.6% of all patients undergoing urethroplasties as the strictures tend to be relatively long (usually >4 cm.)[9][10]

The etiology of urethral stricture disease varies significantly in different regions around the world. Infection was the primary reported etiology of urethral strictures in Nigeria (66.5%) but only responsible for 15.2% of cases in Brazil.[3][7][11][12]

Idiopathic causes are the most common etiology of urethral strictures in Western countries (41%), followed by iatrogenic (35%), usually as sequelae from urethral surgery or transurethral procedures. Trauma tends to be the most common cause of strictures in low-income regions. This is due to higher rates of traffic accidents, less developed infrastructure, and underdeveloped trauma systems.[5]

Regarding idiopathic causes, some clinical features point towards them being caused by unrecognized repetitive minor perineal traumas, eventually leading to the stricture.[13]

Iatrogenic causes are divided into five categories.

1. Transurethral resections (TUR) comprise 41% of all iatrogenic strictures.[9] During these procedures, relatively large instruments are repeatedly passed in and out of the urethra, leading to varying degrees of epithelial injury from urethral stretching and dilation.[14] This urethral mucosal injury eventually leads to stricture formation. 

2. Prolonged catheterization (36%) exerts pressure on the urethra leading to pressure necrosis of the urothelium and rubbing or frictional injury to the urethral mucosa from catheter motion.[9] Changes in the materials used for making and designing catheters (using silicone instead of latex) have helped reduce the incidence of strictures. Strictures may also occur after prolonged periods of intermittent catheterization.[8] 

3. Cystoscopy (12.7%) and simple Foley catheterization can also cause an injury to the urethral epithelium leading to strictures.[9] Inadvertent or inappropriate unplanned Foley catheter extractions may also result in urethral trauma resulting in stricture formation. Such unplanned removal of Foley catheters by confused patients is largely preventable using a variety of nursing initiatives, techniques, and procedures described elsewhere, which are highly recommended.[15] See our companion StatPearls reference article on "Prevention of Inappropriate Self-Extraction of Foley Catheters."[15]

4. Hypospadias repair causes 6.3% of iatrogenic strictures.[9] Children who undergo such a repair have a 10% risk of developing urethral strictures later in life.[8] 

5. Radical prostatectomy (3.2%) is another cause of urethral strictures.[9] Urethral strictures complicate the cases of 8.4% of men undergoing prostate cancer treatment, including prostatectomy, radiotherapy, and chemotherapy, causing stricture formation in the posterior or bulbar urethra and bladder neck.[16] Of these, bladder neck contractures are the most common.[12][17] The direct cause is not clearly understood but is thought to be due to instrumental injuries during the procedure, inflammation, a narrow bladder neck closure, lack of mucosal apposition, or postoperative bladder neck stenosis in the case of radical prostatectomy surgery.[3][7] 

An extensive series of patients (almost 18 000) undergoing radical prostatectomy surgery at the Mayo Clinic over 20 years indicated a postoperative bladder neck stricture developed in about 5%. This incidence was reduced in patients receiving a complete nerve-sparing procedure and using a robotic surgical approach.[18] 

Radiation therapy also raises the urethral stricture risk, particularly brachytherapy, and the risk goes up as the radiation dose increases.[7][19][20][21][22]

Inflammatory strictures can result from postinfectious inflammation leading to the narrowing of the lumen and weakening of the epithelium, most commonly from recurrent gonococcal urethritis. These causes are becoming less common in the developed world due to improved public health measures and education, but are still common in developing countries.[1] The connection of other infectious causes to urethral strictures is still unclear. There are suggestions that chlamydia, tuberculosis, and schistosomiasis can cause postinfectious inflammation and subsequent urethral stricture development.[8] Recurrent urinary tract infections (UTIs) can also cause urethral strictures, with the most isolated microorganism being Escherichia coli.[3] 

Lichen sclerosis (also known as balanitis xerotica obliterans) is another relatively common cause of inflammatory urethral and meatal strictures.[23] The cause and pathophysiology of the disease remain unclear; however, there is a possible genetic predisposition and an autoimmune factor. Lichen sclerosis presents as pale, ivory lesions on the glans around the urethral meatus or vulva and surrounding the anus.[23][24] The lesions can extend into the urethral meatus and cause obstructive symptoms, leading to high-pressure voiding against a narrowed urethra and causing further damage to the urothelium.[8][23] Strictures from lichen sclerosis and those related to hypospadias repairs are typically found in the meatus, fossa navicularis, or penile urethra.[5][11]

Inflammatory urethral strictures due to infection typically only affect the anterior urethra and do not generally cause posterior urethral strictures.[1] Also, these strictures are usually significantly longer than the ones caused by other etiologies and therefore are more likely to require a urethroplasty.[9][25]

Post-traumatic anterior urethral strictures most commonly affect the bulbar urethra. They are frequently due to straddle injuries compressing the bulbar urethra against the symphysis pubis.[26][27] This pattern of injury is rarely associated with a pelvic fracture. Penile urethral strictures due to trauma are rare but can happen following a penile fracture.[1] Significant trauma leading to a pelvic fracture causes strictures almost exclusively in the bulbar or membranous urethra (the etiology of almost 70% of membranous strictures is a traumatic pelvic fracture) as they are the most common site of injury in these scenarios.[3] 

Although only a relatively small fraction of people who sustain a pelvic fracture develop a stricture (3% to 25%), 84% of patients with a traumatic posterior stricture have had a pelvic fracture.[1] Post-traumatic urethral strictures tend to be short, with most of them <4 cm in length.[3]

Epidemiology

Urethral strictures are common, with a prevalence in the US being around 200/100 000 in younger men and more than 600/100 000 in men older than 65.[10] Urethral strictures are more common in older individuals and blacks than in the general population. There is a marked increase in incidence starting at age 55 years.[28] The estimated annual incidence rate in the US is 0.9%.[1] 

Male urethral strictures account for 5000 hospital admissions annually and 1.5 million clinic visits.[7][28] In The UK, the prevalence is considerably less, estimated at 40/100 000 in men up to 65 years of age and 100/100 000 in men older than 65 years.[14] 

Worldwide, it is estimated that male urethral strictures have a prevalence of 229 to 627/100 000.[29]

Pathophysiology

The pathophysiology of urethral stricture is an injury to the urethral epithelium attributed to any of the specific etiologies causing leakage of urine into the corpus spongiosum or by direct trauma to the corpus spongiosum. Either of these etiologies initiates inflammation and fibrous changes in the corpus spongiosum. This fibrous tissue builds up and shrinks, causing contraction and compressing the urethral lumen.[7] 

Metaplasia of the urethral epithelium to stratified squamous epithelium occurs, which is more affected by pressure changes and stretch trauma, causing tears in the mucosa, leading to further urinary leakage into the outer corpus spongiosum, which promotes fibrous changes and stricture formation.[14] This process causes a vicious cycle of strictures and urethral injuries leading to progressive and worsening narrowing of the urethra.[1]

History and Physical

A urethral stricture should be considered in any male patient presenting with unexplained dysuria, a weak urinary stream, incomplete emptying, increased post-void residual urine volume, or a UTI.[5]

Urethral strictures typically develop slowly and result in a progressive narrowing of the urethral lumen. Symptoms are similar to those usually associated with bladder outlet obstruction from benign prostatic hyperplasia (BPH), such as a weak urinary stream, straining to void, incomplete emptying, double-voiding, intermittency, post-void dribbling, unexplained dysuria, and frequent UTIs.[10][30][31] Other presenting symptoms include acute urinary retention and/or hematuria. Overall, 70% of patients present with obstructive symptoms alone.[14]

The severity of the symptoms can vary widely among patients, especially those with a slowly progressive or discrete stricture. Some can present with the absence of any such symptoms. In such cases, the patient is likely to develop compensatory detrusor hypertrophy.

Obstructed ejaculation would be 1 symptomatic difference between BPH (absent) and urethral stricture disease (present).[10] Also, patients with urethral strictures would not respond to typical BPH therapy, such as alpha-blocker medications, and the weak urinary stream would be relatively constant without much variation. 

Following the initial history taking, additional questioning should be focused on uncovering the underlying etiology. Any history of surgical interventions, previous infections, and trauma should also be sought.[5] Finally, appropriate past medical history and comorbidities should be elucidated.[30]

Although the physical examination is usually nondiagnostic, performing a detailed exam is still important. During the physical examination, the clinician should palpate the urethra, feel for any palpable fibrous tissue, and look for skin changes like pale patches indicative of lichen sclerosis. Occasionally, these patches can be confined only to the area immediately surrounding the urethral meatus. Any scars indicating previous surgery should be identified. Examination of the prostate is very important, looking for benign prostatic hyperplasia (BPH), prostatic cancer, or prostatitis.[5][14][30]

Evaluation

The diagnosis of urethral stricture is initially suggested by the history and physical exam, urinalysis, symptomatology, post-void residual urine volume, and peak urinary flow measurements. The diagnosis is made and confirmed by cystoscopy, retrograde urethrography, or voiding cystourethrography.[5] Blood tests do not have a role in the diagnosis of urethral strictures.

Uroflowmetry is the preferred initial investigation as it provides a good noninvasive assessment of the maximum urethral flow.[5][32][33][34][35][36] Interpretation of the uroflowmetry data can help distinguish patterns of healthy individuals, benign prostatic obstruction, and urethral strictures. A peak urinary flow rate (Qmax) of <12 mL/s raises the suspicion of lower urinary tract stricture or at least obstruction.[32][33][34] It is also important to study the shape of the flow curve to differentiate the cause.[37] Urethral strictures typically produce a sharp and distinct plateau at the peak flow rate level.[32][33][34][38] Uroflowmetry studies should ideally consist of more than 150 mL in total voided volume to yield reliable and reproducible results.[30][39][40]

Post-void residual urine volume determinations can be a helpful and objective evaluation tool for bladder emptying but are not diagnostic.[41] Combined with uroflowmetry, it can help confirm a possible bladder outlet obstruction but cannot rule out detrusor hypotonicity or BPH.

Cystoscopy is a relatively easy and straightforward investigative procedure to quickly and definitively diagnose urethral strictures.[5] It can be performed expeditiously under local anesthesia (flexible cystoscopy) in the office or clinic.[5] It immediately confirms the diagnosis, avoids unnecessary delays, offers the opportunity for immediate therapy through dilation, and determines the stricture's distal location. However, it can be of limited use when the cystoscope is unable to pass through the stricture to assess its length or the state of the proximal urethra and prostate.

A smaller caliber ureteroscope can sometimes pass beyond the stricture and provide additional diagnostic information without undue urethral trauma or the need for dilatation.[42] Cystoscopy is unable to provide information about the surrounding tissue fibrosis and is, therefore, somewhat limited, but it provides a quick and definitive diagnosis.[14][30][40]

Retrograde urethrography can visualize the entire urethra up to the bladder if the patient is sufficiently relaxed. When the stricture is significant, and the retrograde urethrogram does not produce sufficient proximal urethral distention, the extent of the stricture may not be determinable.[43] In such cases, a voiding cystourethrography (VCUG) will provide this necessary and valuable additional information.[44] This can be done by asking the patient to void after the bladder is filled with contrast from the retrograde urethrogram or by introducing contrast through a suprapubic catheter.

The combination of a retrograde urethrogram and simultaneous cystogram or VCUG yields an excellent image of the entire urethra. It is particularly useful when the urethrogram shows urethral occlusion with no proximal penetration of contrast.[5][44] It provides detailed imaging and information about strictures' location, number, length, and severity. These are usually very reliable and informative diagnostic imaging tools for diagnosing and evaluating urethral strictures. 

However, there are some limitations when interpreting the images related to the location of the stricture and the state of the proximal urethra, as these radiographic techniques, even taken together, provide only a 2D image of a 3D structure.[14][30] Some studies suggest that using computed tomography (CT), voiding urethrography, or sonoelastography provides better images of the stricture and its characteristics.[44][45][46]

The most complex situations and female urethral strictures can often be best evaluated with videourodynamics, combining bladder function and emptying (urodynamics) with urethrographic imaging.[47][48] It can help identify true urethral obstruction by differentiating actual anatomical strictures from urethral dysfunction. The simultaneous finding of increased detrusor voiding pressure with radiographic evidence of urethral narrowing is highly suggestive of obstruction, such as from a stricture.[49]

A cause of concern is the unacceptably high degree of variability between individual physicians, including radiologists, in the interpretation of retrograde urethrograms with regard to precise stricture location, width, and length in a recent study. A standardized methodology for the interpretation of retrograde urethrograms is suggested.[50] A convolutional neural network machine learning program is under development which may help address this issue.[51] It is recommended that surgeons perform their own retrograde urethrograms to obtain optimal results.[52]

Ultrasonography is mainly used to assess the bladder and upper urinary tract. It can show a thickened urinary bladder wall but cannot directly visualize a stricture, although it may be able to help determine the degree of spongiofibrosis. Residual post-void urine can be seen on ultrasound, which may provide insight into the degree and significance of the obstructed urethra.[14][53] Ultrasound may visualize the strictured zones when the urethra is filled with a physiologic solution through a Foley catheter.[30]   

Some experts recommend a urethral ultrasound examination to delineate the extent of urethral spongiofibrosis and measure the length of the stricture.[54][55][56][57][58][59][60][61] This may be useful in skilled hands but is not used by most experts in urethral stricture management.[62] 

Magnetic resonance imaging (MRI) scan use in diagnosing simple urethral strictures is debatable. However, it can provide excellent images when cancer is suspected as the cause of the stricture, showing the location and extent of the tumor invading surrounding tissues.[30] It may also provide additional detail in cases of urethral strictures associated with diverticula, fistulas, unusual periurethral fibrosis, and pelvic fractures.[5] In women, an endourethral MRI combined with ultrasound and a CT scan can provide the most complete imaging of the urethra and surrounding tissues.[63][64]

Treatment / Management

General Considerations

When there are no complications, the goal of therapy would be symptom relief only. The choice should be based on symptom severity, stricture location, severity, length, and patient preference. Treatment should not be offered if the symptoms are not troublesome or objectively harmful.

If the patient presents with urinary symptoms like recurrent infections or acute retention, treatment will relieve the symptoms, reduce the incidence of complications, and minimize damage to the lower urinary tract.[14] If the diagnosis is in doubt and an infection is suspected, a clinical trial of antibiotics can be instituted. A full course of antibiotics should be utilized if this provides clinical symptomatic relief.[5]

The normal peak urine flow rate in a healthy young male is >15 mL/s. A low peak flow rate for most patients would be <12 mL/s. Patients with strictures and peak flow rates between 10 mL/s to 15 mL/s are usually asymptomatic.[38][37] Intervention is unnecessary if there is no increased bladder wall thickness or incomplete emptying.

A peak urinary flow rate of 5 mL/s to 10 mL/s is usually associated with obstructive symptoms and complications.[38][37] Treatment should only be offered to patients with troublesome symptoms or objective signs of deleterious changes in the bladder. If not, active monitoring should be undertaken with periodic reassessments.

If the flow rate is <5 mL/s, there is an increased risk of acute urinary retention, although this is uncommon.[38][37] This group of patients should be offered treatment, even if the symptoms are not significant.[53] 

Female urethral strictures are most frequently initially treated with urethral dilation, often followed by intermittent self-catheterization for maintenance of urethral patency, but the reported recurrence rate is high at >50%.[49][65] 

Female urethroplasties using buccal grafts or vaginal flaps offer the best outcomes (90% success rate) compared to repeated urethral dilations or endoscopic therapy.[2][5][65][66][67][68][69][70] Such cases are rare, and female urethral reconstructive surgery is complex, so a referral to a specialty-trained urologist at a center of excellence is recommended for women requiring a urethroplasty.[71]

Urgent treatment of a urethral stricture for urinary retention or other acute complications may include urethral dilation, cystoscopy, a direct vision internal urethrotomy, or a suprapubic cystostomy.[5] Going directly to a suprapubic cystostomy avoids further urethral trauma and patient discomfort. It can also provide a urethral rehabilitation and healing period (urethral rest) before a more definitive procedure such as a urethroplasty.[5][72][73] 

Such a urethral rest period is typically 4 to 6 weeks long. This allows the stricture to mature for more accurate imaging and tissue healing.[5] Any existing UTI should be treated with appropriate antibiotics. Once the emergency situation is dealt with and stabilized, definitive treatment for the stricture can be safely undertaken.[40]

Urethral stricture therapies can generally be divided into endoscopic (urethral dilation, internal urethrotomy) and open surgical procedures (stricture resection and anastomosis, urethroplasty, and perineal urethrostomy). The stricture's length and exact location should be determined before deciding on a definitive intervention.[5] It should also be noted that with any treatment options, recurrences tend to occur, especially with long (>4 cm) strictures and previously treated lesions.[40] Early open surgery has been suggested to provide improved outcomes compared to prolonged or repeated courses of endoscopic treatment.[74]

Urethral dilation using sounds and boogies has been the standard initial treatment modality for a long time. Inserting urethral dilators and sequentially increasing the size leads to tissue stretching and disruption or widening of the stricture. A guide wire is suggested when performing urethral dilations, especially for tight strictures. Goodwin metal sounds are also recommended, as they are designed to work over guide wires and have a gentle taper. This gives them a substantial mechanical advantage to successfully dilate even tough strictures safely, as the guide wire prevents inadvertent urethral damage, false passage formation, and bladder injuries. See our companion StatPearls reference article on "Difficult Foley Catheterization."[75]

Compared to DVIU, urethral dilation shows no demonstrable difference regarding overall outcomes.[14][53][76] The need for retreatment within 3 years for both modalities is approximately 65%.[77]

Urethral dilation is usually performed under local anesthesia and can cause significant discomfort and bleeding. Some studies suggest that balloon dilation would exert a pure radial opening force, reducing frictional urethral trauma. Initial numbers are pointing towards fewer recurrences compared to classical methods. 

Direct vision internal urethrotomy (DVIU) is performed by making a transurethral incision at 12 o'clock to release the structure, leaving it to heal by secondary intention, increasing the caliber size of the urethral lumen. It is the first-line treatment of choice for short (<2 cm) bulbar strictures with no previous intervention, as its highest success rates are with such lesions.[5][7] Recurrence rates are high and can reach 65% within 3 years.[77] The complication rate after this procedure is 6.5%, with erectile dysfunction being the most common (5%), followed by urinary incontinence (4%), extravasation (3%), UTI (2%), and hematuria (2%).

There is a difference in opinion on whether to attempt a repeat DVIU after a recurrence of the first procedure or to go directly to a urethroplasty. Some suggest attempting a DVIU at least once more after the initial procedure, while others recommend a urethroplasty as the best option after a recurrence.[76][78] During the procedure, healthy tissue proximal and distal to the stricture is incised, resulting in a somewhat longer stricture when a recurrence happens.[40]

Both urethral dilation and DVIU should be followed by prophylactic antibiotics.[14] The Foley catheter can generally be removed after 72 hours.[5]

The American Urological Association Guideline on Urethral Strictures recommends urethral dilation, DVIU, or urethroplasty as reasonable initial therapeutic options for short (<2 cm) bulbar urethral strictures.[5]

Paclitaxel-coated urethral balloon dilation therapy with a DVIU produced markedly improved results in recurrent bulbar urethral strictures <3 cm in length compared to similar patients treated with the DVIU procedure alone.[79] Paclitaxel is commonly used to prevent arterial restenosis due to its anti-inflammatory and anti-proliferative properties. Coating a urethral dilation balloon with paclitaxel provides uniform, concentric drug delivery to the strictured urethral tissue, preventing new scar tissue growth and significantly reducing the stricture recurrence rate.[79][80][81][82][83][84]

At 1 year, those treated with the paclitaxel-coated balloon plus DVIU enjoyed an 83.2% patency rate compared to the DVIU-only group, where only 21.7% indicated continued urethral patency.[79] Three-year outcomes remained good, with 67% of treated patients reporting functional success.[80] The paclitaxel-coated urethral balloon therapy is FDA-approved for treating anterior urethral strictures, although there is minimal data on its efficacy in penile urethral strictures and no information yet on repeat treatments.[5] 

High paclitaxel levels have been measured in the semen after treatment.[79]  Therefore, men treated with paclitaxel-coated balloons should use contraception for at least 6 months after treatment if their partner is fertile.[79] Further studies and real-world experience will determine if these early but very promising results will hold up.

Regular intermittent self-catheterization following initial treatment helps maintain the patency of the urethral lumen.[5][77][85][86] For intermittent self-catheterization, a 14-French or 16-French catheter is typically used. The patient is instructed to perform a single daily catheterization initially. The interval between catheterizations is gradually lengthened until the patient encounters difficulty in passing the catheter or a satisfactory maintenance schedule is achieved (usually once or twice a month).

If the patient is unable to pass the catheter easily, the catheterization frequency is increased, or a smaller catheter is used. Intermittent self-catheterization training can be enhanced by using readily available video training aids.[87] Reduced recurrence rates were reported in patients doing intermittent self-catheterization for 4 months or longer compared with those who only did self-catheterizations for 3 months or less.[85][88][89][90][91] The optimal duration of intermittent self-catheterization for maintaining urethral patency has not been determined.

Some experts recommend continuing self-catheterization 1-2 times per month indefinitely to identify recurrences early, long before any clinically apparent urinary symptoms appear. Many patients can be successfully maintained on such a schedule, but they should be informed that a urethroplasty is a safe and effective alternative for individuals with urethral strictures otherwise dependent on intermittent self-catheterization to maintain urethral patency.[5][92]

Urethroplasties involve opening or resecting the stricture and either performing a direct anastomosis (short <2 cm bulbar strictures), using some graft material (buccal mucosa, foreskin), or a flap of normal skin as a substitute for the strictured urethral tissue. Urethroplasties can be used for longer strictures and typically have good outcomes with a high overall success rate of >85%.[93] Complications of urethroplasty are relatively uncommon and include erectile dysfunction, UTIs, fistulas, incontinence, chordee, and neuropraxia.[7] 

Recurrent strictures initially treated with either dilation, meatotomy, or a DVIU are unlikely to be cured by repeated similar procedures with an >80% reported failure rate, and a urethroplasty should be considered.[94][95][96] Urethroplasty is also considered the best treatment option for blind-ending strictures and those associated with hypospadias repairs and lichen sclerosis. The American Urological Association Guideline recommends that patients needing a urethroplasty be referred to surgeons and centers with experience and expertise in these procedures.[5]

The optimal duration of Foley catheterization after urethroplasty is somewhat controversial. Typically, the range is from 3 to 21 days, but the optimal timing has not been determined.[97][98][99][100][101] Longer Foley catheterization periods are undesirable as they are uncomfortable for the patient, restrict mobility and significantly limit activities.[102] A systematic review of the medical literature shows early Foley removal (7 days) after urethroplasty caused no increase in complications, extravasation, infections, or recurrences with long-term follow-up.[103]

Strictures that form after pelvic fractures are best treated with a delayed urethroplasty after other significant injuries have stabilized and the patient can be optimally positioned safely for the urethroplasty.[5] The standard recommended delay period is about 3 months, and intervals longer than 6 months are not recommended. Selected patients can minimize their suprapubic catheterization time by having the repair done in 6 weeks or even less.[104]

Bladder neck strictures can be treated with dilation, bladder neck incision, or transurethral resection of the contracture. Open or robotic reconstruction should be considered for intractable or recurrent lesions.[5] Patients should be aware of the potential risks of postoperative incontinence prior to surgery.

Anastomotic urethroplasty is a more commonly used term for stricture resection and end-to-end anastomosis. It is most appropriate when the stricture is short (<2 cm) and located in the bulbar urethra, often resulting from a traumatic straddle-type injury.[1][5] Success rates for urethral dilation or DVIU alone for bulbar strictures >2 cm are disappointing. It is also appropriate after a failed urethral dilation or DVIU.[5] Preferably, the patient would not have had any previous intervention or instrumentation, as these can worsen the outcome.[105] 

The urethra is dissected through a perineal approach, the stricture excised, and an end-to-end tension-free anastomosis is performed.[40] This is followed by placing a Foley catheter that generally stays in for 3 weeks, although recently, 2 weeks have been suggested.[106] The catheter can be removed after a peri-catheter urethrogram shows the repaired urethra to be free of leakage.[105][107]

This procedure is not appropriate for longer strictures or those located in the pendulous (penile) urethra as it will cause a loss of urethral length and result in a ventral penile curvature. It provides excellent outcomes with success rates of >90%.[53][78] Possible complications are erectile dysfunction and stricture recurrence, both reported at 5%.[105] Patient satisfaction with this procedure is quite high.[108]

Substitution or graft urethroplasty is a procedure where the urethra is mobilized in the area of stricture, dissected from the corpora cavernosa, and the urethra opened lengthwise for the entire length of the stricture.[40] This can be achieved through a ventral, dorsal, or lateral approach.[78] Following this, a skin graft is sutured to the defect to create a wider urethra.

Skin grafts can be taken from the foreskin, oral mucosa, and rarely from the upper inner thigh.[40] The oral mucosa provides the most suitable graft material due to its histological features and resistance to urine exposure.[78] Studies have not shown a significant superiority of oral mucosa over non-hair-bearing skin with regard to success rates, so the donor site is chosen based on the effects on the donor site itself. When the graft is taken from the buccal mucosa, pain, scarring, and numbness can occur, leading to considerable discomfort at the donor site.[40] 

The use of lingual mucosa rather than buccal tissue has been suggested for urethroplasty graft material as it may offer fewer complications.[109] Allografts, xenografts, and synthetic materials should never be used for substitution grafts outside of a clinical trial. Hair-bearing skin is also not recommended unless no other alternative is available.[5][110]

Substitution urethroplasties should be used for bulbar strictures that are too long for a direct anastomotic urethroplasty or any penile urethral stricture.[53][111] When the local conditions are not suitable for a skin graft, such as extensive scarring from previous surgery, radiotherapy, active infection, or when the stricture is very long, a local skin flap is preferred.[53] A 2-stage approach is suggested in complex urethral strictures, such as patients with previous hypospadias repair, urethral reconstruction, or patients with lichen sclerosis.[76][112] Single-stage tubularized substitution graft urethroplasties are not recommended.[5]

In a 2-stage urethroplasty, a stricturotomy is performed, a proximal urethrostomy is created, and a skin graft is sutured to the urethral plate. Six months later, if there are no problems or complications, a suprapubic catheter is placed, and the urethra is closed over a sound. A voiding trial is performed, usually 3 weeks later.[112] 

Various other techniques have been described using a combination of skin flaps and grafts in single- and 2-stage procedures.[5]

Perineal urethrostomy (Boutonnière) is a procedure with palliative intent reserved for patients who have had multiple stricture operations, have unusually extensive or complex stricture disease, or do not wish to undergo extensive additional surgeries. It is also a reasonable alternative for patients with multiple comorbidities who cannot tolerate a urethroplasty. 

The bulbar urethra is incised through the perineal skin over a sound. The edges of the urethra are then sutured directly circumferentially to the perineal skin to maintain the urethrostomy. This technique preserves sphincteric function and continence. Most patients who undergo this procedure express high satisfaction with the results.[40][113][114][115]

Recently, a single-stage preputial spiral graft using the foreskin has been described that may be appropriate for some patients with extensive stricture disease who would otherwise be candidates for a perineal urethrostomy.[116]

Pelvic radiation therapy reduces tissue vascularity, prolongs healing, decreases graft survival, and promotes fibrosis, making treating urethral strictures particularly challenging. Endoscopic approaches tend to have limited long-term success. Urethral reconstruction using buccal graft urethroplasties after pelvic radiation therapy is worrisome due to concerns about graft survival but reported long-term success rates to range from 70% to 100%.[22] Robotic surgical reconstruction appears to improve recovery with no increase in complication rate.[117]

All urethral stricture patients should be regularly monitored for recurrence.[5]

Summary

• Retrograde urethrograms, with or without voiding cystourethrograms, are the preferred diagnostic studies for male urethral strictures, while uroflowmetry is preferred for follow-up testing after treatment.

• A suprapubic tube should be considered instead of an endoscopic transurethral procedure to minimize urethral trauma and allow for tissue healing.

• Urethroplasties are suggested in lieu of repeated dilations or urethrotomies for recurrent strictures.

• Meatal stenosis and fossa navicularis strictures can be initially treated with urethral dilation or meatotomy. If recurrent, a urethroplasty should be considered.

• Meatal lichen sclerosis has fewer recurrences if treated with an extended meatotomy and high-dose topical steroids than surgery alone.

• Intermittent self-catheterization can be used to maintain urethral patency after DVIU.

• Patients who require chronic self-catheterization to keep the urethral lumen open should be offered a urethroplasty as an alternative. 

• Penile urethral strictures are usually better treated initially by a urethroplasty, as endoscopic therapy results in a very high recurrence rate.

• Bulbar urethral strictures <2 cm can be initially treated with dilation, DVIU, or a urethroplasty.

• Paclitaxel-balloon dilation therapy combined with a DVIU can provide good long-term outcomes in patients with recurrent bulbar urethral strictures <3 cm in length.

• A urethroplasty can be performed if the paclitaxel-coated balloon treatment fails or the stricture is at least 3 cm in length.

• Oral mucosa is the preferred material for a substitution or graft urethroplasty.

• Some patients may prefer to continue with repeated urethral dilations, multiple endoscopic DVIU procedures, or intermittent self-catheterization instead of undergoing a more complex surgery such as a urethroplasty.

• A perineal urethrotomy is a reasonable option for selected patients with complex strictures or high surgical risk.[5]

Differential Diagnosis

Just as urethral strictures typically present with progressive obstructive symptoms, many other diseases can present similarly. The differential diagnosis includes:

• Bladder calculi
• Detrusor decompensation or hypotonicity
• Central and peripheral neuropathies such as detrusor sphincter dyssynergia
• Drug-related effects
• Prostate enlargement, either benign or cancerous. (BPH is the commonest cause of weak stream) 
• Prostatitis would usually be associated with burning, frequency, urgency, hematuria, deep perineal pain (especially when sitting), and cloudy urine with a high prostate-specific antigen (PSA)
• Posterior urethral valves
• Underactive bladder, bladder stones, sensory underactivity 
• Urethral foreign body (stone)
• Vesicoureteral reflux[118]

Prognosis

As seen from the pathophysiology of urethral strictures, once a stricture is established, it follows a closed-circle pattern of increasing fibrosis and gradually decreasing lumen size.

If definitive treatment is not offered, stricture severity will gradually increase, eventually causing complications. Strictures have high recurrence rates, especially with nonoperative management.

Surgical management with a urethroplasty is the treatment option with the overall best outcomes, with an overall success rate of >85% reported.

Paclitaxel-coated urethral balloon dilation combined with a DVIU offers good, long-term treatment outcomes for bulbar strictures <3 cm in length.

Complications

If left untreated, urethral strictures can cause some of the following complications: 

• Acute urinary retention
• Bilateral vesicoureteric reflux 
• Bladder diverticulum 
• Erectile dysfunction
• Penile curvature or shortening
• Recurrent UTIs 
• Voiding dysfunction
• Unilateral vesicoureteric reflux
• Urethrocutaneous fistula[119][120]

Deterrence and Patient Education

Reducing the incidence of urethral strictures is based on minimizing the incidence of causative etiologies.

• Avoiding pelvic, perineal, and penile trauma. 
• Educating patients about the best and safest way to self-catheterize. Advice should include the liberal use of lubricating gel and using the smallest size catheter possible for short periods of time.
• The least traumatic technique of catheter insertion should be taught and mastered by patients who self-catheterize.
• The practice of safe sex is of paramount importance, as gonorrhea was the most common causative organism leading to strictures. The effectiveness of this intervention has already been demonstrated in developed countries where the number of urethral strictures secondary to gonorrheal urethritis has dropped significantly.[1]

Pearls and Other Issues

Any male patient presenting with unexplained dysuria, a weak stream, incomplete emptying, increased post-void residual urine volume, or a urinary tract infection should be considered for a possible urethral stricture.[5] Unlike BPH, urethral strictures will demonstrate obstructed ejaculation and nonresponsiveness to alpha-blocker medications.

While uroflowmetry and post-void residual determinations are helpful, a quick cystoscopy can definitively determine the diagnosis quickly. A follow-up retrograde urethrogram can help establish further important details of the stricture. In emergent situations, a suprapubic cystostomy avoids urethral trauma and patient discomfort while providing a period of urethral rest prior to any definitive therapy.

No biomarkers for urethral stricture disease are currently available, but research is underway looking at various physiological pathways that may be of future clinical importance.[121]

Paclitaxel-coated urethral balloon dilation combined with a DVIU offers good, long-term treatment outcomes for strictures not longer than 3 cm in length. Otherwise, a urethroplasty provides the best overall cure rate for urethral strictures.

If a urethroplasty is being considered due to endoscopic treatment failure or a long (>4 cm) stricture, consider a referral to a high-volume facility or a center of excellence in urethral reconstruction and stricture disease. Consider a perineal urethroplasty for very high surgical risk patients and those with very long or complex strictures as an alternative to lengthy, complex urethroplasties.

A biopsy should be considered in cases of suspected lichen sclerosis. It is required if a urethral malignancy is suspected.[5]

If lichen sclerosis is diagnosed, genital skin should not be used for a urethroplasty.[5]

Patient satisfaction or dissatisfaction after urethroplasty is related to voiding function, penile curvature, and new onset erectile dysfunction.[120]

Enhancing Healthcare Team Outcomes

Teamwork is paramount in preventing, detecting, and treating urethral strictures. Public education helps reduce the incidence of strictures by informing the general population on the preventive causative etiologies of the condition. Information campaigns should emphasize the importance of safe and hygienic catheterization techniques to minimize the risk of traumatic strictures, particularly among individuals with urinary issues or requiring frequent catheterization. Additionally, promoting regular medical check-ups for urinary symptoms can aid in early detection and intervention.

General practitioners and emergency physicians should be aware of risk factors and presentations of patients with urethral strictures, providing early intervention when needed and avoiding unnecessary additional urethral trauma. They should also counsel any patient who presents with pelvic, perineal, or penile trauma on how to recognize early signs of urethral strictures and encourage them to seek expert help without delay.

When a diagnosis of urethral stricture is made, a team of clinicians, including experienced surgeons, urologists, plastic surgeons, radiologists, advanced care practitioners, nurses, and social workers, should work together to provide the most effective and timely advice and treatment. Each team member should have clearly defined responsibilities to ensure efficient care delivery and minimize errors. 

Ideally, a specialized interprofessional team should be assembled in a large-volume center to care for patients with urethral strictures, as they require expert surgical opinions and treatment as well as proper postoperative care and follow-up for optimal results. The patient's local physicians can do much of this follow-up using non-invasive testing, including flowmetry, post-void residual determinations, and possibly a retrograde urethrogram.