Evaluation + Workup
History
- Symptoms: decreased stream, incomplete emptying, spraying, dysuria, recurrent infections, hematuria
- Hx infections: UTI, STI, epididymitis
- Hx retention: Elevated PVR
- Hx surgeries: hypospadias, cystoscopy, TUR procedures, prostate cancer treatment
- Other hx: trauma (pelvic fracture, straddle injury), lichen sclerosus/BXO, radiation
Testing
- Urinalysis: rule out UTI, assess need for hematuria workup
- Non-invasive uroflow: < 12mL/s concerning for obstruction
- Cystoscopy: identifies presence/absence of stricture
- XR retrograde urethrogram: identifies stricture location, length, and severity
- Voiding cystourethrogram: useful if posterior urethra not visualized with RUG and patient has SPT
- Biopsy: consider if concerned about lichen sclerosus (LS) or cancer, SCC found in 2-8% LS patients
- Ultrasound: contrast enhancement may provide accurate assessment of length, inject saline via meatus to distend retrograde and perform Crede maneuver to distend antegrade
- MRI: helpful for assessing female urethra, diagnosing diverticulum
Retrograde Urethrogram
- Technique: have patient lie on side at 30-degree angle, put penis on stretch, and inject contrast via syringe or catheter at fossa navicularis
- Side effects: contrast extravasation and UTI are rare
- Contrast allergy: consider premedication with steroids + anti-histamines
Endoscopic Management (DVIU + Dilation)
General tips
Indications: emergent treatment of retention, bulbar strictures < 2cm with no prior treatment, patient unable to undergo definitive urethroplasty
- Options: dilation and DVIU shown to have equivalent outcomes
- Catheter: leave for 3 days, no benefit to leaving longer
- Post-treatment CIC: perform daily to weekly, can consider to keep urethra patent, best for patients unable to undergo urethroplasty
- Recurrence: usually within 6-12mo, urethroplasty recommended, repeat endoscopic treatment has failure rates ~80%
Dilation
- Technique: stretch scar without causing further scarring (minimize bleeding), multiple stepwise treatment sessions may be warranted to prevent trauma
- Options: balloon-dilating catheters less traumatic than dilators (use fluoroscopy or visualization for placement)
- Membranous urethra: consider to avoid incision near urethral sphincter
- Optilume: paclitaxel-coated dilating balloon, currently approved for recurrent strictures only, lower rates of stricture recurrence compared to dilation alone, hematuria/dysuria more common than control (11% vs 2%), use protection for 6 months after treatment due to paclitaxel presence in semen (ROBUST trial, Elliot 2022)
DVIU
- Technique: perform at quadrants (12, 3, 6, 9) or Chevron (12, 5, 7), some recommend avoiding 12oclock, cut 5mm proximal and distal to stricture
- Avoid: incisions between 10-2 o'clock may enter corpora cavernosa and cause erectile dysfunction
- Options: can use "cold" knife or laser
Urethroplasty
General tips
- Urethral rest: place SPT for 4-12 weeks if patient has been using CIC or indwelling catheter
- Grafts: always consent for possible graft (buccal works better than lingual)
- DO NOT: perform single-stage tubularized grafts, use hair-bearing skin (risk of UTI, calculi), injure Stensen's duct during graft harvest
- Catheter: leave catheter for 3 weeks to ensure no extravasation
- Success: 86% for anastomotic repair (at 5 and 15 years), 84-87% for flap/graft at 5yr (falls to 58% at 15yr)
- Risks: recurrence (8-15%), erectile dysfunction (1%), diverticulum, postvoid dribbling, fistula, oral pain/tightness
- Recurrence: assess with cystoscopy + RUG + VCUG
Anastomotic urethroplasty
- Location: used in bulbar and posterior strictures, avoid in penile urethra (causes chordee and shortening)
- Technique: complete fibrosis excision, wide spatulation, tension free anastomosis
- Transecting EPA: removes complete fibrosis by transecting spongiosum, but risk of compromising distal blood supply and potentially worsening erectile dysfunction
- Length: usually 1-2cm, but can repair up to 5cm, the closer to the membranous urethra the longer the repair can be
- Pelvic fracture urethral injury: often requires mobilizing bulbar urethra to suspensory ligament, performing inferior pubectomy, routing urethra around corpus
Augmentation urethroplasty
- Graft: tissue harvested from another area without remaining attached to vascular pedicle, usually buccal mucosa is best, works via imbibition (absorb nutrients from graft bed) and inosculation (graft bed vessels grow into graft)
- Flap: island of skin remaining attached to vascular pedicle, most often used with poor graft bed (radiated/scarred tissue)
- Dorsal onlay: preferred in penile urethra (less ventral support), less likely to form diverticulum, requires mobilizing urethra and rolling to one side to incise
- Ventral onlay: can perform in bulbar/perineal area where good ventral support is present
Other Treatments
Meatal stenosis
- Cause: otherwise BXO, prior hypospadias repair, transurethral procedures, prior circumcision (in children)
- Initial treatment: urethroplasty, can also offer dilation or meatotomy
- Meatoplasty: incise ventrally (not dorsally), then stitch edges to prevent reanastomosis
- Augmentation urethroplasty: recommended for lichen sclerosus, prior hypospadias repair, or obliterative strictures
Bladder neck contracture
- Indications: anastomotic stricture usually after radical prostatectomy or TURP
- Technique: resect with hot knife laterally to open bladder neck, avoid posterior incision (rectum may be nearby)
- Success: short term 50-80%
- Recurrence: may require robotic Y-V bladder neck plasty
Perineal Urethrostomy
- Indications: recurrent or complex strictures, advanced age, medical issues, lichen sclerosus, prior failed treatments, patient choice
- Requirements: proximal bulbar, membranous, and prostatic urethra must be free of obstruction
- Postoperative expectations: will have to sit to void postoperatively, up to 97% satisfaction rate in properly selected patient
Other penile/urethral diseases
Urethral conditions
- Urethral hemangioma: present w/ hematuria, confirm with cystoscopy, can observe if asymptomatic (may regress), excise completely if symptomatic
- Reactive arthritis: arthritis + conjunctivitis + urethritis, circinate balanitis - glandular lesion, diagnostic, shallow ulcer with gray borders, can lead to urethral necrosis
- Lichen sclerosus: most common cause of meatal stenosis, can treat with steroids and meatal dilation, may require circumcision or urethroplasty, consider biopsy (needs biopsy if concerned for cancer)
- Urethrocutaneous fistula: caused by prior surgery, strictures, or underlying cancer
- Diverticulum: usually congenital, seen in anterior urethra or prostatic utricle
Foreskin conditions
- Phimosis: may be due to recurrent balanitis or diabetes, manage with circumcision
- Paraphimosis: urologic emergency (can cause glans phimosis), manage with compression, ice, wrapping, dorsal slit, circumcision
- Balanitis: glans inflammation, can lead to balanoposthitis with preputial abscess cavity requiring dorsal slit or circumcision
Penile curvature (non-Peyronie)
- Congenital: seen with or without hypospadias
- Acquired: secondary to trauma from intercourse, almost never seen prior to puberty
- Can incise ventral aspect and place graft or perform Nesbit dorsally
- If scar present, excise and graft over to prevent bilateral indentation from contralateral plication
References
- AUA Core Curriculum
- Chung, Paul H., et al. "Contrast-Enhanced Ultrasound and Shear Wave Elastography: Novel Methods for the Evaluation of Urethral Stricture Disease." The Journal of urology 207.1 (2022): 152-160.
- Elliott, Sean P., et al. "One-year results for the ROBUST III randomized controlled trial evaluating the Optilume® drug-coated balloon for anterior urethral strictures." The Journal of urology 207.4 (2022): 866-875.
- Virasoro, R., G. Jordan, and K. McCammon. "Surgery for Benign Disorders of the Penis and Urethra." Campbell-Walsh Urology 12 (2020).
- Wessells, Hunter, et al. "Male urethral stricture: AUA guideline." The Journal of urology (2023).
- Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.