Urethral Strictures

Bashar Abdeen; Stephen Leslie; Almostafa Badreldin

Urethral Strictures

Author: Bashar M. Abdeen Author: Stephen W. Leslie Editor: Almostafa M. Badreldin Updated: 10/29/2024 10:10:33 PM

Introduction

A urethral stricture is an abnormal narrowing of the urethra, typically caused by scar tissue, leading to obstructive urinary symptoms. These strictures often arise from injuries to the urethral mucosa and the surrounding tissues. This common condition results in many office appointments, emergency room visits, and hospital admissions.[1] Although urethral strictures can occur in both sexes, they are rare in women, resulting in limited guidelines for the diagnosis and treatment of 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 2 portions—the anterior portion extends from the external urethral meatus to the distal membranous urethra and the posterior portion extends from the distal membranous urethra to the bladder neck.[4] The urethra is contained within the corpus spongiosum, which lies in a groove below the 2 corpora cavernosa. The inside of the urethra is lined with stratified squamous epithelium.[4] Please see StatPearls' companion resources, “Anatomy, Abdomen and Pelvis, Male Genitourinary Tract” and “Histology, Male Urethra,” for more information.

Anterior strictures account for 92.2% of cases, with the majority 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%).[5]

The 2002 World Health Organization Conference recommended a more specific descriptive terminology that divides the urethra into 7 segments—the urethral meatus, fossa navicularis, penile (or pendulous), bulbar, membranous and prostatic urethra, and the bladder neck.[6]

Etiology

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Etiology

The etiology of urethral strictures is classified into 4 major groups—idiopathic, iatrogenic, inflammatory, and traumatic, with idiopathic and iatrogenic being the most common, each accounting for 33%. Traumatic causes represent 19%, whereas inflammatory causes account for 15%. Infection may account for up to 26.6% of all patients undergoing urethroplasty, as the strictures tend to be relatively long, typically >4 cm.[7][8]

The etiology of urethral strictures 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][5][9][10]

Idiopathic Causes

Idiopathic causes are the most common etiology of urethral strictures in Western countries (41%), followed by iatrogenic (35%), typically as sequelae from urethral surgery or transurethral procedures. In contrast, trauma tends to be the most common cause of strictures in low-income regions due to higher rates of traffic accidents, less developed infrastructure, and underdeveloped trauma systems.[4] Idiopathic strictures may result from unrecognized repetitive minor perineal traumas, eventually leading to the stricture.[11]

Iatrogenic Causes

Iatrogenic causes are further divided into the following 5 categories:

Transurethral resection: This procedure accounts for 41% of all iatrogenic urethral strictures.[7] During this procedure, relatively large instruments are repeatedly passed in and out of the urethra, leading to varying degrees of epithelial injury from urethral stretching and dilation, ultimately leading to stricture formation.[12]
Prolonged catheterization (36%): This procedure exerts pressure on the urethra, leading to pressure-induced necrosis of the urothelium and rubbing or frictional injury to the urethral mucosa caused by catheter motion.[7] Changes in the materials used for making and designing catheters, including using silicone instead of latex, have helped reduce the incidence of strictures. Strictures may also occur after prolonged periods of intermittent catheterization.[6]
Cystoscopy (12.7%) and simple Foley catheterization: These procedures can damage the urethral epithelium, leading to strictures.[7] Inadvertent or inappropriate unplanned Foley catheter extractions can cause urethral trauma, leading to stricture formation. These incidents, often involving confused patients, are largely preventable through various nursing initiatives, techniques, and procedures described elsewhere, which are highly recommended. Please see StatPearls' companion resource, "Prevention of Inappropriate Self-Extraction of Foley Catheters," for more information.
Hypospadias repair: Hypospadias repair causes 6.3% of iatrogenic strictures.[7] Children who undergo such a repair have a 10% risk of developing urethral strictures later in life.[6]
Radical prostatectomy (3.2%): Radical prostatectomy is another cause of urethral strictures.[7] Urethral strictures complicate the cases of 8.4% of men undergoing prostate cancer treatment, including prostatectomy, radiotherapy, and chemotherapy, leading to stricture formation in the posterior or bulbar urethra and bladder neck.[13] Of these, bladder neck contractures are the most common.[10][14] The direct cause is not clearly understood but is believed 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][5]

An extensive series of almost 18,000 patients 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.[15] Radiation therapy also increases the risk of urethral stricture, particularly brachytherapy, with the incidence rising as the radiation dose increases.[5][16][17][18][19]

Inflammatory Causes

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. Although these causes have become less common in high-resource countries due to improved public health measures and education, they remain prevalent in countries with more limited resources.[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.[6] Recurrent urinary tract infections (UTIs) can also cause urethral strictures, with the most isolated microorganism being Escherichia coli.[3]

Lichen sclerosus (balanitis xerotica obliterans) is another common cause of inflammatory urethral and meatal strictures. The cause and pathophysiology of the disease remain unclear; there is a possible genetic predisposition and an autoimmune factor. Lichen sclerosus presents as pale, ivory lesions on the glans around the urethral meatus or vulva and surrounding the anus.[20] 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.[6] Strictures from lichen sclerosus and those related to hypospadias repairs are typically found in the meatus, fossa navicularis, or penile urethra.[4][9] Please see StatPearls' companion resource, "Lichen Sclerosus," for more information.

Inflammatory urethral strictures caused by infection only affect the anterior urethra and rarely involve the posterior urethra.[1] These strictures are significantly longer than those caused by other etiologies and are more likely to require a urethroplasty.[7][21]

Traumatic Causes

Posttraumatic anterior urethral strictures most commonly affect the bulbar urethra and are often caused by straddle injuries compressing the bulbar urethra against the symphysis pubis. This pattern of injury is rarely associated with a pelvic fracture. Penile urethral strictures due to trauma are rare but can occur following a penile fracture.[1] Significant trauma leading to a pelvic fracture causes strictures almost exclusively in the bulbar or membranous urethra, with traumatic pelvic fractures accounting for nearly 70% of membranous strictures, as these areas are the most common site of injury in such scenarios.[3] Please see StatPearls' companion resources, “Urethral Injury” and “Lower Genitourinary Trauma,” for more information.

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] Posttraumatic urethral strictures are short, with most <4 cm in length.[3]

Epidemiology

Urethral strictures are common, with a prevalence of 200/100,000 in younger men and more than 600/100,000 in men older than 65 in the United States.[8] Urethral strictures are more common in older individuals and Black patients compared to the general population. There is a marked increase in incidence starting at 55.[22] The estimated annual incidence rate in the United States is 0.9%.[1]

Male urethral strictures account for 5000 hospital admissions and 1.5 million clinic visits annually.[5][22] In The United Kingdom, the prevalence is considerably less, estimated at 40/100,000 in men younger than 65 and 100/100,000 in men older than 65.[12]

Worldwide, the prevalence of male urethral strictures is estimated to range from 229 to 627/100,000.[23]

Pathophysiology

The pathophysiology of urethral stricture involves 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.[5]

Metaplasia of the urethral epithelium to stratified squamous epithelium occurs, making it more susceptible to pressure changes and stretch trauma. This increased vulnerability causes tears in the mucosa, leading to further urinary leakage into the outer corpus spongiosum, which promotes fibrous changes and stricture formation.[12] 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.[4]

Urethral strictures typically develop slowly and result in a progressive narrowing of the urethral lumen. Symptoms are similar to those typically associated with bladder outlet obstruction due to benign prostatic hyperplasia, including a weak urinary stream, straining to void, incomplete emptying, double-voiding, intermittency, post-void dribbling, unexplained dysuria, and frequent UTIs.[8][24][25] Other presenting symptoms include acute urinary retention and hematuria. Overall, 70% of patients with urethral strictures present with obstructive symptoms alone.[12]

The severity of the symptoms can vary widely among patients, especially those with a slowly progressive or discrete stricture. Some patients may remain asymptomatic. In such cases, patients are likely to develop compensatory detrusor hypertrophy.

A key difference between benign prostatic hyperplasia and urethral stricture disease is obstructed ejaculation.[8] In addition, patients with urethral strictures do not respond to typical benign prostatic hyperplasia therapy, such as alpha-blocker medications, and the weak urinary stream is relatively constant without much variation.

After obtaining the initial history, further questions should be focused on uncovering the underlying etiology. Any history of surgical interventions, previous infections, and pelvic or urethral trauma should also be sought.[4] Finally, appropriate past medical history and comorbidities should be elucidated.[24]

Although the physical examination is often nondiagnostic, performing a detailed examination is still important. During the physical examination, the clinician should palpate the urethra for any palpable fibrous tissue and assess for skin changes, such as pale patches indicative of lichen sclerosus. Occasionally, these patches can be confined only to the area immediately surrounding the urethral meatus. Scars from previous surgeries should also be noted. Performing a thorough prostate examination is crucial to assess for signs of benign prostatic hyperplasia, prostate cancer, or prostatitis.[4][12][24]

Evaluation

The history and physical exam, urinalysis, symptomatology, post-void residual urine volume, and peak urinary flow measurements initially suggest urethral stricture. Obstructive urinary symptoms that do not respond to alpha-blocker medications suggest either a urethral stricture or a hypotonic detrusor.

Cystoscopy, retrograde urethrography, or voiding cystourethrography make and confirm the diagnosis of urethral strictures.[4] Blood tests do not play a role in this diagnosis.

Uroflowmetry

Uroflowmetry is the preferred initial investigation as it provides a good, noninvasive assessment of the maximum urethral flow.[4][26][27][28][29][30] Interpreting 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.[26][27][28] The shape of the flow curve is also important in identifying the cause.[31] Urethral strictures typically produce a characteristic sharp and distinct plateau at the peak flow rate level.[26][27][28][32] Uroflowmetry studies should ideally consist of more than 150 mL in total voided volume to yield reliable and reproducible results.[24][33][34]

Post-Void Residual Urine Volume

Post-void residual urine volume measurements can be a helpful and objective evaluation tool for bladder emptying but are not diagnostic. Combined with uroflowmetry, it can help confirm a possible bladder outlet obstruction but cannot rule out detrusor hypotonicity or benign prostatic hyperplasia. Please see StatPearls' companion resource, "Bladder Post Void Residual Volume," for more information.

Cystoscopy

Cystoscopy is a relatively straightforward investigative procedure that quickly and definitively diagnoses urethral strictures.[4] This procedure can be performed expeditiously under local anesthesia (flexible cystoscopy) in the office or clinic.[4] Cystoscopy immediately confirms the diagnosis, avoids unnecessary delays, offers the opportunity for immediate therapy through dilation, and determines the stricture's distal location. However, its utility is limited if the cystoscope cannot pass through the stricture to assess its length, proximal urethral pathology, or the state of the prostate. Please see StatPearls' companion resource, "Cystoscopy," for more information.

A smaller caliber ureteroscope can sometimes pass beyond the stricture and provide additional diagnostic information without undue urethral trauma or the need for dilatation.[35] Cystoscopy has limitations as it cannot provide information about surrounding tissue fibrosis, but it offers a quick and definitive initial diagnosis.[12][24][34]

Retrograde Urethrography

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.[36] In such cases, a voiding cystourethrography can provide this necessary and valuable additional information.[37] This procedure can be performed 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.

Combining a retrograde urethrogram and simultaneous cystogram or voiding cystourethrography yields an excellent image of the entire urethra. This approach is beneficial when the urethrogram shows urethral occlusion with no proximal penetration of contrast.[4][37] This combination provides detailed imaging and information about the location, number, length, and severity of strictures, making it a reliable diagnostic imaging tool 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 two-dimensional image of a three-dimensional structure.[12][24] Some studies suggest that advanced imaging techniques, such as computed tomography (CT), voiding urethrography, or sonoelastography, provide detailed images of the stricture and its characteristics.[37][38][39]

In complex cases of urethral strictures, particularly in female patients, videourodynamics is often the preferred evaluation method, combining bladder function and emptying (urodynamics) with urethrographic imaging.[40][41] This technique 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.[42]

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.[43] A convolutional neural network machine learning program is under development, which may help address this issue.[44] Surgeons should perform their retrograde urethrograms to obtain optimal results.[45]

Ultrasonography

Ultrasonography is mainly used to assess the bladder and upper urinary tract. Although ultrasonography can show a thickened urinary bladder wall, it cannot directly visualize a stricture; however, it may be able to help determine the degree of spongiofibrosis. Residual post-void urine can be observed on ultrasound, which may provide insight into the degree and significance of the obstructed urethra.[12][46] Ultrasound may visualize the strictured zones when the urethra is filled with a physiologic solution through a Foley catheter.[24]

Some experts recommend a urethral ultrasound examination to delineate the extent of urethral spongiofibrosis and measure the length of the stricture.[47][48][49][50][51][52][53][54] Although this approach may benefit skilled hands, it is not commonly used among most specialists in urethral stricture management.[55]

Magnetic Resonance Imaging

The use of magnetic resonance imaging (MRI) scans 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's invasion into surrounding tissues.[24] MRI may also provide additional details in cases of urethral strictures associated with diverticula, fistulas, unusual periurethral fibrosis, and pelvic fractures.[4] In women, an endourethral MRI combined with ultrasound and a CT scan can provide the most comprehensive imaging of the urethra and surrounding tissues.[56][57]

Treatment / Management

General Considerations

In the absence of complications, therapy aims to relieve symptoms. The treatment approach should consider symptom severity, stricture location, severity, length, and patient preference. Generally, treatment is not warranted if the symptoms are not troublesome or objectively harmful.

If a patient presents with urinary symptoms such as recurrent infections or acute retention, treatment can relieve the symptoms, reduce the incidence of complications, and minimize damage to the lower urinary tract.[12] 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 used if this provides clinical symptomatic relief.[4]

A healthy young male's normal peak urine flow rate is >15 mL/s. Most patients have a low peak flow rate of <12 mL/s. Patients with strictures and peak flow rates between 10 and 15 mL/s are typically asymptomatic.[31][32] Intervention is unnecessary if there is no increased bladder wall thickness or incomplete emptying.

A peak urinary flow rate of 5 to 10 mL/s is typically associated with obstructive symptoms and complications.[31][32] Treatment should be considered only for patients with troublesome symptoms or objective signs of harmful changes in the bladder. If not treated, active monitoring should be undertaken with periodic reassessments.

For patients with a flow rate <5 mL/s, there is an increased risk of acute urinary retention, although this occurrence is relatively uncommon.[31][32] These patients should be offered treatment, even if their symptoms are insignificant.[46]

Female urethral strictures: Female urethral strictures are most commonly initially treated with urethral dilation, often followed by intermittent self-catheterization to maintain urethral patency. However, the reported recurrence rate is high at >50%.[42][58] (B3)

Female urethroplasty using buccal grafts or vaginal flaps offers the best outcomes (90% success rate) compared to repeated urethral dilations or endoscopic therapy.[2][4][58][59][60][61][62][63] Such cases are rare, and female urethral reconstructive surgery is complex; therefore, a referral to a specialty-trained urologist at a center of excellence is recommended for women requiring a urethroplasty.[64]

Urgent treatment: In cases of acute urinary retention or other complications from urethral strictures, urgent treatment options may include urethral dilation, cystoscopy, direct vision internal urethrotomy (DVIU), or suprapubic cystostomy.[4] Opting for a suprapubic cystostomy avoids further urethral trauma and patient discomfort. This approach can also provide a urethral rehabilitation and healing period known as urethral rest before a more definitive procedure, such as a urethroplasty.[4][65][66]

Such a urethral rest period is typically 4 to 6 weeks long, allowing the stricture to mature for more accurate imaging and tissue healing.[4] Any existing UTI should be treated with appropriate antibiotics. Once the emergency is dealt with and stabilized, definitive treatment for the stricture can be safely undertaken.[34](A1)

Urethral stricture therapies: These therapies can generally be categorized into endoscopic, such as urethral dilation and internal urethrotomy, and open surgical procedures, such as stricture resection and anastomosis, urethroplasty, and perineal urethrostomy. The length and exact location of the stricture should be determined before deciding on a definitive intervention.[4] With any treatment options, recurrences occur, especially with long (>4 cm) strictures and previously treated lesions.[34] Early open surgery has been suggested to provide improved outcomes compared to prolonged or repeated courses of endoscopic treatment.[67](A1)

Urethral dilation: 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 feature gives them a substantial mechanical advantage to safely dilate even tough strictures, as the guide wire prevents inadvertent urethral damage, false passage formation, and bladder injuries. Please see StatPearls' companion resource, "Difficult Foley Catheterization," for more information.

Compared to DVIU, urethral dilation shows no demonstrable difference regarding overall outcomes.[12][46][68] The overall need for retreatment within 3 years for both modalities is approximately 65%.[69]

Urethral dilation is typically performed under local anesthesia and can cause significant discomfort and bleeding. Some studies suggest that balloon dilation exerts 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 the 12 o'clock position to release the stricture, leaving it to heal by secondary intention, increasing the caliber size of the urethral lumen. This technique is the first-line treatment for short (<2 cm) bulbar strictures with no previous intervention, as these strictures have the highest success rates.[4][5] Recurrence rates are high and can reach 65% within 3 years.[69] 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 debate on whether to perform a repeat DVIU after the initial procedure recurs or to proceed directly to a urethroplasty. Some experts suggest attempting DVIU at least once more after the initial procedure, whereas others recommend a urethroplasty as the best option after a recurrence.[68][70] During the procedure, healthy tissue proximal and distal to the stricture is incised, resulting in a somewhat longer stricture when a recurrence happens.[34](A1)

Prophylactic antibiotics should follow both urethral dilation and DVIU.[12] The Foley catheter can generally be removed after 72 hours.[4]

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.[4]

Experimentally, intralesional injections of botulinum toxin at the time of internal urethrotomy improved the prognosis and outcomes in a double-blinded randomized clinical trial, suggesting that this may be a valuable adjunct to standard DVIU therapy.[71](B3)

Paclitaxel-coated urethral balloon dilation therapy: This therapy combined with DVIU produced markedly improved results in recurrent bulbar urethral strictures <3 cm in length compared to similar patients treated with the DVIU procedure alone.[72] 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.[72][73][74][75][76][77](A1)

One-year results showed an 83.2% urethral patency rate in patients treated with the paclitaxel-coated balloon and DVIU, compared to 21.7% in those receiving DVIU alone.[72] Three-year outcomes remained good, with 67% of treated patients reporting functional success.[73] (A1)

Paclitaxel-coated urethral balloon dilation therapy appears ideal for recurrent, small anterior urethral strictures, with a reported success rate of over 90% in a study.[78] Data from 2-year and 5-year follow-ups suggest that over 70% of treated patients do not require additional intervention for their stricture disease.[74][79] Paclitaxel-coated urethral balloon therapy is Food and Drug Administration-approved for treating anterior urethral strictures. However, there is limited data on its efficacy for penile urethral strictures, and no information is available on repeat treatments.[4]

High levels of paclitaxel have been detected in semen after treatment.[72] Therefore, men treated with paclitaxel-coated balloons should use contraception for at least 6 months after treatment if their partner is fertile.[72] Further studies and real-world data are needed to confirm whether these early but promising results hold up.(A1)

Intermittent self-catheterization: Regular intermittent self-catheterization following initial treatment helps maintain the patency of the urethral lumen.[4][69][80][81] Typically, a 14-French or 16-French catheter is used for this procedure. 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, typically once or twice a month.(A1)

If the patient cannot pass the catheter easily, the catheterization frequency is increased, or a smaller catheter is used. Intermittent self-catheterization training can be enhanced using readily available video training aids.[82] 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.[80][83][84][85][86] The optimal duration of intermittent self-catheterization for maintaining urethral patency has not been determined.(A1)

Some experts recommend continuing self-catheterization 1 to 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.[4][87]

Urethroplasty: This technique involves opening or resecting the stricture and either performing a direct anastomosis for short (<2 cm) bulbar strictures, using graft materials such as buccal mucosa or foreskin, or applying a flap of normal skin as a substitute for the strictured urethral tissue. This procedure can be used for longer strictures and typically has good outcomes with a high overall success rate of >85%.[88] Complications of urethroplasty are relatively uncommon and include erectile dysfunction, UTIs, fistulas, incontinence, chordee, and neuropraxia.[5] (B3)

Recurrent strictures initially treated with dilation, meatotomy, or DVIU are unlikely to be cured by repeated similar procedures with >80% reported failure rate, and urethroplasty should be considered.[89][90][91] Urethroplasty is 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 requiring urethroplasty should be referred to surgeons and centers with expertise in these procedures.[4](A1)

Optimal duration of Foley catheterization after urethroplasty: The ideal duration of Foley catheterization following urethroplasty remains somewhat controversial. Typically, the range is from 3 to 21 days, but the optimal timing has not been determined.[92][93][94][95][96] Longer Foley catheterization periods are undesirable as they are uncomfortable for the patient, restrict mobility, and significantly limit activities.[97] A systematic review of the medical literature shows early Foley removal (7 days) after urethroplasty caused no increase in complications, extravasation, infections, or recurrences during long-term follow-up.[98](A1)

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.[4] 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.[99]

Bladder neck strictures can be treated with dilation, bladder neck incision, or transurethral resection of the contracture. For intractable or recurrent lesions, open or robotic reconstruction should be considered.[4] Prior to surgery, patients should be aware of the potential risks of postoperative incontinence.

Anastomotic urethroplasty: Anastomotic urethroplasty is a more commonly used term for stricture resection and end-to-end anastomosis. This technique 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][4] Success rates for urethral dilation or DVIU alone for bulbar strictures >2 cm are disappointing. This technique is also appropriate after a failed urethral dilation or DVIU.[4] Preferably, the patient should not have had any previous intervention or instrumentation, as these can worsen the outcome.[100]

The urethra is dissected through a perineal approach, the stricture is excised, and an end-to-end tension-free anastomosis is performed.[34] A Foley catheter is then placed, typically for 3 weeks, although recently, 2 weeks have been suggested.[101] The catheter can be removed after a peri-catheter urethrogram shows the repaired urethra free of leakage.[100][102](A1)

This procedure is inappropriate for longer strictures or those in the pendulous (penile) urethra, as it causes a loss of urethral length and results in a ventral penile curvature. This procedure provides excellent outcomes with success rates of >90%.[46][70] Possible complications are erectile dysfunction and stricture recurrence, both reported at 5%.[100] Patient satisfaction with this procedure is quite high.[103]

Substitution or graft urethroplasty: This technique involves mobilizing the urethra in the strictured area, dissecting it from the corpora cavernosa, and opening the urethra lengthwise for the entire length of the stricture.[34] This procedure can be performed through a ventral, dorsal, or lateral approach.[70] A skin graft is sutured to the defect to create a wider urethra.(A1)

Skin grafts can be taken from the foreskin, oral mucosa, and rarely from the upper inner thigh.[34] The oral mucosa provides the most suitable graft material due to its histological features and resistance to urine exposure.[70] Studies have not shown a significant superiority of oral mucosa over non–hair-bearing skin concerning success rates; therefore, 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.[34] (A1)

Using lingual mucosa rather than buccal tissue has been suggested for urethroplasty graft material, as it may offer fewer complications.[104] 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.[4][105](A1)

Substitution urethroplasty should be used for bulbar strictures that are too long for a direct anastomotic urethroplasty or any penile urethral stricture.[46][106] When the local conditions are unsuitable 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.[46] A two-stage approach is suggested in complex urethral strictures, such as in patients with previous hypospadias repair, urethral reconstruction, or lichen sclerosus.[68][107] Single-stage tubularized substitution graft urethroplasty is not recommended.[4](B2)

In a two-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.[107] (B2)

Various other techniques have been described using a combination of skin flaps and grafts in single- and two-stage procedures.[4]

Perineal urethrostomy (Boutonnière): This procedure with palliative intent is reserved for patients who have undergone multiple stricture surgeries, have typically extensive or complex stricture disease, or do not wish to undergo extensive additional surgeries. Perineal urethrostomy is also an appropriate alternative for patients with multiple comorbidities who cannot tolerate a urethroplasty.

The procedure involves making an incision in the bulbar urethra 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.[34][108][109][110](A1)

Recently, a single-stage preputial spiral graft using the foreskin has been described as a potential option for some patients with extensive stricture disease who are otherwise candidates for a perineal urethrostomy.[111]

Pelvic radiation therapy: This 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 urethroplasty after pelvic radiation therapy poses challenges related to graft survival; however, reported long-term success rates range from 70% to 100%.[19] Robotic surgical reconstruction appears to improve recovery with no increase in complication rate.[112]

All urethral stricture patients should be regularly monitored for recurrence.[4]

Summary

Retrograde urethrograms, with or without voiding cystourethrograms, are the preferred diagnostic studies for male urethral strictures, whereas 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.
Urethroplasty is suggested in lieu of repeated dilations or urethrotomies for recurrent strictures.
Meatal stenosis and fossa navicularis strictures can be initially managed with urethral dilation or meatotomy, but recurrent cases may require urethroplasty.
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 typically better treated initially with urethroplasty, as endoscopic therapy results in a very high recurrence rate.
Bulbar urethral strictures <2 cm can be initially treated with dilation, DVIU, or urethroplasty.
Paclitaxel-balloon dilation therapy combined with DVIU can provide good long-term outcomes in patients with recurrent bulbar urethral strictures <3 cm in length.
Urethroplasty can be performed if the paclitaxel-coated balloon treatment fails or the stricture is at least 3 cm long.
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 urethroplasty.
A perineal urethrotomy is a reasonable option for selected patients with complex strictures or high surgical risk.[4]

Differential Diagnosis

While urethral strictures typically present with progressive obstructive symptoms, several 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 (benign prostatic hyperplasia is the most common cause of weak stream)
Prostatitis is typically associated with burning; frequency; urgency; hematuria; deep perineal pain, especially when sitting; and cloudy urine with a high prostate-specific antigen
Posterior urethral valves
Underactive bladder, bladder stones, and sensory underactivity
Urethral foreign body (stone)
Vesicoureteral reflux [113]

Prognosis

The pathophysiology of urethral strictures illustrates that 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 gradually worsens, eventually leading to complications. Strictures have high recurrence rates, especially with nonoperative management.

Surgical intervention, specifically urethroplasty, provides the best long-term outcomes, with an overall success rate of >85%. Paclitaxel-coated urethral balloon dilation combined with DVIU has shown to be an effective long-term treatment option for bulbar strictures <3 cm in length.

Complications

If left untreated, urethral strictures can lead to several complications, including:

Acute urinary retention
Bilateral vesicoureteric reflux
Bladder diverticulum
Erectile dysfunction
Penile curvature or shortening
Recurrent UTIs
Voiding dysfunction
Unilateral vesicoureteric reflux
Urethrocutaneous fistula [114][115]

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 on proper self-catheterization techniques, emphasizing the liberal use of lubricating gel and selecting the smallest catheter size needed for short durations.

Ensuring patients who self-catheterize are taught and can master the least traumatic catheter insertion technique.

Promoting the practice of safe sex, as gonorrhea was once 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 UTI should be considered for a possible urethral stricture.[4] Unlike benign prostatic hyperplasia, urethral strictures demonstrate obstructed ejaculation and nonresponsiveness to alpha-blocker medications.

Although 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 before any definitive therapy.

Currently, no biomarkers for urethral stricture disease are available, but research into relevant physiological pathways is ongoing.[116]

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

If urethroplasty is being considered due to endoscopic treatment failure or a long (>4 Cm) stricture, referral to a high-volume facility or a center of excellence in urethral reconstruction and stricture disease is recommended. A perineal urethroplasty is considered 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 sclerosus. If a urethral malignancy is suspected, a biopsy is essential.[4] If lichen sclerosus is diagnosed, genital skin should not be used for a urethroplasty.[4]

Lower success rates for artificial sphincters are likely in patients with a diseased or compromised urethra, as this leads to additional scarring and decreased vascularity with poor wound healing.[117]

Patient satisfaction or dissatisfaction after urethroplasty is related to voiding function, penile curvature, and new onset erectile dysfunction.[115]

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. In addition, 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. These healthcare professionals 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 these patients require expert surgical care, comprehensive treatment plans, and specialized postoperative care and follow-up for optimal results. Local physicians can handle much of the follow-up using noninvasive tests, including flowmetry, post-void residual determinations, and possibly retrograde urethrograms.

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