What is the best course of treatment for a 37-year-old male with a tight prosthetic urethra and bladder neck on cystoscopy who continues to experience urinary stream splitting?

Management of Tight Prosthetic Urethra with Persistent Urinary Stream Splitting

For a 37-year-old male with a tight prosthetic urethra and bladder neck on cystoscopy who continues to experience urinary stream splitting, urethral dilation or direct visual internal urethrotomy (DVIU) is the recommended initial treatment approach. 1

Diagnostic Evaluation

Before proceeding with treatment, a thorough evaluation should be completed to confirm the diagnosis and determine the extent of the stricture:

1. Imaging studies:

   • Retrograde urethrography (RUG) to assess the location, length, and severity of the urethral narrowing 1
   • Voiding cystourethrography (VCUG) to evaluate the bladder neck and posterior urethra 1

2. Urodynamic assessment:

   • Uroflowmetry to measure peak flow rate (typically < 12 mL/sec in significant stricture) 1
   • Post-void residual (PVR) measurement via ultrasound to assess bladder emptying 1

Treatment Algorithm

First-line Treatment:

1. Endoscopic management:
   • Direct visual internal urethrotomy (DVIU) - Incision of the strictured area under direct visualization
   • Urethral dilation - Gradual expansion of the narrowed urethral lumen

Both procedures are minimally invasive and can be performed as outpatient procedures with relatively quick recovery times. The goal is to increase the urethral lumen diameter to improve urinary flow and resolve the stream splitting.

Post-procedure Management:

• Short-term urethral catheterization for 24-72 hours 1
• Consider alpha-blocker therapy (tamsulosin 0.4 mg daily) to relax the bladder neck and prostatic urethra, which may help improve urinary flow 2
• Tamsulosin has been shown to significantly improve urinary symptoms and peak flow rates in clinical trials 2

For Recurrent or Persistent Strictures:

If the initial endoscopic treatment fails to resolve symptoms:

1. Repeat endoscopic treatment may be considered, though success rates diminish with each attempt 1

2. Urethroplasty should be considered for definitive management:

   • End-to-end anastomosis for short strictures
   • Substitution urethroplasty with grafts for longer strictures 1

3. Two-stage approach for complex cases with both stricture and incontinence:

   • First stage: End-to-end urethroplasty to address the stricture
   • Second stage (after 6 months): Artificial urinary sphincter placement if incontinence persists 3

Follow-up Protocol

• Uroflowmetry and post-void residual measurement at 3,6, and 12 months 1
• Urethroscopy may be performed at follow-up to directly visualize the repair site
• Monitor for symptoms of recurrence (decreased stream, splitting, incomplete emptying)

Important Considerations and Pitfalls

• Avoid repeated dilations: Multiple endoscopic treatments have diminishing returns and may worsen scarring, making definitive repair more difficult 1
• Consider the prosthetic nature: The presence of a prosthetic urethra may complicate management and influence the success rate of interventions
• Assess for bladder dysfunction: Concurrent bladder issues should be addressed, as they may contribute to symptoms even after successful treatment of the stricture
• Patient age: At 37 years old, this patient is young and likely to require a durable long-term solution, which may favor more definitive approaches like urethroplasty if initial endoscopic management fails

By following this algorithmic approach and carefully monitoring outcomes, the urinary stream splitting due to tight prosthetic urethra and bladder neck can be effectively managed in most cases.