What is the initial management for a patient with a ureteral stricture?

Initial Management of Ureteral Stricture

For patients with ureteral stricture, the initial management should include urethral endoscopic management (urethral dilation or direct visual internal urethrotomy [DVIU]) or immediate suprapubic cystostomy, especially in cases of symptomatic urinary retention or when catheterization is needed. 1

Diagnostic Evaluation

Before proceeding with treatment, proper diagnosis and characterization of the stricture are essential:

1. Diagnostic Workup:

   • Include urethral stricture in differential diagnosis for patients with decreased urinary stream, incomplete emptying, dysuria, UTIs, and rising post-void residual 1
   • Initial evaluation should include:
     • History and physical examination
     • Urinalysis
     • Uroflowmetry (peak flow typically <12 mL/second indicates obstruction)
     • Ultrasound post-void residual assessment 1

2. Definitive Diagnosis:

   • Confirmation requires one or more of the following:
     • Urethro-cystoscopy
     • Retrograde urethrography (RUG)
     • Voiding cystourethrography (VCUG)
     • Ultrasound urethrography 1

3. Stricture Characterization:

   • Determine length and location of the stricture before non-urgent intervention 1
   • This information is critical for treatment planning and discussing options with patients

Initial Management Algorithm

For Urgent Situations:

1. For symptomatic urinary retention or pre-surgical catheterization needs:

   • Option 1: Urethral dilation over a guidewire (prevents false passage formation)
   • Option 2: Direct visual internal urethrotomy (DVIU) if stricture is too dense for dilation
   • Option 3: Suprapubic (SP) cystostomy if above measures fail 1

2. For patients dependent on indwelling urethral catheter or intermittent self-dilation:

   • Consider suprapubic cystostomy to promote "urethral rest" prior to definitive treatment 1
   • Tissue recovery and stricture maturation typically takes 4-6 weeks 1

For Non-Urgent Situations (Based on Stricture Characteristics):

1. For short (<2 cm) bulbar urethral strictures:

   • Options include:
     • Urethral dilation
     • Direct visual internal urethrotomy (DVIU)
     • Urethroplasty 1
   • Success rates for dilation/DVIU: 35-70% (highest for strictures <1 cm) 1
   • Success rates for urethroplasty: 90-95% 1

2. For longer strictures (>2 cm):

   • Endoscopic management has very low success rates 1
   • Urethroplasty is preferred

Important Considerations

1. Post-procedure catheterization:

   • Catheter can typically be removed after 24-72 hours following dilation or DVIU 1
   • No evidence that longer catheterization improves outcomes 1

2. For patients not suitable for urethroplasty:

   • Consider self-catheterization after DVIU to maintain temporary urethral patency 1

3. Potential complications to monitor:

   • Sexual dysfunction (occurs in a minority of patients) 1
   • Ejaculatory issues (reported in up to 21% following bulbar urethroplasty) 1

Follow-up

Successful treatment is defined as no further need for surgical intervention or instrumentation. Follow-up may include:

• Monitoring for lower urinary tract symptoms
• Uroflowmetry (peak flow >15 mL/second indicates success)
• Post-void residual measurement
• Flexible cystoscopy in some centers 1

The choice between endoscopic management and open surgical reconstruction should consider stricture characteristics, patient factors, and the higher success rates but increased morbidity associated with urethroplasty.