What are the treatment options for urethral strictures?

Treatment Options for Urethral Strictures

Urethroplasty should be offered as the definitive treatment for recurrent anterior urethral strictures, while endoscopic management (urethral dilation or direct visual internal urethrotomy) is appropriate for initial management of short bulbar strictures and urgent cases. 1

Diagnosis and Initial Evaluation

• Key symptoms to identify: Decreased urinary stream, incomplete emptying, dysuria, urinary tract infections, and rising post-void residual 1
• Initial diagnostic workup:
  • History and physical examination
  • Urinalysis
  • Uroflowmetry (peak flow <12 mL/second suggests obstruction)
  • Ultrasound post-void residual assessment 2
• Confirmatory tests:
  • Retrograde urethrography (RUG)
  • Voiding cystourethrography (VCUG)
  • Urethroscopy
  • Ultrasound urethrography 1

Treatment Algorithm

1. Urgent Management

• For symptomatic urinary retention or pre-surgical catheterization needs:
  • Urethral dilation over a guidewire (prevents false passage formation)
  • Direct visual internal urethrotomy (DVIU) for dense strictures
  • Suprapubic cystostomy if above measures fail 1

2. Non-Urgent Management

• Critical step: Determine stricture length and location before treatment planning 1

For Short (<2cm) Bulbar Urethral Strictures:

• First-line options:
  • Urethral dilation
  • Direct visual internal urethrotomy
  • Success rates: 35-70% 2
• Post-procedure care: Remove catheter after 24-72 hours 2

For Recurrent or Long (>2cm) Strictures:

• Preferred treatment: Urethroplasty (90-95% success rate) 1, 2
• Avoid: Repeated endoscopic procedures have diminishing returns
  • After third dilation/urethrotomy, stricture-free rate at 24 months is 0% 3

For Patients Not Candidates for Urethroplasty:

• Self-catheterization after DVIU to maintain temporary patency
• Most effective when continued for >4 months 1

3. Special Considerations

For Patients Dependent on Indwelling Catheter:

• Consider suprapubic cystostomy for "urethral rest" (4-6 weeks)
• Allows tissue recovery and accurate assessment before definitive treatment 1

For Female Urethral Strictures:

• Urethroplasty using oral mucosa grafts or vaginal flaps is preferred over endoscopic treatment 1

Etiology and Complications

• Common causes:
  • Iatrogenic (45%): From urological procedures, catheterization
  • Idiopathic (30%)
  • Bacterial urethritis (20%) 4
• Potential complications:
  • Sexual dysfunction (minority of patients)
  • Ejaculatory issues (up to 21% following bulbar urethroplasty)
  • Obstructive voiding with risk of renal impairment if untreated 2, 4

Follow-up Protocol

• Monitor for recurrent lower urinary tract symptoms
• Perform uroflowmetry and post-void residual measurement
• Consider flexible cystoscopy in selected cases 2

Important Caveats

• Urethral stents (e.g., Urolume wallstent) have high complication rates (58%) and often require additional procedures (45%), making them suitable only for patients unfit for or refusing urethroplasty 5
• Retrograde urethrography alone can be misleading; combining with urethroscopy improves diagnostic accuracy 6
• The success of endoscopic management decreases significantly with each repeated procedure, making urethroplasty the better option for recurrent strictures 3