How should a 70-year-old man with Parkinson's disease (PD) and a long penile urethral stricture be managed?

Management of Long Penile Urethral Stricture in a 70-Year-Old Man with Parkinson's Disease

For a 70-year-old man with Parkinson's disease and a long penile urethral stricture, urethroplasty with oral mucosal grafts should be offered as the primary treatment option, or alternatively, perineal urethrostomy may be considered due to his advanced age and comorbidity. 1

Initial Assessment and Considerations

When managing this patient, several key factors must be considered:

• Stricture characteristics: Long penile urethral stricture has very poor response to endoscopic treatments
• Patient factors: Advanced age (70 years) and Parkinson's disease affect surgical candidacy
• Expected outcomes: Focus on quality of life, voiding function, and minimizing complications

Treatment Algorithm

Step 1: Rule Out Endoscopic Management

• Endoscopic treatments (dilation or direct visual internal urethrotomy) have extremely poor success rates for penile urethral strictures, with only 20% success for strictures >4cm 1
• Penile urethral strictures are more likely to be related to hypospadias, lichen sclerosus, or iatrogenic etiologies, making them particularly resistant to endoscopic management 1

Step 2: Evaluate Surgical Options Based on Patient Factors

Option A: Urethroplasty with Oral Mucosal Grafts

• Success rates >80% for long strictures 1
• Oral mucosa should be the first choice for graft material due to:
  • Higher patient satisfaction
  • Less post-void dribbling
  • Fewer penile skin problems 1

Option B: Perineal Urethrostomy

• Particularly appropriate for this patient due to:
  • Advanced age (70 years)
  • Medical comorbidity (Parkinson's disease)
  • Long/complex stricture 1
• Can be used as a permanent solution with good quality of life outcomes
• Patients with Parkinson's disease often already sit to void, making adaptation easier

Special Considerations for Parkinson's Disease

Patients with Parkinson's disease frequently experience urinary symptoms:

• Storage symptoms occur in 57-83% of patients
• Voiding symptoms in 17-27% 2
• Detrusor overactivity is common (45-93% of patients) 2

These factors must be considered when planning treatment, as they may compound urinary symptoms from the stricture and affect postoperative management.

Surgical Technique Recommendations

If urethroplasty is chosen:

• One-stage or multi-stage techniques may be used depending on stricture complexity
• Oral mucosal grafts are strongly preferred over skin flaps or other materials 1
• Avoid using genital skin, as it has high failure rates, especially if lichen sclerosus is present 1

If perineal urethrostomy is chosen:

• Use a flap-based technique rather than a simple puncture technique to avoid restenosis 1
• An inverted U incision on the perineum is recommended 1

Postoperative Monitoring

• Monitor for recurrent lower urinary tract symptoms
• Perform regular uroflowmetry and post-void residual measurements 3
• Consider flexible cystoscopy for follow-up in selected cases 3

Common Pitfalls to Avoid

1. Do not attempt endoscopic management for long penile urethral strictures as the success rate is extremely low
2. Do not use genital skin for grafting as it has high failure rates, particularly if lichen sclerosus is present
3. Do not use synthetic materials for substitution urethroplasty outside of experimental protocols 1
4. Do not underestimate the impact of Parkinson's disease on lower urinary tract function and postoperative care
5. Avoid tubularized urethroplasty in a single stage, as it has a high risk of restenosis 1

By following these recommendations, the best possible outcome can be achieved for this patient with complex urological needs.