Is urethral dilation a common occurrence?

Urethral Dilation in Urethral Stricture Management

Urethral dilation is a common procedure used in the management of urethral strictures, particularly as an initial treatment option for short bulbar urethral strictures and for urgent management of urinary retention. 1

Epidemiology and Indications

• Urethral strictures are a common cause of obstructed micturition in men, with idiopathic causes being most common in developed countries, followed by iatrogenic causes such as instrumentation and transurethral procedures 1
• In women, strictures are less common and typically iatrogenic, often resulting from traumatic catheterization or multiple urethral dilations 1
• Urethral dilation is commonly used in several clinical scenarios:
  • Initial treatment of short (<2cm) bulbar urethral strictures 1
  • Urgent management of urinary retention 1
  • Discovery of stricture during catheterization for another surgical procedure 1
  • As part of self-dilation protocols to maintain urethral patency after other interventions 1

Efficacy and Success Rates

• Dilation and direct visual internal urethrotomy (DVIU) have similar success and complication rates and can be used interchangeably for initial treatment of urethral strictures 1
• Success rates for urethral dilation vary widely from 10-90% at 12 months 2
• Success rates diminish significantly as stricture length increases, with particularly poor outcomes for:
  • Strictures ≥2cm in length 1
  • Penile urethral strictures 1
  • Recurrent strictures (failure rates >80% for previously treated strictures) 1

Comparison with Other Treatment Options

• For first-time treatment of short bulbar urethral strictures, dilation and DVIU are considered equivalent options 1
• For recurrent strictures, urethroplasty is recommended over repeated dilation or DVIU due to significantly higher success rates 1
• For strictures in the penile urethra, urethroplasty is preferred due to high recurrence rates with endoscopic treatments 1
• For strictures ≥2cm in length, urethroplasty should be offered as initial treatment due to low success rates with dilation or DVIU 1

Self-Dilation Protocols

• Self-catheterization after DVIU can maintain temporary urethral patency in patients who are not candidates for urethroplasty 1
• Regular self-dilation protocols (weekly for the first month, then at 3 months, 6 months, and annually) have been shown to significantly reduce stricture recurrence rates compared to observation alone 3
• Self-dilation for more than 4 months after DVIU reduces recurrence rates compared to performing self-catheterization for less than 3 months 1

Complications and Considerations

• Potential complications of urethral dilation include:
  • Iatrogenic urethral trauma leading to spongiofibrosis 4
  • Bleeding 5
  • Urinary tract infections 5
  • Discomfort during the procedure 5
• Repeated endoscopic treatments may cause longer strictures and increase the complexity of subsequent urethroplasty 1
• Balloon dilation under vision may reduce iatrogenic trauma compared to sequential rigid dilation by applying radial rather than shearing forces 4

Recent Advances

• Drug-coated balloons may be used for recurrent bulbar urethral strictures <3cm in length, with improved freedom from intervention at 1 year (83.2% vs 21.7%) compared to standard DVIU/dilation 1
• Proper evaluation of a urethral stricture may require a period of "urethral rest" without instrumentation to determine the true severity and extent of the stricture 1

Key Pitfalls to Avoid

• Avoid repeated dilations for recurrent strictures, especially for penile urethral strictures or those ≥2cm in length, as this has poor long-term outcomes and may complicate future urethroplasty 1
• Do not overlook the need for accurate delineation of stricture length and location before deciding on treatment approach 1
• Remember that urethral catheter can be safely removed within 72 hours following uncomplicated dilation or DVIU 1

In conclusion, while urethral dilation remains a common and widely used procedure in the management of urethral strictures, its effectiveness is limited by high recurrence rates, particularly for longer strictures, penile urethral strictures, and recurrent strictures. For these cases, urethroplasty offers significantly better long-term outcomes.