What is the management approach for fibrosis of the urethra (urethral stricture)?

Management of Urethral Stricture (Fibrosis of the Urethra)

The management of urethral stricture should follow a stepwise approach, with urethroplasty being the definitive treatment for recurrent strictures after failed endoscopic management. 1

Diagnosis and Initial Evaluation

• Urethral stricture should be considered in patients presenting with decreased urinary stream, incomplete emptying, dysuria, urinary tract infections, and rising post-void residual 1
• Initial evaluation should include patient-reported symptoms, uroflowmetry (peak flow <15 ml/second suggests obstruction), and ultrasound post-void residual assessment 1
• Definitive diagnosis requires urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography 1
• Determining stricture length and location is essential for treatment planning and should be done before any non-urgent intervention 1

Management Algorithm

Urgent Management

• For symptomatic urinary retention or when catheterization is needed before another surgical procedure:
  • Urethral dilation over a guidewire (to prevent false passage formation) 1
  • Direct visual internal urethrotomy (DVIU) for strictures too dense for dilation 1
  • Suprapubic cystostomy if the above measures fail or when definitive treatment is planned soon 1

Initial Treatment for Short (<2 cm) Bulbar Urethral Strictures

• Either urethral dilation or DVIU may be performed as first-line treatment 1
• Success rates for endoscopic management range from 35-70%, with better outcomes for strictures <1 cm 1
• Consider "urethral rest" via suprapubic cystostomy for 4-6 weeks prior to definitive treatment to allow tissue recovery and accurate assessment 1

Management of Recurrent Strictures

• Urethroplasty should be offered instead of repeated endoscopic management for recurrent anterior urethral strictures 1
• Repeated endoscopic treatments have >80% failure rate and may increase stricture length and complexity of subsequent urethroplasty 1
• For patients who are not candidates for urethroplasty, intermittent self-catheterization after DVIU may maintain temporary urethral patency 1
• Drug-coated balloon dilation may be considered for recurrent bulbar urethral strictures <3cm in length 1

Specific Treatment Based on Stricture Location

Bulbar Urethral Strictures

• Short strictures (<2 cm): Initial endoscopic management (dilation or DVIU) 1
• Long strictures or recurrent strictures: Urethroplasty options include:
  • Excision and primary anastomosis for short strictures 1
  • Non-transecting end-to-end anastomosis 2
  • Augmentation urethroplasty with buccal mucosa graft for longer strictures 1, 2

Penile Urethral Strictures

• Endoscopic treatment has low success rates; urethroplasty is preferred 2
• Oral mucosa grafts are the preferred tissue for reconstruction 2
• One or multiple stage procedures depending on stricture complexity 2

Strictures Due to Lichen Sclerosus

• Avoid using genital skin for reconstruction due to high failure rates 1
• Use non-genital tissue grafts (buccal mucosa preferred) 1
• Consider staged repair with complete excision of the urethral plate 1

Postoperative Care and Follow-up

• Urinary catheter placement following intervention to divert urine and prevent extravasation 1
• Catheterization period of 24-72 hours is typically sufficient after dilation or DVIU 1
• RUG or VCUG typically performed 2-3 weeks after open urethral reconstruction 1
• Monitor for complications (stricture recurrence, erectile dysfunction, incontinence) for at least one year 1
• Surveillance may include uroflowmetry, retrograde urethrogram, and/or cystoscopy 1

Complications to Monitor

• Erectile dysfunction may occur transiently after urethroplasty, with resolution typically within six months 1
• Ejaculatory dysfunction (pooling of semen, decreased force, discomfort) reported in up to 21% of men following bulbar urethroplasty 1
• Urinary incontinence is rare and generally related to the original injury rather than treatment 1
• Stricture recurrence is the most common complication, typically developing within the first year 1

Special Considerations

• Perineal urethrostomy (boutonnière procedure) may be considered for patients with complex strictures or those seeking a straightforward solution 2
• Novel techniques such as transurethral resection of fibrotic scar tissue combined with temporary urethral stenting show promise but require further investigation 3
• High-pressure balloon dilation may offer longer stricture-free periods compared to traditional optical internal urethrotomy in selected cases 4