What is the follow-up care for urethral stricture?

Follow-Up for Urethral Stricture

Consensus has not been reached on a single optimal surveillance protocol, but successful follow-up combines clinical assessment (symptoms, peak flow >15 ml/second, low post-void residual) with selective use of flexible cystoscopy, with most recurrences occurring within the first year. 1

Defining Treatment Success

• Success is defined as no further need for surgical intervention or instrumentation rather than complete anatomic resolution 1
• Two surveillance approaches are acceptable: 1
  • Non-invasive monitoring: Absence of lower urinary tract symptoms, low post-void residual (PVR), non-flattened urinary flow pattern on uroflow, and peak urine flow >15 ml/second 1, 2
  • Endoscopic confirmation: Flexible cystoscopy to directly visualize and confirm lack of recurrence 1

Immediate Post-Procedure Care

After Endoscopic Management (Dilation or DVIU)

• Short catheterization period of 24-72 hours is typically sufficient 2
• No routine imaging required for simple endoscopic procedures 1

After Open Urethroplasty

• Urinary catheter (urethral preferred over suprapubic) should remain in place to divert urine and prevent extravasation 1, 2
• Perform retrograde urethrography (RUG) or voiding cystourethrography (VCUG) at 2-3 weeks post-operatively to assess complete urethral healing before catheter removal 1, 2, 3

Long-Term Surveillance Schedule

First Year (Critical Period)

• Most stricture recurrences develop within the first 12 months, making this the highest-risk period 2
• Monitor at 3,6,9, and 12 months with: 1
  • Symptom assessment (weak stream, incomplete emptying, spraying, dysuria)
  • Uroflowmetry (peak flow <15 ml/second suggests recurrence)
  • Post-void residual measurement
  • Consider flexible cystoscopy if non-invasive parameters are concerning

Beyond First Year

• Continue annual surveillance for at least 24-48 months 4
• Late sequelae can occur years after repair: perineal fistula up to 2 years, urethral stones up to 8 years, and stricture recurrence up to 12 years post-operatively 5
• Extended follow-up is essential, particularly after complex reconstructions 5

Monitoring for Specific Complications

Sexual Dysfunction

• Erectile dysfunction may occur transiently after urethroplasty but typically resolves within 6 months 1, 2
• Ejaculatory dysfunction (pooling, decreased force, discomfort, decreased volume) occurs in up to 21% of men after bulbar urethroplasty 1, 2
• Assess at 6-month and 12-month visits using validated questionnaires 1

Urinary Incontinence

• Rare complication, generally related to original injury rather than treatment 2
• If present, evaluate bladder neck competency with VCUG 3

Stricture Recurrence Patterns

• After single successful dilation or DVIU (stricture-free at 3 months): 55-60% remain stricture-free at 24 months and 50-60% at 48 months 4
• After second procedure for early recurrence (at 3 months): only 30-50% stricture-free at 24 months and 0-40% at 48 months 4
• After third procedure: 0% stricture-free at 24 months—urethroplasty should be offered instead 4
• Recurrence rate is 69% at 3 months and 25% at 12 months after initial endoscopic treatment 6

Critical Pitfalls to Avoid

• Do not rely solely on patient symptoms—asymptomatic patients may have significant residual stricture or elevated PVR 1
• Do not offer repeated endoscopic procedures (>2 attempts) as alternative to urethroplasty—failure rates exceed 80% 2, 4
• Do not discharge patients after 1 year—late complications can occur many years post-operatively 5
• Do not ignore sexual function assessment—proactively counsel patients that most erectile dysfunction resolves by 6 months 1, 2