What are the treatment options for penile constriction during urination?

Treatment of Penile Constriction During Urination (Urethral Stricture)

For penile urethral strictures causing constriction during urination, urethroplasty should be offered as the primary treatment rather than endoscopic procedures, as penile strictures have high recurrence rates (>80%) with dilation or urethrotomy. 1

Why Penile Strictures Require Different Management

Penile urethral strictures behave differently than bulbar strictures and are unlikely to respond to simple endoscopic treatments. 1 These strictures are more commonly related to:

• Hypospadias complications 1
• Lichen sclerosus 1
• Iatrogenic causes (prior instrumentation or surgery) 1

Most patients with penile urethral strictures should be offered urethroplasty at the time of diagnosis, avoiding repeated endoscopic treatments that will likely fail. 1

Initial Diagnostic Workup

Before any treatment, you must determine the exact stricture characteristics:

• Perform definitive imaging: retrograde urethrography (RUG), voiding cystourethrography (VCUG), urethro-cystoscopy, or ultrasound urethrography 2, 3
• Measure stricture length precisely - this determines whether single-stage or multi-stage reconstruction is needed 1, 2
• Identify the etiology - lichen sclerosus requires non-genital tissue grafts 2

Peak urinary flow <15 ml/second on uroflowmetry suggests significant obstruction and warrants further evaluation. 2

Treatment Algorithm Based on Stricture Characteristics

For Penile Urethral Strictures (Your Patient's Presentation)

Primary recommendation: Urethroplasty 1

• Penile strictures are more likely to require tissue transfer and/or staged approaches compared to bulbar strictures 1
• Use oral mucosa (buccal mucosa preferred) as first-choice graft material 1, 2
• Patient satisfaction is higher with oral mucosa compared to skin flaps due to less post-void dribbling and fewer penile skin problems 1

If Lichen Sclerosus is Present

• Use non-genital tissue grafts (buccal mucosa strongly preferred) 2
• Consider staged repair with complete excision of the urethral plate 2

For Multi-Segment or Long Strictures (>10 cm)

Reconstruction may use: 1

• Oral mucosal grafts
• Penile fasciocutaneous flaps
• Combination techniques
• Success rates appear similar across these approaches in published series 1

What NOT to Do

Critical pitfalls to avoid:

• Never use hair-bearing skin for reconstruction - this causes urethral calculi, recurrent UTIs, and obstruction from hair in the lumen 1
• Do not perform tubularized urethroplasty in single stage - this has high restenosis rates 1
• Avoid allograft, xenograft, or synthetic materials except under experimental protocols - long-term success rates are unknown 1
• Do not perform repeated endoscopic treatments - failure rates exceed 80% and may complicate subsequent urethroplasty 1, 4

When Endoscopic Treatment Might Be Considered

Endoscopic management (dilation or direct visual internal urethrotomy) may be appropriate ONLY for: 2, 4

• Short (<2 cm) bulbar strictures as first-line treatment (success rates 35-70%) 2, 4
• Acute urinary retention requiring urgent decompression before definitive surgery 2
• Previously untreated, short penile strictures in highly select cases 1

For any other penile stricture presentation, proceed directly to urethroplasty. 1

Postoperative Management

• Urinary catheter remains in place to divert urine and prevent extravasation 2
• Perform RUG or VCUG at 2-3 weeks post-operatively before catheter removal 2
• Monitor at 3,6,9, and 12 months with symptom assessment, uroflowmetry, and post-void residual 2

Expected Complications to Counsel About

• Erectile dysfunction: May occur transiently but typically resolves within 6 months 2
• Ejaculatory dysfunction: Occurs in up to 21% (pooling of semen, decreased force, discomfort) 2
• Stricture recurrence: Most common complication, typically within first year 2
• Urinary incontinence is rare and usually related to original injury rather than treatment 2

Alternative for Non-Surgical Candidates

Perineal urethrostomy may be offered as permanent alternative to urethroplasty for: 1

• Advanced age
• Medical comorbidities precluding extended operative time
• Extensive lichen sclerosus
• Multiple failed urethroplasty attempts
• Patient preference