What is the appropriate management for a male patient with intermittent urethral meatus swelling and dysuria?

Management of Intermittent Urethral Meatus Swelling and Dysuria

This patient requires diagnostic imaging with retrograde urethrography (RUG) or urethro-cystoscopy to evaluate for urethral stricture, which is the most likely diagnosis given the intermittent obstructive symptoms, dysuria, and negative infectious workup.

Clinical Reasoning

This presentation is highly suggestive of urethral stricture disease. The key features include:

• Intermittent urethral meatus swelling with dysuria that improves throughout the day matches the classic presentation of urethral stricture, where men commonly report weak stream, incomplete emptying, and urethral pain (dysuria) 1
• Negative urinalysis and culture effectively rules out infectious urethritis or UTI as the primary cause 1
• Trace hematuria without infection can occur with urethral stricture due to local mucosal trauma 2
• History of vigorous exercise may be relevant, as trauma is a recognized cause of stricture, though idiopathic and iatrogenic causes are most common in developed countries 2, 3

Diagnostic Workup Algorithm

Step 1: Objective Voiding Assessment

• Perform uroflowmetry to assess for significant obstruction; peak flow <12 mL/second suggests significant stricture 1
• Measure post-void residual (PVR) by ultrasound to detect incomplete bladder emptying 2, 1

Step 2: Definitive Stricture Diagnosis

• Obtain retrograde urethrography (RUG) as the gold standard imaging study to confirm stricture presence and characterize its length, location, and severity 2, 1, 4
• Consider adding voiding cystourethrography (VCUG) to RUG for complete urethral assessment 2, 4
• Alternative: Urethro-cystoscopy allows direct visualization and can both diagnose and localize the stricture 2, 1, 4

The combination of RUG/VCUG provides superior anatomic detail compared to cystoscopy alone, as imaging delineates stricture length and periurethral involvement that guides treatment selection 2, 5, 4.

Step 3: Physical Examination Specifics

• Examine the penile skin and glans carefully for signs of lichen sclerosus (whitish plaques, scarring), as this etiology requires different management and has higher cancer risk 2, 1
• Inspect the urethral meatus for visible stenosis or scarring 2

Treatment Approach Based on Stricture Characteristics

For Short Bulbar Strictures (<2 cm):

• Initial treatment options include urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty 2
• Endoscopic treatments (dilation/DVIU) have 35-70% success rates for short strictures, with highest success in bulbar strictures <1 cm 2
• Urethroplasty offers 90-95% long-term success but requires general anesthesia and has higher morbidity 2

For Meatal or Fossa Navicularis Strictures:

• First-time presentation: treat with dilation or meatotomy 2
• Recurrent strictures: offer urethroplasty due to poor response to repeated endoscopic treatment 2

For Penile Urethral Strictures:

• Offer urethroplasty at diagnosis rather than endoscopic treatment, as these strictures have high recurrence rates with dilation/DVIU and are often related to lichen sclerosus or iatrogenic causes 2

For Strictures >2 cm or Recurrent Disease:

• Urethroplasty is the definitive treatment with superior long-term outcomes 2

Critical Pitfalls to Avoid

• Do not assume benign prostatic hyperplasia (BPH) is the cause in younger men with obstructive symptoms; urethral stricture must be excluded 1
• Do not rely on urinalysis alone to exclude urethral pathology; stricture diagnosis requires imaging or endoscopy 2, 1
• Do not perform multiple failed endoscopic treatments for recurrent strictures, as this may compromise subsequent urethroplasty success 2
• Do not miss lichen sclerosus on physical examination, as these strictures behave differently and may require more extensive reconstruction 2, 1
• Avoid blind catheterization if urethral injury is suspected; obtain imaging first 6

Post-Diagnosis Counseling

Once stricture is confirmed and characterized:

• Discuss treatment options based on stricture length, location, and patient goals 2
• Explain recurrence risks: endoscopic treatments have higher recurrence rates (30-65%) compared to urethroplasty (5-10%) 2
• Warn about potential complications including erectile dysfunction (usually transient, resolving by 6 months) and ejaculatory dysfunction (up to 21% after bulbar urethroplasty) 2