Urethral Dilatation for Urethral Stricture
For initial treatment of short (<2 cm) bulbar urethral strictures, urethral dilation is an acceptable first-line option with equivalent outcomes to direct visual internal urethrotomy (DVIU), though success rates are modest (35-70%) and decline significantly with increasing stricture length. 1
Initial Treatment Selection Based on Stricture Characteristics
Short Bulbar Strictures (<2 cm)
- Dilation and DVIU can be used interchangeably for initial endoscopic management, as they demonstrate similar success rates (35-70%) and complication profiles. 1
- Success is highest for strictures <1 cm in the bulbar location. 1
- The urethral catheter may be safely removed within 72 hours following uncomplicated dilation—there is no evidence supporting longer catheterization to improve outcomes. 1, 2
Longer Strictures (≥2 cm)
- Urethroplasty should be offered as initial treatment rather than dilation for bulbar strictures ≥2 cm, given the very low success rates of endoscopic approaches. 1
- For strictures >4 cm, endoscopic treatment success drops to only 20%, while buccal mucosa graft urethroplasty achieves >80% success. 1
- Each 1 cm increase in stricture length increases recurrence risk by 1.22-fold after dilation or DVIU. 3
Meatal or Fossa Navicularis Strictures
- Simple dilation or meatotomy may be used for first-time presentation of uncomplicated strictures confined to the meatus or fossa navicularis. 1
- This applies only when NOT associated with previous hypospadias repair, prior failed endoscopic manipulation, previous urethroplasty, or lichen sclerosus. 1
Penile Urethral Strictures
- Urethroplasty should be offered at diagnosis rather than dilation due to expected high recurrence rates with endoscopic treatments. 1
- These strictures are more likely related to hypospadias, lichen sclerosus, or iatrogenic causes, making them poorly responsive to dilation. 1, 2
Technique for Urgent Situations
- When urethral strictures are discovered during attempted catheterization for another surgical procedure, strictures may be dilated over a guidewire to prevent false passage formation or rectal injury. 1
- If the stricture is too dense to dilate adequately, internal urethrotomy may be performed, or suprapubic cystostomy placed if these maneuvers fail. 1
Management After Initial Dilation
For Patients Not Candidates for Urethroplasty
- Self-catheterization after dilation may be recommended to maintain temporary urethral patency. 1
- Self-catheterization for >4 months reduces recurrence rates compared to <3 months. 1, 2
- Regular dilation protocols (weekly for first month, then at 3 and 6 months, then yearly) significantly reduce stricture recurrence rates compared to observation alone. 4
For Recurrent Strictures After Failed Dilation
- Urethroplasty should be offered instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation. 1
- Failure rates exceed 80% with repeated endoscopic procedures. 1
- One exception: For recurrent bulbar urethral strictures <3 cm, dilation combined with drug-coated balloons may be considered, showing 83.2% freedom from intervention at 1 year versus 21.7% with dilation alone. 1, 2
Critical Pitfalls to Avoid
- Repeated endoscopic treatments may cause longer strictures and increase the complexity of subsequent urethroplasty—warn patients that success of future reconstructive procedures may be compromised. 1
- The risk of stricture recurrence is greatest at 6 months, with minimal risk after 12 months. 3
- At 12 months, recurrence rates are approximately 40% for strictures <2 cm and 80% for those >4 cm. 3
- Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise when evaluating recurrent strictures, given the superior success rates of definitive reconstruction. 1, 2