What are the management options for a patient with a penile urethral stricture?

Management of Penile Urethral Stricture

Surgeons should offer urethroplasty to patients with penile urethral strictures at the time of diagnosis, rather than attempting endoscopic treatments, because of the expected high recurrence rates (>80%) with dilation or urethrotomy. 1, 2

Why Penile Strictures Require Different Management

Penile urethral strictures behave fundamentally differently than bulbar strictures and warrant immediate definitive surgical reconstruction rather than endoscopic temporizing measures. 1

• Penile strictures are more likely related to hypospadias, lichen sclerosus, or iatrogenic etiologies compared to bulbar strictures, making them inherently resistant to simple endoscopic treatments 1
• Endoscopic treatments (dilation or DVIU) have very low success rates for penile strictures except in highly select cases of previously untreated, short strictures 1
• Repeated endoscopic procedures may compromise subsequent reconstructive success, so avoiding multiple failed attempts is critical 1

Diagnostic Workup Before Treatment

Before proceeding with urethroplasty, stricture characteristics must be precisely defined:

• Determine stricture length and location using retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography 1
• Urethro-cystoscopy identifies and localizes the stricture and evaluates distal urethral caliber, though it cannot assess length or proximal anatomy 1
• Consider suprapubic cystostomy for "urethral rest" (4-6 weeks) in patients dependent on indwelling catheters or intermittent catheterization to allow tissue recovery and accurate stricture assessment before definitive surgery 1, 2

Urethroplasty Techniques for Penile Strictures

Penile urethral strictures are more likely to require tissue transfer and/or staged approaches compared to bulbar strictures 1

• For strictures associated with lichen sclerosus, use non-genital tissue grafts (buccal mucosa preferred) and consider staged repair with complete excision of the urethral plate 2
• Long multi-segment strictures can be reconstructed with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or combinations 1
• Excision and primary anastomosis is generally not suitable for penile strictures due to location and length considerations 1

Urgent Management Scenarios

If a penile stricture is discovered during attempted catheterization or in acute urinary retention:

• Urethral dilation over a guidewire or direct visual internal urethrotomy may be performed for immediate relief 1
• Suprapubic cystostomy provides urinary drainage if initial maneuvers fail or when definitive treatment is planned soon 1
• These are temporizing measures only—definitive urethroplasty should still be offered subsequently 1

Postoperative Management

• Urinary catheter should remain in place to divert urine and prevent extravasation after urethroplasty 2, 3
• Perform RUG or VCUG at 2-3 weeks post-operatively to assess complete urethral healing before catheter removal 2
• Monitor at 3,6,9, and 12 months with symptom assessment, uroflowmetry, post-void residual measurement, and flexible cystoscopy if non-invasive parameters are concerning 2

Complications to Monitor

• Erectile dysfunction may occur transiently but typically resolves within 6 months 2
• Ejaculatory dysfunction (pooling, decreased force, discomfort) occurs in up to 21% of men following urethroplasty 2
• Stricture recurrence is most common within the first year and requires ongoing surveillance 2
• Urinary incontinence is rare and generally related to the original injury rather than treatment 2

Critical Pitfalls to Avoid

• Do not attempt repeated endoscopic treatments for penile strictures—this wastes time, increases costs, and may compromise subsequent reconstruction 1, 4
• Do not use genital skin grafts for lichen sclerosus-related strictures—buccal mucosa is preferred 2
• Do not rely solely on patient symptoms during follow-up—asymptomatic patients may have significant residual stricture or elevated post-void residual 2
• Do not ignore sexual function assessment—proactively counsel patients that most erectile dysfunction resolves by 6 months 2