Can local anesthesia be used for a patient with a urethral stricture presenting to the Emergency Department?

Local Anesthesia for Urethral Procedures in Emergency Department Urethral Stricture Patients

Local anesthesia can be used for urgent urethral procedures in the Emergency Department setting for patients with urethral stricture, but only for simple urethral dilation or catheter placement—not for direct visual internal urethrotomy (DVIU), which requires proper operating room conditions with appropriate anesthesia and equipment. 1

Emergency Department Management Algorithm

Immediate Priorities for Symptomatic Urethral Stricture

• For urgent management of urethral stricture presenting with symptomatic urinary retention, surgeons may utilize urethral endoscopic management (urethral dilation) or immediate suprapubic (SP) cystostomy. 1

• Repeated attempts at placing a urethral catheter should be avoided given the likelihood of increasing injury extent and delaying drainage. 1

• The first priority in management is establishment of urinary drainage, with suprapubic tube (SPT) placement remaining the accepted treatment for the vast majority of cases requiring urgent intervention. 1

When Local Anesthesia Is Appropriate

Local urethral anesthesia can be used for:

• Simple urethral catheter placement attempts (limited attempts only) 1
• Gentle urethral dilation in stable patients when performed by experienced operators 1
• Diagnostic urethro-cystoscopy to confirm stricture presence 1

When Local Anesthesia Is NOT Appropriate in the ED

The Emergency Department setting is inappropriate for endoscopic realignment or DVIU of urethral strictures, even with local anesthesia. 1

• DVIU requires proper operating room conditions with flexible or rigid cystoscopes, video monitors, fluoroscopy, and a regular urology operating room team—requirements best met once the patient has stabilized. 1

• Prolonged and heroic attempts at endoscopic procedures must be avoided as the process may increase injury severity and long-term sequelae, delay other medical services the patient requires, and has not been shown to improve long-term outcomes. 1, 2

Local Anesthesia Techniques for Outpatient Urethral Procedures (When Appropriate)

Evidence for Local Anesthesia Efficacy

When DVIU is performed in appropriate outpatient settings (not the ED), local anesthesia has demonstrated feasibility:

• Intraurethral 2% lidocaine gel achieved successful completion of internal urethrotomy in 96.1% of patients (151 of 157), with most patients experiencing mild to moderate pain. 3

• The addition of intravenous sedoanalgesia to local urethral anesthesia significantly improved pain scores (mean VAS 2.86 cm versus 4.5 cm without sedation, P=0.001). 4

• Intracorpus spongiosum anesthesia (3 mL of 1% lidocaine injected into the glans penis) achieved successful completion in all 23 patients, with 95.7% reporting no pain or discomfort. 5

Critical Limitations and Contraindications

Local anesthesia should NOT be used for:

• Strictures at or near the membranous urethra—these require open urethroplasty by experienced reconstructive surgeons to avoid catastrophic sphincter injury. 2

• Pelvic fracture-associated urethral injuries, which frequently involve the membranous urethra and sphincter mechanism. 2

• Any situation requiring prolonged manipulation or multiple attempts, as conversion to general anesthesia may be needed (13% conversion rate in one series). 4

Recommended ED Approach for Urethral Stricture with Retention

Step 1: Initial Assessment

• Confirm suspected stricture using history and physical examination findings (decreased urinary stream, incomplete emptying, urinary retention). 1

Step 2: Establish Drainage

• Attempt gentle urethral catheter placement (single attempt only) with intraurethral lidocaine gel if patient is stable and cooperative. 1

• If initial catheter placement is unsuccessful, immediately proceed to suprapubic cystostomy placement rather than repeated urethral attempts. 1

• SPT placement is the definitive ED intervention for urethral stricture with retention when urethral catheterization fails. 1

Step 3: Definitive Management Planning

• Once drainage is established, arrange for proper diagnostic imaging (retrograde urethrography, voiding cystourethrography, or urethro-cystoscopy) to determine stricture length and location before any definitive treatment. 1

• Definitive endoscopic or surgical treatment should be performed in the operating room setting after appropriate imaging and anesthetic planning. 1

Critical Pitfalls to Avoid

• Never perform multiple forceful attempts at urethral catheterization, as this increases injury extent and may convert a simple stricture into a complex urethral injury. 1

• Do not attempt DVIU in the Emergency Department—this requires proper OR equipment, imaging capability, and anesthesia support. 1

• Avoid any urethral manipulation in patients with suspected membranous urethral involvement (pelvic fracture, prior pelvic surgery) without proper imaging first. 1, 2

• Do not use local anesthesia alone for procedures expected to take more than a few minutes or require significant manipulation—conversion rates to general anesthesia can reach 13% even in selected patients. 4