What is the best treatment approach for a 31-year-old male with a urethral stricture caused by sexual friction?

Treatment of Urethral Stricture from Sexual Friction in a 31-Year-Old Male

For a 31-year-old male with urethral stricture caused by sexual friction, urethroplasty should be offered as the primary treatment rather than endoscopic procedures, given the traumatic etiology and expected high recurrence rates with dilation or urethrotomy. 1

Initial Diagnostic Evaluation

Before proceeding with treatment, confirm the diagnosis and characterize the stricture:

• Perform urethrocystoscopy or retrograde urethrogram (RUG) with voiding cystourethrogram (VCUG) to establish the exact location, length, and severity of the stricture 1, 2
• Assess for signs of lichen sclerosus (LS), though this is less likely in traumatic strictures; biopsy must be performed if LS or urethral malignancy is suspected 1, 3
• Evaluate urinary flow rate and post-void residual volume to quantify the degree of obstruction 1

Treatment Algorithm Based on Stricture Characteristics

For Short Bulbar Strictures (<2 cm):

• Endoscopic treatment (dilation or direct visual internal urethrotomy) may be considered as initial therapy for first-time presentation of short bulbar strictures 1, 4
• Dilation and DVIU have similar success rates and can be used interchangeably, with cold knife and laser incision showing comparable outcomes 1
• However, be aware that success rates are only 20% for strictures longer than 4 cm, and recurrence rates are high even for shorter strictures 1, 5

For Penile Urethral Strictures:

• Urethroplasty should be offered at the time of diagnosis because penile strictures are unlikely to respond to endoscopic treatments except in select cases of previously untreated, short strictures 1
• Penile strictures more commonly require tissue transfer and/or staged approaches compared to bulbar strictures 1

For Long Bulbar Strictures (≥2 cm):

• Urethroplasty should be offered as initial treatment given the low success rate (only 20%) of DVIU or dilation for longer strictures 1
• Buccal mucosa graft urethroplasty achieves success rates greater than 80% for strictures of this length 1

Definitive Surgical Management: Urethroplasty

Oral mucosa should be used as the first choice when grafts are needed for urethroplasty, as patient satisfaction is higher compared to skin flaps and grafts due to less post-void dribbling and fewer penile skin problems 1

Key Technical Considerations:

• Excision and primary anastomosis is preferred for short bulbar strictures when feasible 4, 6
• Substitution urethroplasty with oral mucosa grafts (dorsal, lateral, or ventral onlay) for longer strictures 1, 6
• Never use hair-bearing skin for substitution urethroplasty, as this results in urethral calculi, recurrent UTIs, and urinary stream obstruction 1, 3
• Do not use allograft, xenograft, or synthetic materials except under experimental protocols 1
• Avoid tubularized urethroplasty in a single stage, as this has high risk of restenosis 1

Perioperative Management

Preoperative:

• Obtain preoperative urine cultures to guide antibiotic choice and treat active UTIs before intervention 1
• Provide appropriate prophylactic antibiotics following AUA Best Practice Policy Statement 1

Postoperative:

• Place a urethral catheter (preferred over suprapubic) following urethroplasty to divert urine and prevent extravasation 1
• Urethral catheter can be safely removed within 72 hours following endoscopic procedures 1, 3
• For open reconstruction, perform RUG or VCUG typically two to three weeks postoperatively to assess for complete urethral healing before catheter removal 1

Critical Pitfalls to Avoid

• Do not perform repeated endoscopic treatments after initial failure, as this increases patient morbidity, may harm sexual function long-term, and compromises success of subsequent reconstructive procedures 1, 3, 5
• Avoid delaying definitive urethroplasty in patients who have already failed one endoscopic attempt, as multiple failures worsen outcomes 3
• Never use genital skin for reconstruction if lichen sclerosus is present, due to very high long-term failure rates 1

Expected Outcomes and Counseling

• Erectile dysfunction may occur transiently after urethroplasty with resolution of nearly all symptoms approximately six months postoperatively 1
• Ejaculatory dysfunction (pooling of semen, decreased force, discomfort, decreased volume) has been reported by up to 21% of men following bulbar urethroplasty 1
• Success is defined as no further need for surgical intervention or instrumentation 1

Follow-Up Protocol

• Monitor for symptomatic recurrence using a combination of clinical assessment, uroflowmetry (peak flow >15 mL/second), post-void residual, and flexible cystoscopy 1
• Urethral stricture recurrence can occur at any time postoperatively, requiring ongoing surveillance 1
• Urethrocystoscopy, ultrasound urethrography, or RUG provides the most definitive confirmation of stricture recurrence 1