Treatment of Penile Urethral Strictures
Penile urethral strictures should be treated with urethroplasty at the time of diagnosis, not with endoscopic procedures like dilation or urethrotomy, as these have unacceptably high failure rates in this location. 1, 2
Why Urethroplasty is the Gold Standard for Penile Strictures
The American Urological Association guidelines are clear that penile urethral strictures have expected high recurrence rates with endoscopic treatment, making urethroplasty the appropriate initial intervention 1. This differs fundamentally from bulbar strictures where endoscopic approaches may be attempted first for short lesions. The penile location has poor outcomes with dilation or internal urethrotomy due to the anatomy and underlying spongiofibrosis 3, 2.
Surgical Approach Selection
The choice of urethroplasty technique depends on stricture length, severity, presence of lichen sclerosus, and whether this is a primary or recurrent stricture:
One-Stage Augmentation Urethroplasty
- Buccal mucosa (from cheek or tongue) is the preferred graft material for one-stage augmentation procedures in penile strictures 2
- This approach is suitable for less severe strictures without extensive lichen sclerosus involvement 2
- Oral mucosa is preferred over penile/preputial skin for penile strictures to avoid complications 3
Staged Urethroplasty (Two or More Stages)
- Severe obstructions, long strictures, recurrent strictures, or those associated with lichen sclerosus require staged reconstruction 2
- The first stage creates a urethral plate, and subsequent stages tubularize the neourethra 2
- This approach respects the glans anatomy and provides better aesthetic preservation 2
Critical Pitfall: Lichen Sclerosus
Always evaluate for lichen sclerosus as the underlying cause, as this fundamentally changes management 4, 5, 2:
- Lichen sclerosus is implicated in up to 30% of urethral strictures and is particularly common in penile strictures 5
- Biopsy should be performed if lichen sclerosus is suspected or if initial treatment fails 4
- Presence of lichen sclerosus typically necessitates staged urethroplasty rather than one-stage repair 2
- Never use hair-bearing skin for reconstruction, as this causes urethral calculi, recurrent UTIs, and obstruction 6, 4
Alternative for Complex or Recurrent Cases
Perineal urethrostomy should be offered as a definitive alternative for patients with:
- Multiple failed urethroplasties where tissue quality is compromised 6
- Extensive lichen sclerosus affecting the penile urethra 6
- Significant medical comorbidities or advanced age precluding extended operative time 6
- Patient preference for a single-stage definitive solution over complex reconstruction 6, 3
This "boutonnière procedure" provides a straightforward solution that avoids the need for repeated complex reconstructions 3.
Referral Considerations
Surgeons without expertise in urethral reconstruction should refer patients to high-volume reconstructive centers, particularly for recurrent strictures, as these centers demonstrate superior outcomes for complex cases 6.