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Urethral Stricture
Aka: Urethral Stricture
- Definitions
- Urethral Stricture
- Abnormal narrowing of the Urethral lumen due to inflammation, dysplasia or scar
- Epidemiology
- Males are primarily affected (rare in females)
- Annual U.S. Incidence: 0.9% in males
- Prevalence
- Young males: 200 per 100,000
- Age >65 year males: 600 per 100,000
- Pathophysiology
- Inflammation (esp. leakage of urine in a break of the Urethral epithelium) or Trauma to the corpus spongiousum
- Causes
- Idiopathic (30% of cases)
- Iatrogenic (45% of cases)
- Indwelling Urinary Catheter (esp. prolonged catheterization; less common with silicone catheters)
- Transurethral Procedures (e.g. TURP)
- Hypospadias correction
- Prostatectomy
- Brachytherapy
- Trauma
- Pelvic Fracture with Urethral rupture
- Straddle or perineal injury (e.g. Bicycle riding)
- Infection
- Bacterial Urethritis (20% of cases)
- Gonorrhea
- Chlamydia
- Tuberculosis
- Schistosomiasis
- Recurrent Urinary Tract Infection (esp. Escherichia coli)
- Inflammatory Conditions
- Lichen Sclerosus et atrophicus
- Balanitis Xerotica Obliterans
- Types
- Posterior Urethra (rare location for strictures)
- Prostatic Urethra
- Membranous Urethra (passes through pelvic floor)
- Anterior Urethra (most cases)
- Bulbar Urethra (fixed to pelvic floor, 50% of strictures)
- Penile Urethra (30% of strictures)
- Glandular Urethra including the navicular fossa (20% of strictures)
- Symptoms
- Decreased, slower, weaker urine flow with prolonged urination time
- Incomplete Bladder emptying
- Urinary Frequency
- Urinary urgency
- Irritative symptoms on urinating (Dysuria)
- Exam
- Skin changes (e.g. Lichen Sclerosus)
- Penile Urethra may have palpable fibrous swelling
- Prostate exam (BPH, Prostatitis, nodularity)
- Diagnostics
- Uroflowmetry (measures urine flow rate over time)
- Low urine flow (flat plateau)
- Prolonged urination time
- Retrograde Cystourethrogram (with or without Voiding Cystourethrogram)
- Identifies Urethral Stricture length and location
- Cystoscopy
- Cystourethrogram is preferred over cystoscopy for defining the extent of stricture
- Cystoscope may not be able to pass the stricture
- Differential Diagnosis
- See Urinary Retention
- See Medication Causes of Urinary Retention
- Benign Prostatic Hyperplasia
- Prostatitis
- Management: Acute
- Manage complete urinary obstruction
- Avoid indwelling Foley Catheter if possible (tissue Trauma worsens the stricture)
- Subprapubic catheter is preferred
- Treat acute infection (e.g. Gonorrhea)
- Management: Surgery
- Precautions
- Stricture recur regardless of treatment strategy
- Endoscopic Procedures
- Bougienage
- Temporary solution only in nonsurgical candidates
- Stricture typically recurs after only 4-6 weeks
- Results in increased Urethral scarring
- Internal urethrotomy
- Stricture scar incised via endoscopy
- Results in increased Urethral scarring that is always longer than the original scar
- Recurs in 50-60% of cases
- Consider in short (<1.5 cm) or first time strictures of the bulbar Urethra
- Open Surgical Procedures
- Stricture resection and end-to-end anastomosis
- Most effective in short strictures (<2.5 cm) of the bulbar Urethra
- Risk of Urethral shortening and downward bent Erection
- Contraindicated in prior Hypospadias repair
- Urethroplasty with Free Graft
- Indicated in long bulbar stricture and penile strictures
- Urethroplasty with pedicled flap
- Indicated in long bulbar stricture and penile strictures
- Complicated by fistula formation (5%) and skin necrosis (15%)
- Perineal Urethostomy (Boutonniere)
- Palliative procedure in complex recurrent strictures
- Bulbar Urethra is Sutured directly into the perineal skin inferior to the Scrotum
- Bulboprostatic anastomosis
- Prognosis
- Strictures recur
- Factors predicting worse outcome
- Extensive stricture
- Distal stricture
- History of prior stricture treatment
- Complications
- Recurrent Urinary Tract Infection
- Acute Urinary Retention
- Bladder diverticulum
- Vesicoureteral reflux
- References
- Abdeen (2021) Urethral Strictures, StatPearls, Treasure Island, accessed 4/13/2022 [PubMed]
- Tritchler (2013) Dtsch Arztebl Int 110(13): 220-6 [PubMed]