Urethral Stricture

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