Editing AUA: Urethral Stricture Disease (2023) (section)

==Diagnosis and Evaluation==
===UrologySchool.com Summary===
*'''<span style="color:#ff0000">Mandatory (2):</span>'''
*#'''<span style="color:#ff0000">History and Physical Exam</span>'''
*#'''<span style="color:#ff0000">Urinalysis</span>'''
*'''<span style="color:#ff0000">Optional (4):</span>'''
*#'''<span style="color:#ff0000">Uroflowmetry</span>'''
*#'''<span style="color:#ff0000">Post-void residual</span>'''
*#'''<span style="color:#ff0000">Patient reported measures</span>'''
*#'''<span style="color:#ff0000">Biopsy</span>'''
*'''Confirmation of a urethral stricture diagnosis is made with (3):'''
*#'''Urethroscopy'''
*#'''Retrograde urethrography (RUG)'''
*#'''Ultrasound urethrography'''
*#'''Voiding cystourethrography (VCUG) only if female'''
===Mandatory===
====History and Physical Exam====
*'''History'''
**'''<span style="color:#ff0000">Signs and symptoms:</span>'''
**#'''<span style="color:#ff0000">Voiding</span>'''
**##'''<span style="color:#ff0000">Decreased urinary stream</span>'''
**##'''<span style="color:#ff0000">Incomplete emptying</span>'''
**##'''<span style="color:#ff0000">Dysuria</span>'''
**##'''<span style="color:#ff0000">Urinary spraying</span>'''
**#'''<span style="color:#ff0000">Urinary tract infection (UTI)/epididymitis</span>'''
**#'''<span style="color:#ff0000">Sexual dysfunction</span>'''
**##'''<span style="color:#ff0000">Erectile dysfunction more commonly reported than ejaculatory dysfunction (decreased force of ejaculation)</span>'''
**##'''<span style="color:#ff0000">More common among males with a history of hypospadias failure or lichen sclerosis</span>'''
**#'''<span style="color:#ff0000">Rising post void residual</span>'''
**#May also be asymptomatic
**'''<span style="color:#ff0000">Risk factors</span>'''
**'''<span style="color:#ff0000">Assess preoperative erectile function and urinary continence</span>'''
**'''In the case of pelvic fracture urethral injury (PFUI), document all associated injuries and angiographic embolization of any pelvic vessels'''
*'''<span style="color:#ff0000">Physical exam (4)</span>'''
*#'''<span style="color:#ff0000">Abdomen</span>'''
*#'''<span style="color:#ff0000">Genitals</span>'''
*#'''<span style="color:#ff0000">Digital rectal exam</span>'''
*#'''<span style="color:#ff0000">Assessment of lower extremity mobility for operative positioning</span>'''
====Laboratory====
*'''Urinalysis'''
===Optional===
*'''Options (4):'''
*#'''<span style="color:#ff0000">Uroflowmetry</span>'''
*#'''<span style="color:#ff0000">Post-void residual</span>'''
*#'''<span style="color:#ff0000">Patient reported measures</span>'''
*#'''<span style="color:#ff0000">Biopsy</span>'''
====Uroflowmetry====
*To determine severity of obstruction
**May definitively delineate low flow, which is typically considered to be <12 mL/second
*Patients with symptomatic urethral stricture typically have a reduced peak flow rate
*'''The presence of voiding symptoms as described above, in combination with reduced peak flow rate for age, place patients at higher probability for urethral stricture, therefore indicating definitive evaluation such as cystoscopy, RUG, VCUG, or ultrasound urethrography.'''
====Post-void residual====
*To identify urinary retention
====Patient reported measures====
*Help evaluate the presence and severity of patient symptoms and bother
*Several have been developed specific to urethral stricture disease
====Biopsy====
*'''<span style="color:#ff0000">Indications'''
**'''<span style="color:#ff0000">Must be performed: suspected urethral cancer</span>'''
**'''<span style="color:#ff0000">May be performed: suspected lichen sclerosis</span>'''
***'''Lichen sclerosis associated strictures have a higher association with urethral cancer'''
****2-9% of male patients with LS have been found to have squamous cell carcinoma , further indicating the need for biopsy in selected cases both to confirm the diagnosis as well as to exclude malignant or premalignant changes.
====MRI====
*Can provide important detail in select cases (i.e., PFUI, diverticulum, fistula, cancer).
===Differential Diagnosis===
#'''<span style="color:#ff0000">Benign prostate enlargement in males'''
#'''<span style="color:#ff0000">Pelvic organ prolapse in females'''
#'''<span style="color:#ff0000">Abnormal detrusor function'''

===Preoperative Assessment===
*'''<span style="color:#ff0000">Important stricture characteristics for subsequent treatment planning (4):</span>'''
*#'''<span style="color:#ff0000">Stricture location in the urethra</span>'''
*#'''<span style="color:#ff0000">Length of the stricture</span>'''
*#'''<span style="color:#ff0000">Degree of lumen narrowing</span>'''
*#'''<span style="color:#ff0000">Prior treatments</span>'''
*'''<span style="color:#ff0000">If planning non-urgent intervention for a known stricture, determine the length and location of the urethral stricture by (4):</span>'''
#'''<span style="color:#ff0000">Retrograde urethrography</span>'''
#*See [https://radiopaedia.org/cases/urethral-stricture-post-radiation Figures] of retrograde urethrogram demonstrating post-radiation stricture
#'''<span style="color:#ff0000">Voiding cystourethrography</span>'''
#'''<span style="color:#ff0000">Cystourethroscopy</span>'''
#'''<span style="color:#ff0000">Ultrasound urethography</span>'''

* '''<span style="color:#ff0000">Males with a urethral stricture who have been managed with either an indwelling urethral catheter or self-dilation should generally undergo suprapubic cystostomy placement prior to imaging</span>'''
** This allows the full length of the stricture to develop to determine the true severity of the stricture including its degree of narrowing, and accurate determination of definitive treatment options
**'''A period of “urethral rest” between 4-6 weeks allows the stricture to mature prior to evaluation and management'''.
***A similar period of observation is recommended before reassessing a stricture after failure or dilation or DVIU.
**If a patient can forgo  clean intermittent catheterization (CIC) without acute urinary retention, a SP tube may be omitted during urethral rest.

==== Retrograde urethrogram, with or without voiding cystourethrography ====
*'''<span style="color:#ff0000">Remains the study of choice for delineation of stricture length, location, and severity in men'''
*'''Advantages'''
**'''Can be used to evaluate stricture'''
**#'''Location in the urethra'''
**#'''Length'''
**#'''Degree of lumen narrowing'''
*'''Disadvantages'''
**'''Complete or near complete occlusion of the urethra may make the assessment of the urethra proximal to the stricture difficult.''' 
***In this instance, RUG may be combined with antegrade VCUG or other methods to define the extent of the stricture.
**Image quality and accuracy of RUG is operator-dependent; surgical planning should be based on high quality images generated by experienced practitioners or the surgeon him/herself
*Adverse Events
**Patient discomfort
**UTI (rare)
**Hematuria
**Contrast extravasation (very rare)
**Contrast reaction, should there be an allergy
***Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers

==== Voiding Cystourethrography ====
*Technique
**Performed by passing a small catheter proximal to the stricture, by retrograde filling of the bladder during RUG, or by antegrade filling via a SP tube
*When used in conjunction with urodynamics to asses complex voiding dysfunction, elevated detrusor voiding pressures and urethral narrowing on VCUG indicate a clinically significant urethral stricture or other obstructive process.
**In females, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG)
*'''Advantage'''
**'''Allows visualization of the urethra'''
*'''Disadvantage'''
**'''Not always sufficient to completely delineate the distal extent of an urethral stricture'''

==== Urethroscopy ====
*'''Advantage'''
**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber'''
*'''Disadvantage'''
**'''Length of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases'''
***When flexible cystoscopy does not allow visual assessment proximal to the urethral stricture, small caliber cystoscopy with a ureteroscope or flexible hysteroscope can be useful adjuncts.

==== Ultrasound Urethrography ====
*'''Can be used to evaluate stricture'''
*#'''Location in the urethra'''
*#'''Length'''
*#'''Degree of lumen narrowing'''
*High sensitivity and specificity in the male anterior urethra
*Adverse events
**Patient discomfort
*Dependent on a skilled ultrasonographer
*Further studies are needed to validate its value in clinical practice.