AUA: Urethral Stricture Disease (2023): Difference between revisions

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* [https://pubmed.ncbi.nlm.nih.gov/27497791/ '''2016''']

* [https://pubmed.ncbi.nlm.nih.gov/37096574/ '''2023 Amendment''']

*See [https://www.youtube.com/watch?v=8kCI5DAHii4 Video 1 Review of AUA Guidelines on Urethral Stricture Disease]

*See [https://www.youtube.com/watch?v=-VSyortn7YQ Video 2 Review of AUA Guidelines on Urethral Stricture Disease]

'''See [https://test.urologyschool.com/index.php/Penis_and_Urethra_Surgery#Urethral_stricture_disease Urethral Stricture Disease Chapter Notes]'''

==Background==

*'''See [~~https://test.urologyschool.com/index.php/~~Urethra Urethral Anatomy Chapter Notes]'''

*'''See [[Urethra|Urethral Anatomy Chapter Notes]]'''

*'''“Urethral stricture” is the preferred term for any abnormal narrowing of the anterior urethra''', which is surrounded by the corpus spongiosum; urethral strictures are associated with varying degrees of spongiofibrosis.

**'''Narrowing of the posterior urethra, which lacks surrounding spongiosum, is referred to as a “stenosis.”'''

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===Preoperative Assessment===

*'''~~Stricture~~ characteristics ~~important~~ for subsequent treatment planning (3):'''

*'''Important stricture characteristics for subsequent treatment planning (4):'''

*#'''Stricture location in the urethra'''

*#'''Length of the stricture'''

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#'''Cystourethroscopy'''

#'''Ultrasound urethography'''

*'''Retrograde urethrogram, with or without voiding cystourethrography~~'''~~

**'''Remains the study of choice for delineation of stricture length, location, and severity in men'''

* '''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'''

** 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 ====

*'''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

**Risks

*Adverse Events

***Patient discomfort

**Patient discomfort

***UTI (rare)

**UTI (rare)

***Hematuria

**Hematuria

***Contrast extravasation (very rare)

**Contrast extravasation (very rare)

***Contrast reaction, should there be an allergy

**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

***Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers

**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.

*'''Voiding Cystourethrography~~'''~~

==== 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

**Allows visualization of the urethra but is not always sufficient to completely delineate the distal extent of an urethral stricture.

*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.

**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)

***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'''

*'''Urethroscopy'''

**'''Allows visualization of the urethra'''

**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber~~, but the length~~ of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases.'''

*'''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

==== Ultrasound Urethrography ====

**#Location in the urethra

*'''Can be used to evaluate stricture'''

**#Length

*#'''Location in the urethra'''

**#Degree of lumen narrowing

*#'''Length'''

**High sensitivity and specificity in the male anterior urethra

*#'''Degree of lumen narrowing'''

**Adverse events

*High sensitivity and specificity in the male anterior urethra

***Patient discomfort

*Adverse events

**Dependent on a skilled ultrasonographer

**Patient discomfort

**Further studies are needed to validate its value in clinical practice.

*Dependent on a skilled ultrasonographer

*'''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'''

*Further studies are needed to validate its value in clinical practice.

**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.

==Management==

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* '''Generally divided into tissue transfer vs. non-tissue transfer techniques'''

** '''Non-tissue transfer procedures'''

***'''Primary anastomotic urethroplasty'''

***'''Primary anastomotic urethroplasty'''

***'''Can be performed in both a transecting (removing spongiosum) and non-transecting manner.'''

****'''Transecting anastomotic urethroplasty: involves removal of the narrowed segment of the urethra and corresponding spongiofibrosis with anastamosis of the two healthy ends of the urethra'''

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*****#'''Inner lower lip'''

*****Lingual mucosa is thinner than buccal mucosa, and thus may provide an advantage in reconstructive procedures of the distal urethra and meatus by causing less restriction of the urethral lumen.

*****Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.

*****Buccal mucosal grafts carried a higher risk of donor site swelling, oral numbness, and difficulty with mouth opening, while patients undergoing lingual mucosal grafts demonstrated higher risk of difficulty with speech and difficulty with tongue protrusion

*****When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily.

*****Adverse Events

******Buccal mucosal grafts

*******Donor site swelling

*******Oral numbness

*******Difficulty with mouth opening

******Lingual mucosal grafts

*******Difficulty with speech

*******Difficulty with tongue protrusion

******Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.

****'''Should not be performed with hair-bearing skin'''

*****Hair-bearing skin for substitution urethroplasty may result in urethral calculi, recurrent UTI and a restricted urinary stream due to hair obstructing the lumen

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*****Urethroplasty in these instances is also more complicated, time-consuming, and has a higher failure rate as compared to urethroplasty for less complicated strictures

******Reconstruction of panurethral strictures should be addressed with all of the tools in the reconstructive armamentarium including fasciocutaneous flaps, oral mucosal grafts, or other ancillary tissue sources, and may require a combination of these techniques.

*'''Adverse Events'''

**'''Erectile dysfunction'''

***'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''

***'''The risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%'''

***'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''

**'''Ejaculatory dysfunction'''

***Signs (4):

***#Pooling of semen

***#Decreased ejaculatory force

***#Ejaculatory discomfort

***#Decreased semen volume

***Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction

****Has been reported by up to 21% of men following bulbar urethroplasty

***Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.

====Selecting Approach====

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=====Bulbar urethra=====

*'''Initial treatment of stricture < 2cm: endoscopic management or urethroplasty'''

**'''Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''

**'''Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''

***ROBUST III

***'''ROBUST III'''

****Patients with recurrent anterior urethral strictures <3cm in length

****Randomized to endoscopic treatment of the stricture combined with paclitaxel-coated urethral balloon versus DVIU/dilation

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***'''Increase the complexity of subsequent urethroplasty'''

**In patients who are unable to undergo, or who prefer to avoid urethroplasty, repeated endoscopic procedures, or intermittent self-catheterization may be considered as palliative measures.

===~~Operative~~ Considerations===

*'''Antibiotic ~~prophylaxis'''~~

===Pre-operative Considerations===

**'''Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.'''

***'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''

==== Antibiotic Prophylaxis ====

***'''~~Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention~~.'''

*'''Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.'''

***To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours. Antibiotics can be extended in the setting of ~~an active UTI or if there is an existing indwelling catheter~~

**'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''

*'''[https://www.auanet.org/documents/Guidelines/PDF/Antimicrobial%20Prophylaxis%20Table%20V.pdf 2016 AUA Antibiotic Prophylaxis Guidelines]'''

**'''Antibiotic of choice: cefazolin'''

***'''With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins'''

*~~Positioning~~

*'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''

**~~Positioning of the extremities should~~ be ~~careful to avoid pressure on~~ the ~~calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position.~~

*To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours.

**Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter

==== Deep Venous Thromboembolism Prophylaxis ====

*Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries.

*Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.

===Special Scenarios===

====Perineal Urethrostomy====

==== Positioning ====

*'''When using the lithotomy position, positioning of the extremities should be careful to avoid pressure on (3)'''

*#'''Calf muscles'''

*#'''Peroneal nerve'''

*#'''Ulnar nerve'''

===Post-operative Care===

*'''Following urethral stricture intervention, either a urethral catheter or suprapubic cystostomy catheter should be placed to divert urine from the site of intervention and prevent urinary extravasation'''

**A urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal

*'''Duration of catheterization'''

**'''Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours'''

***There is no evidence that leaving the catheter longer than 72 hours improves safety or outcome, and catheters may be removed after 24-72 hours.

***Catheters may be left in longer for patient convenience or if in the surgeon’s judgment early removal will increase the risk of complications.

**'''In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after DVIU to maintain temporary urethral patency'''.

***The optimal protocol for DVIU plus self-catheterization remains uncertain. However, data suggests that performing self-catheterization for > 4 months after DVIU reduced recurrence rates compared to performing self-catheterization for < 3 months.

***Even though the risk of UTI does not appear to be increased in patients performing self-catheterization after DVIU, the ability to continue with self-catheterization may be limited in some patients by manual dexterity or pain with catheterization

**'''Following open urethral reconstruction, the catheter is maintained typically 2-3 weeks until urethrography or voiding cystography, demonstrates complete urethral healing'''

***'''Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula.'''

***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''

*'''Antibiotic prophylaxis at the time of urethral catheter removal'''

**'''Recommended in patients with certain risk factors'''

===Post-operative follow-up===

*'''Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''

**'''Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.'''

***Other descriptions for successful treatment:

****Absence of postoperative or post-procedural patient reported obstructive voiding symptoms

****Patient-reported improvement in LUTS

****Peak uroflow >15m/sec

****PVR urine <100mL

****"Unobstructed" flow curve shape on uroflowmetry

****Absence of UTI

****Ability to pass a urethral catheter

**Consider more frequent follow-up intervals in '''males at an increased risk for stricture recurrence (7):'''

**#'''Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)'''

**#'''Long stricture'''

**#'''Repair involving a flap or graft'''

**#'''LS-related stricture'''

**#'''Hypospadias-related stricture'''

**#'''Smoking''' (tobacco use)

**#'''Diabetes'''

*Urethral Stents

**Although stents are not currently recommended for the treatment of urethral stricture, patients treated with a urethral stent after dilation or internal urethrotomy should be monitored for recurrent stricture and complications as these can occur at any time point after stent placement.

**Patients with completely obstructed stents may require open urethroplasty and removal of the stent.

**'''Stents do not need to be prophylactically removed and should be followed conservatively unless associated with significant urethral or voiding symptoms.'''

== Special Scenarios ==

===Perineal Urethrostomy===

*'''May be offered as a long term treatment option to patients as an alternative to urethroplasty.'''

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#'''Patient choice'''

#'''Poor access to urologic care'''

=~~===Difficulty with intermittent self-catheterization====~~

===Pelvic fracture urethral injury (PFUI)===

*Urethroplasty may be offered in men with urethral stricture causing difficulty intermittent self-catheterization (e.g., neurogenic bladder)

**In patients with neurogenic bladder, bladder function must be considered prior to urethroplasty as significant underlying detrusor dysfunction it may alter the course of treatment

==Pelvic fracture urethral injury (PFUI)==

*'''Acute management of PFUI'''

**'''Options (2)'''

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*'''Delayed urethroplasty, instead of delayed endoscopic procedures, should be performed after urethral obstruction/obliteration due to PFUI'''

**Repeated endoscopic maneuvers including intermittent catheterization should be avoided because they are not successful in the majority of PFUI, increase patient morbidity, and may delay the time to anastomotic reconstruction.

**Anastomotic reconstruction is performed through a perineal approach. Excision of the scar tissue and wide spatulation of the anastomosis is required.

**Technique

**Several methods to gain urethral length and reduce tension can be employed when necessary including ~~mobilization~~ of the bulbar urethra~~, crural~~ separation~~, inferior~~ pubectomy~~, and supracrural~~ rerouting~~, but in~~ most cases the latter two maneuvers are not required. In rare cases, trans abdominal or transpubic techniques may be required.

***Anastomotic reconstruction is performed through a perineal approach.

***Excision of the scar tissue and wide spatulation of the anastomosis is required.

***'''Several methods to gain urethral length and reduce tension can be employed when necessary including (4):'''

***#'''Mobilization of the bulbar urethra'''

***#'''Crural separation'''

***#'''Inferior pubectomy'''

***#'''Supracrural rerouting'''

***#*In most cases the latter two maneuvers are not required. In rare cases, trans abdominal or transpubic techniques may be required.

*Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.

**Reconstruction should occur when patient factors allow the surgery to be performed, usually within 3 to 6 months after the trauma.

**Patient positioning in the lithotomy (standard, high, or exaggerated) may be limited until orthopedic and lower extremity soft tissues injuries have resolved.

==Bladder Neck Contracture/Vesicourethral Stenosis==

===Bladder Neck Contracture/Vesicourethral Stenosis===

*'''Bladder neck contracture after endoscopic prostate procedure'''

**'''Options (3):'''

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***Reconstruction is challenging and may cause significant urinary incontinence requiring subsequent artificial urinary sphincter implantation.

***For the patient who does not desire urethroplasty, repeat urethral dilation, incision or resection of the stenosis is appropriate. Intermittent self-dilation with a catheter may be used to prolong the time between operative interventions. Suprapubic diversion is an alternative.

~~==Post-operative Care==~~

*'''Following urethral stricture intervention, either a urethral catheter or suprapubic cystostomy catheter should be placed to divert urine from the site of intervention and prevent urinary extravasation'''

=== Difficulty with intermittent self-catheterization ===

**A urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal

*Urethroplasty may be offered in men with urethral stricture causing difficulty intermittent self-catheterization (e.g., neurogenic bladder)

*'''Duration of catheterization'''

**In patients with neurogenic bladder, bladder function must be considered prior to urethroplasty as significant underlying detrusor dysfunction it may alter the course of treatment

**'''Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours'''

***There is no evidence that leaving the catheter longer than 72 hours improves safety or outcome, and catheters may be removed after 24-72 hours.

***Catheters may be left in longer for patient convenience or if in the surgeon’s judgment early removal will increase the risk of complications.

**'''In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after DVIU to maintain temporary urethral patency'''.

***The optimal protocol for DVIU plus self-catheterization remains uncertain. However, data suggests that performing self-catheterization for > 4 months after DVIU reduced recurrence rates compared to performing self-catheterization for < 3 months.

***Even though the risk of UTI does not appear to be increased in patients performing self-catheterization after DVIU, the ability to continue with self-catheterization ~~may be limited in some patients by manual dexterity or pain with catheterization~~

**'''Following open urethral reconstruction, the catheter is maintained typically 2-3 weeks until urethrography or voiding cystography, demonstrates complete urethral healing'''

***'''Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula.'''

***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''

*'''Antibiotic prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors'''.

==~~Complications~~==

*'''Erectile dysfunction'''

**'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''

**'''The risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%'''

**'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''

*'''Ejaculatory dysfunction'''

**Signs (4):

**#Pooling of semen

**#Decreased ejaculatory force

**#Ejaculatory discomfort

**#Decreased semen volume

**Urethroplasty ~~technique~~ may ~~play a role~~ in ~~the occurrence of ejaculatory dysfunction~~

***Has been reported by up to 21% of men ~~following bulbar urethroplasty~~

**Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with ~~pre-operative ejaculatory dysfunction related to obstruction caused by the~~ stricture.

~~==Post~~-~~operative follow-up==~~

*'''Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''

**'''Successful treatment for urethral stricture (~~endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation~~.~~'''~~

***Other descriptions for successful treatment:

****Absence of postoperative or post-procedural patient reported obstructive voiding symptoms

****Patient-reported improvement in LUTS

****Peak uroflow >15m/sec

****PVR urine <100mL

****"Unobstructed" flow curve shape on uroflowmetry

****Absence of UTI

****Ability to pass a urethral catheter

**Consider more frequent follow-up intervals in '''males at an increased risk for stricture recurrence (7)~~:'''~~

**~~#'''Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)'''~~

**#'''Long stricture'''

**#'''Repair involving a flap or graft'''

**#'''LS-related stricture'''

**#'''Hypospadias-related stricture'''

**#'''Smoking''' (tobacco use)

**#'''Diabetes'''

*Urethral Stents

**Although stents are not currently recommended for the treatment of urethral stricture, patients ~~treated~~ with ~~a urethral stent after dilation or internal urethrotomy should~~ be ~~monitored for recurrent stricture and complications~~ as ~~these can occur at any time point after stent placement.~~

**Patients with completely obstructed stents may ~~require open urethroplasty and removal~~ of ~~the stent.~~

**'''Stents do not need to be prophylactically removed and should be followed conservatively unless associated with significant urethral or voiding symptoms.'''

==Female Urethral Stricture==

*Relatively rare ~~condition~~

*Can cause significant LUTS and can impact QoL

=== Epidemiology ===

*Causes

**Most common etiology is iatrogenic

*Relatively rare

***Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.

**Other causes ~~can include blunt~~ pelvic trauma~~, obstetric~~ complications, particularly cephalopelvic disproportion~~, as well as malignancy, radiation, urethral~~ or/and vaginal atrophy~~, recurrent~~ infections~~, and skin~~ disease such as lichen planus and LS.

=== Causes ===

**Idiopathic

*'''Most common etiology is iatrogenic'''

*Diagnosis and Evaluation

**Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.

**History and Physical Exam

*Other causes

***History

**Blunt pelvic trauma

****Storage or voiding symptoms

**Obstetric complications, particularly cephalopelvic disproportion

*****~~Patients may present with LUTS, recurrent UTI, hesitancy~~, poor flow, frequency urgency~~, urethral~~ pain~~, high PVR, or acute~~ urinary retention.

**Malignancy

***Physical exam

**Radiation

****Pelvic exam

**Urethral or/and vaginal atrophy

**Labs

**Recurrent infections

***Urinalysis +/- culture

**Skin disease such as lichen planus and LS.

**Imaging

***Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities

=== Diagnosis and Evaluation ===

**An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.

*History and Physical Exam

*Management

**History

**Urethroplasty should be offered to patients with female urethral strictures

***Storage or voiding symptoms

***Low efficacy of endoscopic treatment

****LUTS

**Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.

*****Hesitancy, poor flow, frequency urgency

****Recurrent UTI

****Urethral pain

****Acute urinary retention

***Can impact QoL

**Physical exam

***Pelvic exam

*Labs

**Urinalysis +/- culture

*Imaging

**Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities

*Other

**Post-void residual

***High PVR

*An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.

=== Management ===

*'''Urethroplasty should be offered to patients with female urethral strictures'''

**'''Low efficacy of endoscopic treatment'''

*Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.

==Questions==

#List risk factors associated with urethral stricture disease

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#What is the risk of new onset erectile dysfunction following anterior urethroplasty?

#*1%

== References ==

* [https://pubmed.ncbi.nlm.nih.gov/27497791/ Wessells, Hunter, et al. "Male urethral stricture: American urological association guideline." ''The Journal of urology'' 197.1 (2017): 182-190.]

* [https://pubmed.ncbi.nlm.nih.gov/37096574/ Wessells, Hunter, et al. "Urethral stricture disease guideline amendment (2023)." ''The Journal of Urology'' 210.1 (2023): 64-71.]

@@ Line 3: / Line 3: @@
 * [https://pubmed.ncbi.nlm.nih.gov/27497791/ '''2016''']
 * [https://pubmed.ncbi.nlm.nih.gov/37096574/ '''2023 Amendment''']
+*See [https://www.youtube.com/watch?v=8kCI5DAHii4 Video 1 Review of AUA Guidelines on Urethral Stricture Disease]
+*See [https://www.youtube.com/watch?v=-VSyortn7YQ Video 2 Review of AUA Guidelines on Urethral Stricture Disease]
 '''See [https://test.urologyschool.com/index.php/Penis_and_Urethra_Surgery#Urethral_stricture_disease Urethral Stricture Disease Chapter Notes]'''
 ==Background==
-*'''See [https://test.urologyschool.com/index.php/Urethra Urethral Anatomy Chapter Notes]'''
+*'''See [[Urethra|Urethral Anatomy Chapter Notes]]'''
 *'''<span style="color:#ff0000">“Urethral stricture” is the preferred term for any abnormal narrowing of the anterior urethra</span>''', which is surrounded by the corpus spongiosum; urethral strictures are associated with varying degrees of spongiofibrosis.
 **'''Narrowing of the posterior urethra, which lacks surrounding spongiosum, is referred to as a “stenosis.”'''
@@ Line 95: / Line 97: @@
 ===Preoperative Assessment===
-*'''<span style="color:#ff0000">Stricture characteristics important for subsequent treatment planning (3):</span>'''
+*'''<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>'''
@@ Line 106: / Line 108: @@
 #'''<span style="color:#ff0000">Cystourethroscopy</span>'''
 #'''<span style="color:#ff0000">Ultrasound urethography</span>'''
-*'''Retrograde urethrogram, with or without voiding cystourethrography'''
-**'''Remains the study of choice for delineation of stricture length, location, and severity in men'''
+* '''<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
-**Risks
+*Adverse Events
-***Patient discomfort
+**Patient discomfort
-***UTI (rare)
+**UTI (rare)
-***Hematuria
+**Hematuria
-***Contrast extravasation (very rare)
+**Contrast extravasation (very rare)
-***Contrast reaction, should there be an allergy
+**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
+***Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers
-**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.
-*'''Voiding Cystourethrography'''
+==== 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
-**Allows visualization of the urethra but is not always sufficient to completely delineate the distal extent of an urethral stricture.
+*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.
-**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)
-***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'''
-*'''Urethroscopy'''
+**'''Allows visualization of the urethra'''
-**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber, but the length of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases.'''
+*'''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
+==== Ultrasound Urethrography ====
-**#Location in the urethra
+*'''Can be used to evaluate stricture'''
-**#Length
+*#'''Location in the urethra'''
-**#Degree of lumen narrowing
+*#'''Length'''
-**High sensitivity and specificity in the male anterior urethra
+*#'''Degree of lumen narrowing'''
-**Adverse events
+*High sensitivity and specificity in the male anterior urethra
-***Patient discomfort
+*Adverse events
-**Dependent on a skilled ultrasonographer
+**Patient discomfort
-**Further studies are needed to validate its value in clinical practice.
+*Dependent on a skilled ultrasonographer
-*'''<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>'''
+*Further studies are needed to validate its value in clinical practice.
-**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.
 ==Management==
@@ Line 180: / Line 197: @@
 * '''<span style="color:#ff0000">Generally divided into tissue transfer vs. non-tissue transfer techniques</span>'''
 ** '''<span style="color:#ff0000">Non-tissue transfer procedures</span>'''
-***'''Primary anastomotic urethroplasty'''
+***'''<span style="color:#ff0000">Primary anastomotic urethroplasty'''
 ***'''<span style="color:#ff0000">Can be performed in both a transecting (removing spongiosum) and non-transecting manner.</span>'''
 ****'''Transecting anastomotic urethroplasty: involves removal of the narrowed segment of the urethra and corresponding spongiofibrosis with anastamosis of the two healthy ends of the urethra'''
@@ Line 199: / Line 216: @@
 *****#'''<span style="color:#ff0000">Inner lower lip</span>'''
 *****Lingual mucosa is thinner than buccal mucosa, and thus may provide an advantage in reconstructive procedures of the distal urethra and meatus by causing less restriction of the urethral lumen.
-*****Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.
-*****Buccal mucosal grafts carried a higher risk of donor site swelling, oral numbness, and difficulty with mouth opening, while patients undergoing lingual mucosal grafts demonstrated higher risk of difficulty with speech and difficulty with tongue protrusion
 *****When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily.
+*****Adverse Events
+******Buccal mucosal grafts
+*******Donor site swelling
+*******Oral numbness
+*******Difficulty with mouth opening
+******Lingual mucosal grafts
+*******Difficulty with speech
+*******Difficulty with tongue protrusion
+******Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.
 ****'''Should not be performed with hair-bearing skin'''
 *****Hair-bearing skin for substitution urethroplasty may result in urethral calculi, recurrent UTI and a restricted urinary stream due to hair obstructing the lumen
@@ Line 217: / Line 241: @@
 *****Urethroplasty in these instances is also more complicated, time-consuming, and has a higher failure rate as compared to urethroplasty for less complicated strictures
 ******Reconstruction of panurethral strictures should be addressed with all of the tools in the reconstructive armamentarium including fasciocutaneous flaps, oral mucosal grafts, or other ancillary tissue sources, and may require a combination of these techniques.
+*'''Adverse Events'''
+**'''<span style="color:#ff0000">Erectile dysfunction'''
+***'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''
+***'''The risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%'''
+***'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''
+**'''<span style="color:#ff0000">Ejaculatory dysfunction'''
+***Signs (4):
+***#Pooling of semen
+***#Decreased ejaculatory force
+***#Ejaculatory discomfort
+***#Decreased semen volume
+***Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction
+****Has been reported by up to 21% of men following bulbar urethroplasty
+***Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.
 ====Selecting Approach====
@@ Line 238: / Line 276: @@
 =====Bulbar urethra=====
 *'''<span style="color:#ff0000">Initial treatment of stricture < 2cm: endoscopic management or urethroplasty</span>'''
-**'''Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''
+**'''<span style="color:#ff0000">Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''
-***ROBUST III
+***'''<span style="color:#ff00ff">ROBUST III'''
 ****Patients with recurrent anterior urethral strictures <3cm in length
 ****Randomized to endoscopic treatment of the stricture combined with paclitaxel-coated urethral balloon versus DVIU/dilation
@@ Line 258: / Line 296: @@
 ***'''Increase the complexity of subsequent urethroplasty'''
 **In patients who are unable to undergo, or who prefer to avoid urethroplasty, repeated endoscopic procedures, or intermittent self-catheterization may be considered as palliative measures.
-===Operative Considerations===
-*'''Antibiotic prophylaxis'''
+===Pre-operative Considerations===
-**'''Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.'''
-***'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''
+==== Antibiotic Prophylaxis ====
-***'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''
+*'''<span style="color:#ff0000">Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.</span>'''
-***To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours. Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter
+**'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''
+*'''[https://www.auanet.org/documents/Guidelines/PDF/Antimicrobial%20Prophylaxis%20Table%20V.pdf 2016 AUA Antibiotic Prophylaxis Guidelines]'''
+**'''<span style="color:#ff0000">Antibiotic of choice: cefazolin'''
 ***'''With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins'''
-*Positioning
+*'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''
-**Positioning of the extremities should be careful to avoid pressure on the calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position.
+*To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours.
+**Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter
+==== Deep Venous Thromboembolism Prophylaxis ====
 *Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries.
 *Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.
-===Special Scenarios===
-====Perineal Urethrostomy====
+==== Positioning ====
+*'''When using the lithotomy position, positioning of the extremities should be careful to avoid pressure on (3)'''
+*#'''Calf muscles'''
+*#'''Peroneal nerve'''
+*#'''Ulnar nerve'''
+===Post-operative Care===
+*'''<span style="color:#ff0000">Following urethral stricture intervention, either a urethral catheter or suprapubic cystostomy catheter should be placed to divert urine from the site of intervention and prevent urinary extravasation</span>'''
+**A urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal
+*'''<span style="color:#ff0000">Duration of catheterization</span>'''
+**'''<span style="color:#ff0000">Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours</span>'''
+***There is no evidence that leaving the catheter longer than 72 hours improves safety or outcome, and catheters may be removed after 24-72 hours.
+***Catheters may be left in longer for patient convenience or if in the surgeon’s judgment early removal will increase the risk of complications.
+**'''In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after DVIU to maintain temporary urethral patency'''.
+***The optimal protocol for DVIU plus self-catheterization remains uncertain. However, data suggests that performing self-catheterization for > 4 months after DVIU reduced recurrence rates compared to performing self-catheterization for < 3 months.
+***Even though the risk of UTI does not appear to be increased in patients performing self-catheterization after DVIU, the ability to continue with self-catheterization may be limited in some patients by manual dexterity or pain with catheterization
+**'''<span style="color:#ff0000">Following open urethral reconstruction, the catheter is maintained typically 2-3 weeks until urethrography or voiding cystography, demonstrates complete urethral healing</span>'''
+***'''Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula.'''
+***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''
+*'''<span style="color:#ff0000">Antibiotic prophylaxis at the time of urethral catheter removal'''
+**'''<span style="color:#ff0000">Recommended in patients with certain risk factors'''
+===Post-operative follow-up===
+*'''<span style="color:#ff0000">Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''
+**'''Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.'''
+***Other descriptions for successful treatment:
+****Absence of postoperative or post-procedural patient reported obstructive voiding symptoms
+****Patient-reported improvement in LUTS
+****Peak uroflow >15m/sec
+****PVR urine <100mL
+****"Unobstructed" flow curve shape on uroflowmetry
+****Absence of UTI
+****Ability to pass a urethral catheter
+**Consider more frequent follow-up intervals in '''males at an increased risk for stricture recurrence (7):'''
+**#'''Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)'''
+**#'''Long stricture'''
+**#'''Repair involving a flap or graft'''
+**#'''LS-related stricture'''
+**#'''Hypospadias-related stricture'''
+**#'''Smoking''' (tobacco use)
+**#'''Diabetes'''
+*Urethral Stents
+**Although stents are not currently recommended for the treatment of urethral stricture, patients treated with a urethral stent after dilation or internal urethrotomy should be monitored for recurrent stricture and complications as these can occur at any time point after stent placement.
+**Patients with completely obstructed stents may require open urethroplasty and removal of the stent.
+**'''Stents do not need to be prophylactically removed and should be followed conservatively unless associated with significant urethral or voiding symptoms.'''
+== Special Scenarios ==
+===Perineal Urethrostomy===
 *'''May be offered as a long term treatment option to patients as an alternative to urethroplasty.'''
@@ Line 280: / Line 371: @@
 #'''<span style="color:#ff0000">Patient choice</span>'''
 #'''<span style="color:#ff0000">Poor access to urologic care</span>'''
-====Difficulty with intermittent self-catheterization====
+===Pelvic fracture urethral injury (PFUI)===
-*Urethroplasty may be offered in men with urethral stricture causing difficulty intermittent self-catheterization (e.g., neurogenic bladder)
-**In patients with neurogenic bladder, bladder function must be considered prior to urethroplasty as significant underlying detrusor dysfunction it may alter the course of treatment
-==Pelvic fracture urethral injury (PFUI)==
 *'''<span style="color:#ff0000">Acute management of PFUI</span>'''
 **'''<span style="color:#ff0000">Options (2)</span>'''
@@ Line 297: / Line 385: @@
 *'''<span style="color:#ff0000">Delayed urethroplasty, instead of delayed endoscopic procedures, should be performed after urethral obstruction/obliteration due to PFUI</span>'''
 **Repeated endoscopic maneuvers including intermittent catheterization should be avoided because they are not successful in the majority of PFUI, increase patient morbidity, and may delay the time to anastomotic reconstruction.
-**Anastomotic reconstruction is performed through a perineal approach. Excision of the scar tissue and wide spatulation of the anastomosis is required.
+**Technique
-**Several methods to gain urethral length and reduce tension can be employed when necessary including mobilization of the bulbar urethra, crural separation, inferior pubectomy, and supracrural rerouting, but in most cases the latter two maneuvers are not required. In rare cases, trans abdominal or transpubic techniques may be required.
+***Anastomotic reconstruction is performed through a perineal approach.
+***Excision of the scar tissue and wide spatulation of the anastomosis is required.
+***'''Several methods to gain urethral length and reduce tension can be employed when necessary including (4):'''
+***#'''Mobilization of the bulbar urethra'''
+***#'''Crural separation'''
+***#'''Inferior pubectomy'''
+***#'''Supracrural rerouting'''
+***#*In most cases the latter two maneuvers are not required. In rare cases, trans abdominal or transpubic techniques may be required.
 *Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.
 **Reconstruction should occur when patient factors allow the surgery to be performed, usually within 3 to 6 months after the trauma.
 **Patient positioning in the lithotomy (standard, high, or exaggerated) may be limited until orthopedic and lower extremity soft tissues injuries have resolved.
-==Bladder Neck Contracture/Vesicourethral Stenosis==
+===Bladder Neck Contracture/Vesicourethral Stenosis===
 *'''Bladder neck contracture after endoscopic prostate procedure'''
 **'''Options (3):'''
@@ Line 321: / Line 416: @@
 ***Reconstruction is challenging and may cause significant urinary incontinence requiring subsequent artificial urinary sphincter implantation.
 ***For the patient who does not desire urethroplasty, repeat urethral dilation, incision or resection of the stenosis is appropriate. Intermittent self-dilation with a catheter may be used to prolong the time between operative interventions. Suprapubic diversion is an alternative.
-==Post-operative Care==
-*'''<span style="color:#ff0000">Following urethral stricture intervention, either a urethral catheter or suprapubic cystostomy catheter should be placed to divert urine from the site of intervention and prevent urinary extravasation</span>'''
+=== Difficulty with intermittent self-catheterization ===
-**A urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal
+*Urethroplasty may be offered in men with urethral stricture causing difficulty intermittent self-catheterization (e.g., neurogenic bladder)
-*'''<span style="color:#ff0000">Duration of catheterization</span>'''
+**In patients with neurogenic bladder, bladder function must be considered prior to urethroplasty as significant underlying detrusor dysfunction it may alter the course of treatment
-**'''<span style="color:#ff0000">Following uncomplicated dilation or DVIU, the urethral catheter can be safely removed within 72 hours</span>'''
-***There is no evidence that leaving the catheter longer than 72 hours improves safety or outcome, and catheters may be removed after 24-72 hours.
-***Catheters may be left in longer for patient convenience or if in the surgeon’s judgment early removal will increase the risk of complications.
-**'''In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after DVIU to maintain temporary urethral patency'''.
-***The optimal protocol for DVIU plus self-catheterization remains uncertain. However, data suggests that performing self-catheterization for > 4 months after DVIU reduced recurrence rates compared to performing self-catheterization for < 3 months.
-***Even though the risk of UTI does not appear to be increased in patients performing self-catheterization after DVIU, the ability to continue with self-catheterization may be limited in some patients by manual dexterity or pain with catheterization
-**'''<span style="color:#ff0000">Following open urethral reconstruction, the catheter is maintained typically 2-3 weeks until urethrography or voiding cystography, demonstrates complete urethral healing</span>'''
-***'''Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula.'''
-***'''A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.'''
-*'''Antibiotic prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors'''.
-==Complications==
-*'''Erectile dysfunction'''
-**'''May occur transiently after urethroplasty with resolution of nearly all reported symptoms ≈6 months postoperatively'''
-**'''The risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%'''
-**'''Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of PFUI repair'''
-*'''Ejaculatory dysfunction'''
-**Signs (4):
-**#Pooling of semen
-**#Decreased ejaculatory force
-**#Ejaculatory discomfort
-**#Decreased semen volume
-**Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction
-***Has been reported by up to 21% of men following bulbar urethroplasty
-**Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.
-==Post-operative follow-up==
-*'''Following dilation, DVIU or urethroplasty for urethral stricture, patients should be monitored to identify symptomatic recurrence'''
-**'''Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.'''
-***Other descriptions for successful treatment:
-****Absence of postoperative or post-procedural patient reported obstructive voiding symptoms
-****Patient-reported improvement in LUTS
-****Peak uroflow >15m/sec
-****PVR urine <100mL
-****"Unobstructed" flow curve shape on uroflowmetry
-****Absence of UTI
-****Ability to pass a urethral catheter
-**Consider more frequent follow-up intervals in '''males at an increased risk for stricture recurrence (7):'''
-**#'''Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)'''
-**#'''Long stricture'''
-**#'''Repair involving a flap or graft'''
-**#'''LS-related stricture'''
-**#'''Hypospadias-related stricture'''
-**#'''Smoking''' (tobacco use)
-**#'''Diabetes'''
-*Urethral Stents
-**Although stents are not currently recommended for the treatment of urethral stricture, patients treated with a urethral stent after dilation or internal urethrotomy should be monitored for recurrent stricture and complications as these can occur at any time point after stent placement.
-**Patients with completely obstructed stents may require open urethroplasty and removal of the stent.
-**'''Stents do not need to be prophylactically removed and should be followed conservatively unless associated with significant urethral or voiding symptoms.'''
 ==Female Urethral Stricture==
-*Relatively rare condition
-*Can cause significant LUTS and can impact QoL
+=== Epidemiology ===
-*Causes
-**Most common etiology is iatrogenic
+*Relatively rare
-***Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.
-**Other causes can include blunt pelvic trauma, obstetric complications, particularly cephalopelvic disproportion, as well as malignancy, radiation, urethral or/and vaginal atrophy, recurrent infections, and skin disease such as lichen planus and LS.
+=== Causes ===
-**Idiopathic
+*'''Most common etiology is iatrogenic'''
-*Diagnosis and Evaluation
+**Patients will often have a history of painful or traumatic catheterization or multiple urethral dilations, which can lead to fibrosis from bleeding and extravasation.
-**History and Physical Exam
+*Other causes
-***History
+**Blunt pelvic trauma
-****Storage or voiding symptoms
+**Obstetric complications, particularly cephalopelvic disproportion
-*****Patients may present with LUTS, recurrent UTI, hesitancy, poor flow, frequency urgency, urethral pain, high PVR, or acute urinary retention.
+**Malignancy
-***Physical exam
+**Radiation
-****Pelvic exam
+**Urethral or/and vaginal atrophy
-**Labs
+**Recurrent infections
-***Urinalysis +/- culture
+**Skin disease such as lichen planus and LS.
-**Imaging
-***Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities
+=== Diagnosis and Evaluation ===
-**An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.
+*History and Physical Exam
-*Management
+**History
-**Urethroplasty should be offered to patients with female urethral strictures
+***Storage or voiding symptoms
-***Low efficacy of endoscopic treatment
+****LUTS
-**Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.
+*****Hesitancy, poor flow, frequency urgency
+****Recurrent UTI
+****Urethral pain
+****Acute urinary retention
+***Can impact QoL
+**Physical exam
+***Pelvic exam
+*Labs
+**Urinalysis +/- culture
+*Imaging
+**Endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis and exclude associated abnormalities
+*Other
+**Post-void residual
+***High PVR
+*An inability to pass even a small catheter due to stenosis in the distal urethra is suggestive of the diagnosis of stricture, although the caliber of the female urethra at which pathological conditions may arise is unknown.
+=== Management ===
+*'''Urethroplasty should be offered to patients with female urethral strictures'''
+**'''Low efficacy of endoscopic treatment'''
+*Urethroplasty may be performed using oral mucosa grafts, vaginal flaps, or a combination of these techniques.
 ==Questions==
 #List risk factors associated with urethral stricture disease
@@ Line 445: / Line 512: @@
 #What is the risk of new onset erectile dysfunction following anterior urethroplasty?
 #*1%
+== References ==
+* [https://pubmed.ncbi.nlm.nih.gov/27497791/ Wessells, Hunter, et al. "Male urethral stricture: American urological association guideline." ''The Journal of urology'' 197.1 (2017): 182-190.]
+* [https://pubmed.ncbi.nlm.nih.gov/37096574/ Wessells, Hunter, et al. "Urethral stricture disease guideline amendment (2023)." ''The Journal of Urology'' 210.1 (2023): 64-71.]