AUA: Male Urethral Stricture (2016)

See Original Guideline

See Urethral Stricture Disease Chapter Notes

Background

• See 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.”

Risk Factors

• Trauma History Increases Loo Time (5):

1. Trauma
2. Hypospadias surgery
3. Instrumentation or urethral catheterization
4. Lichen sclerosus (LS)
5. Transurethral surgery

• Most common cause depends on country income level
  • In high-income countries: idiopathic (41%) followed by iatrogenic (35%), with transurethral surgery as the most common iatrogenic cause.
  • In low- and middle-income countries: trauma (36%), from

• LS-related strictures
  • Less common etiology
  • Tend to be longer
• Most common location of stricture in males is bulbar urethra
  • Traumatic strictures and stenoses tend to be located in the bulbar and posterior urethra
  • Strictures related to hypospadias and lichen sclerosis are generally located in the penile urethra

Diagnosis and Evaluation

UrologySchool.com Summary

• Mandatory (2):
  1. History and Physical Exam
  2. Urinalysis
• Optional (4):
  1. Uroflowmetry
  2. Post-void residual
  3. Patient reported measures
  4. Biopsy
• Confirmation of a urethral stricture diagnosis is made with (3):
  1. Urethroscopy
  2. Retrograde urethrography (RUG)
  3. Ultrasound urethrography
  4. Voiding cystourethrography (VCUG) only if female

Mandatory

History and Physical Exam

• History
  • Signs and symptoms (5):
    1. Decreased urinary stream
    2. Incomplete emptying
    3. Dysuria
    4. Urinary spraying
    5. Urinary tract infection (UTI)/epididymitis
    6. Rising post void residual
    7. Sexual dysfunction
       1. Erectile dysfunction more commonly reported than ejaculatory dysfunction (decreased force of ejaculation)
       2. More common among males with a history of hypospadias failure or lichen sclerosis
    8. May be asymptomatic
  • Risk factors
  • Assess preoperative erectile function and urinary continence
  • In the case of pelvic fracture urethral injury (PFUI), document all associated injuries and angiographic embolization of any pelvic vessels
• Physical exam (4)
  1. Abdomen
  2. Genitals
  3. Digital rectal exam
  4. Assessment of lower extremity mobility for operative positioning

Laboratory

• Urinalysis

Optional

• Options (4):
  1. Uroflowmetry
  2. Post-void residual
  3. Patient reported measures
  4. Biopsy

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

• Indications
  • Must be performed: suspected urethral cancer
  • May be performed: suspected lichen sclerosis
    • 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 been, 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). In women, imaging of the urinary tract using endourethral MRI, ultrasonogram, and CT scan can confirm presence of periurethral fibrosis76 and exclude associated abnormalities

Differential Diagnosis

• Benign prostate enlargement in men
• Pelvic organ prolapse in women
• Abnormal detrusor function

Preoperative Assessment

• Stricture characteristics important for subsequent treatment planning (3):
  1. Stricture location in the urethra
  2. Length of the stricture
  3. Degree of lumen narrowing
  4. Prior treatments
• If planning non-urgent intervention for a known stricture, determine the length and location of the urethral stricture by (4):

1. Cystourethrscopy
2. Retrograde urethrography
   • See Figures of retrograde urethrogram demonstrating post-radiation stricture
3. Voiding cystourethrography
4. Ultrasound urethography

• Urethroscopy
  • 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.
    • 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.
• RUG, with or without VCUG
  • Allows for identification of stricture location in the urethra, length of the stricture, and degree of lumen narrowing.
  • Remains the study of choice for delineation of stricture length, location, and severity in men
  • 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
    • 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
  • 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
  • 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.
    • In women, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG)
• Ultrasound Urethrography
  • Can be used to evaluate the location, length, and severity of narrowing of strictures
  • High sensitivity and specificity in the male anterior urethra
  • Risks include patient discomfort and dependence on a skilled ultrasonographer
  • While ultrasound urethrography is a promising technique, further studies are needed to validate its value in clinical practice.
• 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.

Management

Urgent

Indications

1. Discovery of symptomatic urinary retention
2. Need for catheterization prior to another surgical procedure

Options

1. Endoscopic (e.g. urethral dilation or direct visual internal urethrotomy [DVIU])
2. Immediate suprapubic cystostomy

• Dilation over a guidewire is recommended to prevent false passage formation or rectal injury
• If the stricture is too dense to be adequately dilated, internal urethrotomy may be performed
• if these initial maneuvers are unsuccessful, or when subsequent definitive treatment for urethral stricture is planned in the near future, SP cystotomy may be performed

Delayed

Options

1. Endoscopic (e.g. urethral dilation or direct visual internal urethrotomy [DVIU])
2. Urethroplasty
   • Generally divided into tissue transfer vs. non-tissue transfer techniques
     • Non-tissue transfer procedures
       • 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
         • Non-transecting anastomotic urethroplasty: preserves the corpus spongiosum, thus allowing the strictured urethra to be excised and reanastamosed, or incised longitudinally through the narrowed segment of the urethra and closed in a Heineke-Mikulicz fashion.
     • Tissue transfer procedures
       • Categorized into (2):
         • Single stage
         • Multi-stage procedures

Approach

• Initial treatment based on location of stricture

Fossa navicularis

• Initial treatment of uncomplicated urethral stricture confined to the meatus or fossa navicularis: simple dilation or meatotomy, with or without guidewire placement
• Associated with previous hypospadias repair, prior failed endoscopic manipulation, previous urethroplasty, or LS: urethroplasty
  • Meatal and fossa navicularis strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments. Furthermore, urethroplasty is the best option for completely obliterated strictures or strictures associated with previous hypospadias repair or LS.

Penile urethra

• Initial treatment: urethroplasty
  • High recurrence rates are expected with endoscopic treatments.
• Penile urethral strictures are more likely to require tissue transfer and/or a staged approach compared to bulbar urethral strictures

Bulbar urethra

• Initial treatment of stricture < 2cm: endoscopic management or urethroplasty
  • Dilation and DVIU have similar success and complication rates and can be used interchangeably.
    • Few studies exist that compare different methods of performing DVIU, but cold knife and laser incision of the stricture scar appear to have similar success rates and may be used interchangeably.
  • Urethroplasty should be offered following failed endoscopic management of anterior urethral strictures
    • Urethral strictures that have been previously treated with dilation or DVIU are unlikely to be successfully treated with another endoscopic procedure with failure rates of >80%.
    • Repeated endoscopic treatment may cause longer strictures, and may 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.
• Initial treatment of stricture ≥2cm: urethroplasty
  • Longer strictures are less responsive to endoscopic treatment

Operative Considerations

• Antibiotic prophylaxis
  • 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
    • Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.
    • 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
    • With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins
• Positioning
  • Positioning of the extremities should be careful to avoid pressure on the calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position.
• 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.

Urethroplasty Technical Considerations

• Grafts for substitution urethroplasty
  • Oral mucosa
    • Should be used as the first choice
    • May be harvested from the
      1. Inner cheeks
         1. Provide the largest graft area
         2. Results in fewer complications and better outcomes as compared to a lower lip donor site
         3. When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily
      2. Undersurface of the tongue
      3. Inner lower lip
  • Should not be performed with hair-bearing skin
  • Should not be performed with allograft, xenograft, or synthetic materials except under experimental protocols
• A single-stage tubularized graft urethroplasty should not be performed.
  • Tubularized urethroplasty consists of a technique in which a graft or flap is rolled into a tube over a catheter to completely replace a segment of urethra. This approach, when attempted in a single stage, has a high risk of restenosis and should be avoided.
  • When no alternative exists, a tubularized flap can be performed with results that are inferior to onlay flaps.
• In LS proven urethral stricture, genital skin should not be used for reconstruction.
  • Treatment of genital skin LS reduces symptoms, such as skin itching and bleeding, and may serve to prevent meatus stenosis and progression to extensive stricture of the penile urethra. Current therapies rely heavily on topical moderate- to high-potency steroid creams, such as clobetasol or mometasone creams.
  • The use of genital skin flaps and grafts should be avoided due to very high long-term failure rates.

• Long multi-segment strictures (panurethral) may be reconstructed with one stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps or a combination of these techniques.

Special Scenarios

Perineal Urethrostomy

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

• Indications (6):

1. Recurrent or primary complex anterior stricture
2. Numerous failed attempts at urethroplasty
3. Extensive LS
4. Advanced age
5. Medical co-morbidities precluding extended operative time
6. Patient choice

Difficulty with intermittent self-catheterization

• Urethroplasty may be offered

Pelvic fracture urethral injury (PFUI)

• Acute management of PFUI
  • Options (2)
    1. Endoscopic primary catheter realignment
    2. Insertion of a SP tube
  • The resulting distraction defect, stenosis or obliteration should be managed with delayed perineal anastomotic urethroplasty
• Preoperative planning of delayed urethroplasty after PFUI
  • Perform retrograde urethrography with voiding cystourethrogram (VCUG) and/or retrograde + antegrade cystoscopy
    • VCUG may include a static cystogram to determine
      1. Competency of the bladder neck mechanism
      2. Level of the bladder neck in relation to the symphysis pubis
• 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.
• Definitive urethral reconstruction for PFUI should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty.

Bladder Neck Contracture/Vesicourethral Stenosis

• Bladder neck contracture after endoscopic prostate procedure
  • Options (3):
    • Dilation
    • Bladder neck incision
    • Transurethral resection
  • Repeat endoscopic treatment may be necessary for successful outcomes
• Post-prostatectomy vesicourethral anastomotic stenosis
  • Options (3):
    • Dilation
    • Vesicourethral incision
    • Transurethral resection
  • Patients should be made aware of the risk of incontinence after any of these procedures.
• Recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis
  • Open reconstruction may be performed
    • The treatment of recalcitrant vesicourethral anastomotic stenosis must be tailored to the preferences of the patient, taking into consideration prior radiotherapy and the degree of urinary incontinence.
    • 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
  • 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.
    • 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):
    1. Pooling of semen
    2. Decreased ejaculatory force
    3. Ejaculatory discomfort
    4. 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):
    1. Prior failed treatment (multiple endoscopic procedures or previous urethroplasty)
    2. Long stricture
    3. Repair involving a flap or graft
    4. LS-related stricture
    5. Hypospadias-related stricture
    6. Smoking (tobacco use)
    7. 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
• Causes
  • Most common etiology is iatrogenic
    • 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.
  • Idiopathic
• Diagnosis and Evaluation
  • History and Physical Exam
    • History
      • Storage or voiding symptoms
        • Patients may present with LUTS, recurrent UTI, hesitancy, poor flow, frequency urgency, urethral pain, high PVR, or acute urinary retention.
    • Physical exam
      • Pelvic exam
  • Labs
    • Urinalysis +/- culture
  • 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.

Questions

1. List risk factors associated with urethral stricture disease
2. What is the most common cause of urethral stricture disease in the developed vs. developing world?
3. What investigations are recommended in patients with suspected urethral stricture disease?
4. What are different methods to characterize a urethral stricture pre-operatively?
5. As per the 2016 AUA Guidelines, what is the management of urethral stricture disease involving the fossa navicularis? Penile urethra? Bulbar urethra?
6. Following uncomplicated DVIU, when should the foley catheter be removed?
7. Which are indications for a perineal urethrostomy?
8. What is the preferred site to harvest a graft for use during anterior urethroplasty?
9. What is the risk of new onset erectile dysfunction following anterior urethroplasty?

Answers

1. List risk factors associated with urethral stricture disease
   • Trauma History Increases Long Pee Time
   1. Trauma
   2. Hypospadia
   3. Idiopathic
   4. LS
   5. Prostate cancer treatment
   6. Transurethral surgery
2. What is the most common cause of urethral stricture disease in the developed vs. developing world?
   1. Developed: idiopathic
   2. Developing: trauma
3. What are the initial investigations recommended in patients with suspected urethral stricture disease?
   1. History and physical exam
   2. Urinalysis
4. What are different methods to characterize a urethral stricture pre-operatively?
   1. Cystourethrscopy
   2. Retrograde urethrography
   3. Voiding cystourethrography
   4. Ultrasound urethography
5. As per the 2016 AUA Guidelines, what is the management of urethral stricture disease involving the fossa navicularis? Penile urethra? Bulbar urethra?
   • Fossa navicularis: dilation, if fails urethroplasty
   • Penile urethra: urethroplasty
   • Bulbar urethra:
     • Stricture <2cm: endoscopic or urethroplasty
     • Stricture >2cm: urethroplasty
6. Following DVIU, when should the foley catheter be removed?
   • Within 72 hours
7. Which are indications for a perineal urethrostomy?
   1. Recurrent or primary complex anterior stricture
   2. Numerous failed attempts at urethroplasty
   3. Extensive LS
   4. Advanced age
   5. Medical co-morbidities precluding extended operative time
   6. Patient choice
8. What is the preferred site to harvest a graft for use during anterior urethroplasty?
   • Oral mucosa (inner cheek, undersurface of tongue, inner lower lip)
9. What is the risk of new onset erectile dysfunction following anterior urethroplasty?
   • 1%