para>Meatal stenosis is a common pediatric diagnosis seen in circumcised boys. One theory is that irritation from friction on the meatus after circumcision leads to inflammation and scar formation. ‚
Genetics
No genetic risk factors are known. ‚
Risk Factors
- Urethral trauma
- Catheterization
- Transurethral surgery (i.e., transurethral resection of the prostate or TURP)
- Hypospadias or other urethral surgery
- Unprotected sexual intercourse
- Untreated gonococcal urethritis
General Prevention
- Appropriate catheterization technique
- Prevention of sexually transmitted infections
Commonly Associated Conditions
- Urinary tract infections (UTIs)
- If severe luminal narrowing or complete obliteration of the urethral lumen occurs, urinary retention and acute renal failure may develop.
- Bladder stones
- Loss of bladder contractility could develop if left untreated for many years.
Diagnosis
History
- Obstructive voiding symptoms
- Straining
- Decreased force of stream
- Hesitancy
- Dribbling
- Incomplete emptying
- Frequency
- UTIs including prostatitis and epididymitis
- Urinary retention
- Dysuria
- Incontinence
- Previous sexually transmitted diseases (STDs)
- Prior urethral surgery or trauma
- Hematuria
Physical Exam
- Suprapubic fullness or tenderness
- Blood at the meatus
- Hematoma
- Palpable spongiofibrosis
Differential Diagnosis
- Benign prostatic hypertrophy (BPH)
- Bladder neck contracture
- Posterior urethral distraction defect
- Neurogenic bladder
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Urinalysis
- Uroflowmetry (4)[C]
- Peak flow rate <15 suggestive of obstruction
- Visualization of the shape of the curve is more important. A flat-topped curve is suggestive of obstruction.
- At least 150 mL voided volume needed for proper interpretation
- Postvoid residual (PVR)
Diagnostic Procedures/Other
- Retrograde urethrogram (RUG)
- Fill the urethra with 10 " “20 mL of dilute water-soluble contrast by injecting at the meatus.
- The patient must be placed at a 45-degree angle with the penis on stretch to accurately define the bulbar urethra.
- Incorrect positioning can lead to underestimation of stricture length, particularly in the bulbar urethra (4)[C].
- Voiding cystourethrogram (VCUG) is helpful to visualize the urethra proximal to the stricture (4)[C].
- Cystoscopy is the gold standard for diagnosis. The urethra proximal to the stricture often cannot be evaluated (4)[C].
- Ultrasound can be used as an adjunct to better define stricture length and spongiofibrosis (4)[C].
- CT/marginal resonance imaging (MRI) is typically not necessary but can be helpful in evaluating for pelvic fracture (4)[C].
Test Interpretation
- Position, length, caliber, and degree of spongiofibrosis need to be assessed for every stricture (4)[C].
- It is important to rule out associated fistula, false passage, and stones (4)[C].
Treatment
General Measures
- There are no recommended medical treatments.
- Surgical treatment varies depending on the characteristics of the stricture.
- Patients should be adequately counseled regarding realistic expectations and goals of surgery.
Issues for Referral
Any patient diagnosed with a urethral stricture should be evaluated and treated by a urologist and subspecialization in reconstruction may be required. ‚
Surgery/Other Procedures
- Urethral dilation
- Technique: Stretch the scar tissue without causing bleeding. Bleeding indicates a tear, which will heal and lead to worsening stricture (5)[C].
- Dilation is thought to be palliative not curative (5)[B].
- Direct visual internal urethrotomy (DVIU) (5)[C]
- Technique: Incise the scar tissue endoscopically. One incision is made at the 12 o 'clock position or multiple incisions radially.
- Healing is by secondary intention.
- Can be attempted once for a short bulbar stricture with minimal spongiofibrosis with an expected success rate as high as 75%
- Repeat DVIUs have very low success rates and should be thought of as temporary palliation not curative. This potentially worsens strictures making reconstruction more difficult.
- Urethroplasty: Open surgery is the gold standard for urethral reconstruction (4)[C].
- Three basic types of open reconstruction procedures:
- Excision and primary anastomosis (EPA)
- Grafts
- Flaps
- EPA (6)[C]
- Highest success rate for reconstructive options at approximately 93%
- Technique: Excise the scar tissue, mobilize the urethra, and reanastomose healthy tissue.
- Used for shorter bulbar strictures
- Based on the principle that there is antegrade and retrograde blood supply to the urethra
- Grafts (7)[C]
- Transfer tissue without its blood supply to a new location.
- Buccal mucosa is used most often although bladder mucosa, rectal mucosa, and skin grafts have been described.
- Grafts survive by a process called take which is broken down into imbibition and inosculation.
- Imbibition: The graft receives nutrients via osmosis for the first 48 hours.
- Inosculation: During the subsequent 48 hours, microcirculation is established.
- Grafts are commonly placed onto the urethra in a dorsal or ventral onlay fashion.
- Grafts are used most commonly on longer bulbar strictures or any stricture in the penile urethra or fossa navicularis.
- Flaps (7)[C]
- Tissue transfer on a pedicle with its own blood supply
- Non " “hair-bearing penile skin is used most commonly.
- Used most commonly for penile and fossa navicularis strictures
- Commonly placed in a dorsal onlay fashion
- Flaps and grafts have approximately 85% success rate in most series (7)[C].
- Surgeries can be done in one stage or multiple stages if complex reconstruction is required (7)[C].
Pediatric Considerations
Meatal stenosis is treated surgically with a meatotomy or meatoplasty. This typically involved a ventral incision to enlarge the meatus.
Stricture recurrence after meatotomy should raise clinical suspicion for LS.
‚
Complementary & Alternative Therapies
Injection of steroids or mitomycin C after DVIU can be tried although there is limited evidence of efficacy (5)[C]. ‚
Inpatient Considerations
Admission Criteria/Initial Stabilization
Most urethral surgery can be done as an outpatient. Patients may be observed for 24 " “48 hours in complicated reconstruction cases. ‚
Ongoing Care
Follow-up Recommendations
- RUG at the time of catheter removal to ensure there is no leak (4)[C]
- Consider history and uroflowmetry routinely to evaluate for recurrence (4)[C].
- If symptoms recur or a decrease in flow rate is seen, a repeat RUG and cystoscopy are advised (4)[C].
Patient Monitoring
Monitor for recurrence of the symptoms. ‚
Diet
No restrictions ‚
Prognosis
Open urethral reconstruction carries a relatively good prognosis for a patent urethra with voluntary voiding. ‚
Complications
- Bleeding
- Infection
- Stricture recurrence
- Fistula
- Incontinence
- Postvoid dribbling
- Erectile dysfunction
- Chordee
References
1.Santucci ‚ RA, Joyce ‚ GJ, Wise ‚ M. Male urethral stricture disease. J Urol. 2007;177(5):1667 " “1674. ‚
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2.Fenton ‚ AS, Morey ‚ AF, Aviles ‚ R, et al. Anterior urethral strictures: etiology and characteristics. Urology. 2005;65(6):1055 " “1058. ‚
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3.Stewart ‚ L, McCammon ‚ K, Metro ‚ M, et al. SIU/ICUD consultation on urethral strictures: anterior urethra-lichen sclerosus. Urology. 2014;83(3)(Suppl):S27 " “S30. ‚
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4.Angermeier ‚ KW, Rourke ‚ KF, Dubey ‚ D, et al. SIU/ICUD consultation on urethral strictures: evaluation and follow-up. Urology. 2014;83(3)(Suppl):S8 " “S17. ‚
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5.Buckley ‚ JC, Heyns ‚ C, Gilling ‚ P, et al. SIU/ICUD consultation on urethral strictures: dilation, internal urethrotomy, and stenting of male anterior urethral strictures. Urology. 2014;83(3)(Suppl):S18 " “S22. ‚
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6.Morey ‚ AF, Watkin ‚ N, Shenfeld ‚ O, et al. SIU/ICUD consultation on urethral strictures: anterior urethra " ”primary anastomosis. Urology. 2014;83(3)(Suppl):S23 " “S26. ‚
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7.Chapple ‚ C, Andrich ‚ D, Atala ‚ A, et al. SIU/ICUD consultation on urethral strictures: the management of anterior urethral stricture disease using substitution urethroplasty. Urology. 2014;83(3)(Suppl):S31 " “S47. ‚
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Additional Reading
- Jordan ‚ GH, McCammon ‚ KA. Surgery of the penis and urethra. In: Wein ‚ AJ, Louis ‚ R, eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders-Elsevier; 2012.
Codes
ICD09
- 598.9 Urethral stricture, unspecified
- 598.00 Urethral structure due to unspecified infection
- 598.1 Traumatic urethral stricture
- 598.8 Other specified causes of urethral stricture
- 098.0 Gonococcal infection (acute) of lower genitourinary tract
ICD10
- N35.9 Urethral stricture, unspecified
- N35.114 Postinfective anterior urethral stricture, NEC
- N35.013 Post-traumatic anterior urethral stricture
- N35.8 Other urethral stricture
- A54.01 Gonococcal cystitis and urethritis, unspecified
SNOMED
- 76618002 Urethral stricture (disorder)
- 80375002 Urethral stricture due to infection (disorder)
- 86347007 Traumatic urethral stricture (disorder)
- 431941000124103 Idiopathic urethral stricture (disorder)
- 72225002 Urethral stricture due to gonococcal infection (disorder)
Clinical Pearls
- Anterior urethral stricture is a narrowing of the lumen caused by spongiofibrosis.
- Caused by trauma, inflammation, or previous urethral surgery
- Patients often present with obstructive voiding symptoms or UTIs.
- Diagnosis is made with RUG and cystoscopy.
- Treatment depends on length and location of the stricture.
- Open urethroplasty is vastly superior to endoscopic treatment.
- Multiple surgical options are best managed by a urologist with specialty training in urethral reconstruction.