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Urethral Stricture Disease

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 symptomsStrainingDecreased force of streamHesitancyDribblingIncomplete emptyingFrequency
  • 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 obstructionVisualization 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 dilationTechnique: 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)GraftsFlaps
  • 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 stricturesBased 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 supplyNon " “hair-bearing penile skin is used most commonly.Used most commonly for penile and fossa navicularis stricturesCommonly 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.

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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.