EAU 2025 Guidelines: Urethral Strictures

What This Guideline Covers

The EAU 2025 Urethral Strictures guideline provides evidence-based recommendations across 25 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Advise safe sexual practices, recognise symptoms of sexually transmitted infection and provide access to prompt investigation and treatment for men with urethritis.

• Avoid unnecessary urethral catheterisation.

• Implement training programmes for physicians and nurses performing urinary catheterisation.

• Avoid using non-coated latex catheters.

• Do not routinely perform urethrotomy when there is no pre-existent urethral stricture.

• Use a validated patient reported outcome measure (PROM) to assess symptom severity and impact upon quality of life in men undergoing surgery for urethral stricture disease.

• Use a validated tool to assess sexual function in men undergoing surgery for urethral stricture disease.

• Perform uroflowmetry and estimation of post-void residual in patients with suspected urethral stricture disease.

• Perform retrograde urethrography (RUG) to assess stricture location and length in men with urethral stricture disease being considered for reconstructive surgery.

• Combine RUG with voiding cystourethrography to assess (nearly)- obliterative strictures, stenoses and pelvic fracture urethral injuries (PFUI).

• Consider magnetic resonance imaging urethrography as an ancillary test in posterior urethral stenosis.

• Do not use direct vision internal urethrotomy (DVIU) for penile strictures.

• Do not use DVIU/dilatation as solitary treatment for long (> 2 cm) segment strictures.

• Do not perform repetitive (> 2) DVIU/ dilatations if urethroplasty is a viable option.

• Do not use permanent urethral stents.

• Do not use urethral stents for penile strictures.

• Offer men with penile urethral stricture disease augmentation urethroplasty by either a single-stage or staged approach taking into consideration previous interventions and stricture characteristics.

• Do not offer anastomotic urethroplasty to patients with penile strictures > 1 cm due to the risk of penile chordee post- operatively.

• Counsel patients with penile strictures that single-stage procedures might be converted to staged ones in the face of adverse intra-operative findings.

• Do not use penile skin grafts or flaps in failed FHR patients with lichen sclerosus (LS) or scarred skin.

• Do not use genital skin in augmentation penile urethroplasty in men with LS-related strictures.

• Use transecting excision and primary anastomosis (tEPA) for short post-traumatic bulbar strictures with (nearly) complete obliteration of the lumen and full thickness spongiofibrosis.

• Use free graft urethroplasty for bulbar strictures not amendable to excision and primary anastomosis (EPA).

• Use oral mucosa free graft urethroplasty for ReDo urethroplasty in the case of a long stricture.

• Use dorsal, dorsal-lateral or ventral approach according to surgical practice, expertise and intra-operative findings.

• Offer perineal urethrostomy (PU) as a management option to men with complex anterior urethral stricture disease.

• Do not perform deep incisions at the 6 and 12 o’ clock position during DVIU for VUAS or radiation-induced BMS.

• Perform transurethral resection (TUR) or “hot-knife” DVIU as 1st line-treatment for patients with non-obliterative bladder neck stenosis (BNS) after surgery for benign prostatic obstruction.

• Do not perform endoluminal treatment in case of VUAS, BMS and BNS with complete obliteration.

• Warn patient that urinary incontinence (UI) is inevitable after transperineal ReDo VUA and that subsequent anti-UI surgery might be needed in a next stage, after at least three to six months.

• Warn patients about de novo UI after reconstruction for BNS or bulbomembranous strictures (BMS) with previous benign prostatic obstruction surgery as aetiology.

• Warn patients about the risk of de novo UI and new onset erectile dysfunction after urethroplasty for radiation-induced BMS.

• Do not perform endoscopic treatment for an obliterative stenosis.

• Perform progressive perineal excision and primary anastomosis (EPA) for obliterative stenosis.

• Perform progressive perineal EPA for non- obliterative stenosis after failed endoluminal treatment.

• Perform a midline perineal incision to gain access to the posterior urethra.

• Do not perform total pubectomy during abdomino-perineal reconstruction.

• Perform flow rate, post-void residual and voiding cystourethrogram or video- urodynamics in all women with refractory lower urinary tract symptoms.

• Perform urethroplasty in women with a 2nd recurrence of FUS and who cannot perform ISD or wish definitive treatment. The technique for urethroplasty should be determined by the surgeon’s experience, availability and quality of graft/flap material, and the quality of the ventral vs. dorsal urethra.

• Do not perform endoscopic incision or urethroplasty within six months after neophalloplasty.

• Do not perform more than two endoscopic incisions for strictures in transmen unless with palliative intent.

• Use a graft above a flap when both are equally indicated.

• Do not use grafts in a tubularised fashion in a single-stage approach.

• Do not use hair-bearing perineal or scrotal flaps unless no other option is feasible.

• Inform the patient about the potential complications of the different types of oral grafting (buccal versus lingual versus lower lip) when an oral graft is proposed.

• Do not use genital skin graft in case of lichen sclerosus.

• Do not use autologous tissue-engineered oral mucosa grafts outside the frame of a clinical trial.

• Administer an intra-operative prophylactic regimen with antibiotics at the time of urethral surgery.

• Perform a form of validated urethrography after urethroplasty to assess for urinary extravasation prior to catheter removal.

• Offer follow-up to all patients after urethroplasty surgery.

• Use patient-reported outcome measures (PROM) questionnaires to assess subjective outcomes and patient satisfaction.

• Use validated questionnaires to evaluate sexual function after urethral stricture surgeries.

• Offer a routine follow-up of at least one year after urethroplasty.