Urethral Stricture

Definitions — "stricture" is an anterior-urethra word

• Stricture = urethral epithelium + spongy erectile tissue of the corpus spongiosum → spongiofibrosis
• Anatomy that drives technique
  • Bulbar urethra sits eccentrically — closer to the dorsum
    • Distally the penile urethra becomes central within the spongiosum.
    • (This is why a 12 o'clock DVIU is a debated incision — see the Endoluminal treatment section.)
  • Corpus spongiosum has a dual blood supply
    • Proximal (common penile artery, terminal branch of internal pudendal) + retrograde through the dorsal arteries as they arborize in the glans.
    • (This is the whole rationale for the non-transecting rule under Urethroplasty.)

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Etiology

Share by cause — developed-world series. Geography flips the answer: idiopathic is the commonest cause in developed countries, straddle trauma in developing ones.

Anterior urethra — penile & bulbar

• Straddle injury (Bulbar)
• Infection
• LS (lichen sclerosus)
• Surgery / instrumentation
• Radiation

Detail on each cause:

Lichen sclerosus in more detail

• Previously called balanitis xerotica obliterans; diagnosis is by biopsy
  • Biopsy also excludes malignant change — LS is associated with penile SCC, particularly HPV-negative variants → long-term follow-up
• Appears as a whitish plaque that may involve the prepuce, glans, urethral meatus and fossa navicularis
  • Late stage (balanitis xerotica obliterans): whitish, scarred distal penis + meatal stenosis + long anterior urethral stricture; typically men over 60
• If only the foreskin is involved, circumcision may be curative
• Surgery — urethroplasty with a buccal graft — is indicated in young patients with severe meatal stenosis
  • LS (commonest cause of adult meatal stenosis) is a disease of genital skin → genital skin is unsuitable for reconstruction
    • Excision + oral (buccal) mucosal graft urethroplasty is preferred
• Because long-standing meatal stenosis often carries severe PROXIMAL stricture disease, perform a retrograde urethrogram before starting therapy

Posterior urethra — membranous & bladder neck

• Pelvic fracture
• Prostate surgery
• Radiation
• After radical prostatectomy the entity is a vesicourethral distraction defect / anastomotic stenosis
• PFUI accompanies ~10% of pelvic fractures
• the most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra

Female urethral stricture

• Fixed anatomical narrowing of the female urethra; normal caliber 18–30 Fr
• Obstructive LUTS + a 16 Fr cystoscope won't pass → suspect a fixed stricture from LS
  • LS is a scarring disease of genital skin → seek it on pelvic exam (vulvar LS; also lichen planus, vulvovaginal atrophy)

Commonest causes overall — pooled series:

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You should determine the following

• Length of the stricture
• Location
• Number
• density (spongiofibrosis)

How each is measured

• Length + location → radiography, urethroscopy, ultrasonography
• Depth + density → deduced from physical exam, appearance on contrast studies, and elasticity on urethroscopy.
  • "The depth and density of fibrosis are difficult to determine objectively" — and the absolute length of spongiofibrosis may not be evident on ultrasound

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Evaluation for stricture

• Hx + Physical Exam
• UA
• PVR (if high → Renal US & Cr)
• UFM → plateau curve
• QoL
• Urethrogram (Retrograde + Voiding)
• Cystoscopy
  • cystourethroscopy reliably detects (or rules out) a stricture · also picks up lichen sclerosus and proximal bulbomembranous strictures that RUG may miss
• MRI is not beneficial for routine strictures or for pelvic fracture urethral distraction defects
• Urethral biopsy is unnecessary for a first-time urethral stricture

Two evaluation principles worth memorizing:

• "Blind passage of filiforms and blind dilation without knowledge of the anatomy of the stricture is condemned."
  • In retention, if a catheter won't pass → RUG, and selectively place a suprapubic catheter to buy time for a proper plan — don't reflexively dilate.
• Evaluate the urethra completely proximal AND distal to the stricture with endoscopy + bougienage intra-operatively.
  • Hydraulic pressure from voiding keeps proximal segments falsely patent; unless included in the repair they contract once the obstruction is relieved.
  • in select patients, place an SPC to defunctionalize the urethra; after 6–8 weeks the hydro-dilated proximal urethra contracts and the true stricture length can be measured
  • Coning down of the urethra → it is involved in the scar.

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Treatment for anterior urethral stricture

Click the algorithm to open it full size.

• Bulbar stricture management turns on LENGTH; penile stricture management turns on ETIOLOGY
• Fossa navicularis and meatal strictures are the other setting where initial endoscopic treatment is warranted — unlike the penile urethra
  • Meatotomy opened to the coronal margin but lumen still 12 Fr → more than meatal stenosis
    • Stop extending the urethrotomy and get a RUG to define the full stricture length (no further treatment, not even dilation, until the length is known)
• Should offer urethroplasty for penile stricture as high recurrence
• Do not intervene at all in asymptomatic incidental (>16 Fr) strictures — Weak [EAU]
• Consider a long-term suprapubic catheter in radiation-induced bulbomembranous strictures and/or poor performance status — Weak [EAU]
  • Urethroplasty for radiation-induced stricture → success ~70% at a mean 3.5 yr follow-up · new-onset incontinence ~20% · sexual function appears unchanged

DVIU / dilation success — bulbar, <2 cm:

• Dilation = DVIU. Both get worse as length increases. Never DVIU a penile stricture.
• EPA limit: 2 cm is the rule, not the ceiling — 3–5 cm can be excised, and the closer to the membranous urethra, the longer it may be.
• Transecting: post-traumatic (straddle / pelvic fracture) with obliteration + full-thickness spongiofibrosis (Strong).
• Non-transecting: prior penile surgery or hypospadias (retrograde supply) — EAU extends this to any short bulbar stricture not from straddle injury.
• The "reconstructive ladder" (always try the simplest first, repeat after failure) is considered archaic in modern urethral reconstruction.

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Endoluminal treatment — dilation & DVIU

Success rate for dilation, bulbar, for first, less than 2 cm is 50–75%. Repeated trials decrease the success. After the 3rd trial reaches 0%.

• Dilation = DVIU.
  • The only high-level evidence — an RCT of n=210 with RUG at 7 visits over 48 months — showed urethral dilatation is equally effective as DVIU, and both get less effective as stricture length increases
• Goal of dilation = "stretch the scar without producing more scarring."
  • If bleeding occurs, the stricture has been torn rather than stretched.
  • Safest method = balloon dilating catheter over a guidewire placed under endoscopic control.
  • No evidence that steroid ointment improves the outcome of urethral dilation
• DVIU technique — single incision at 12 o'clock, normal saline irrigant.
• DVIU adverse events:
  • Recurrence (most common)
  • Bleeding (almost always from erections immediately post-op)
  • Extravasation of irrigant into perispongial tissues
  • ED
    • ED is the recognized complication — 5.3% (overall cold-knife complication rate 6.5%): a deep 12 o'clock incision carried beyond the spongiofibrosis can enter the corpora cavernosa
  • Decreased success rate of any future reconstruction
  • (deep cuts) spongiosum–cavernosum fistula
• Internal urethrotomy succeeds only when all three hold:
  • The stricture is in the bulbous urethra
  • It is short (<2 cm)
  • It is not associated with dense, deep spongiofibrosis
  • a single stricture suits DVIU best; discourage it in the penile urethra → poor patency and a higher ED risk from the incision
• Dilation may be CURATIVE in an epithelial stricture with no spongiofibrosis — the one setting where it is definitive rather than temporizing
• Catheterize for 3 to 7 days after dilation
  • After uncomplicated DVIU: Foley only briefly — 3 to 5 days; EAU → remove within 72 hours · prolonged catheterization gives no advantage
  • Why a catheter after DVIU at all → cover for the bleeding and irrigant extravasation listed under adverse events above
• If a short bulbar stricture recurs, a second endoscopic attempt is reasonable. Do not do a third — recurrence is effectively 100%, and it lowers the success of any later urethroplasty
  • Exam answer: confirm a suspected recurrence with cystourethroscopy before any treatment
    • Once confirmed → urethroplasty is preferred over repeat endoluminal treatment (see OPEN trial below)
• Laser urethrotomy: results mixed, no better than cold knife
• Optilume (paclitaxel drug-coated balloon, FDA-approved 2023) — ROBUST III at 1 yr
  • Stricture-free 74.6% vs 26.8% (p<0.0001), IPSS 9 vs 19.9, after multiple prior failed endoscopic interventions.
  • Whether it works as initial rather than salvage therapy, and whether the cost is justified, is undetermined
• OPEN trial — urethroplasty vs DVIU for recurrent strictures (n=220)
  • Re-intervention 13.8% vs 25.9% → 48% lower risk with urethroplasty (HR 0.52, 95% CI 0.31–0.89, p=0.017)
  • 2.6× odds of a >10 mL/s Qmax gain.
  • QoL similar at 2 yrs, urethroplasty costs more

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Urethroplasty

Success Rate 85% even after 15 years (→ EPA). Success Rate 85% but drops to 50% after 15 years (→ Augmentation).

• With follow-up limited to 1 year, the success rate with tissue transfer clusters around 95% — but with longer follow-up it deteriorates over time.
  • The success of excision and primary anastomosis at 1 year is more durable and does not deteriorate at the same rate.

EPA — for less than 2 cm, Bulbar & membranous

• "In general, 'short bulbar strictures' are those amenable to stricture excision and subsequent tension-free anastomotic repair. The limit is usually around 2 cm".
• <2 cm → EPA.
  • The RCT evidence for EPA comes from strictures < 2 cm
  • Best in proximal bulbar strictures → the more compliant proximal urethra can be mobilized further for a tension-free anastomosis
• Three technical points that define success — memorize as a triad:
  1. The area of fibrosis is totally excised
  2. The anastomosis is widely spatulated — a large ovoid anastomosis
  3. The anastomosis is tension free
• EPA reliably repairs: a PFUI with a 3 cm gap · short (1–2 cm) bulbar strictures from straddle, perineal or iatrogenic (transurethral resection) trauma
• Excision with primary anastomosis should be avoided in patients with a history of hypospadias repair
  • Due to expected altered or absent retrograde blood supply to the urethra through the normal arborization in the glans
  • Avoid any transecting repair here unless vessel-sparing → risk of ischemic urethral stenosis
    • Use inlay or onlay grafts or flaps instead — they don't disrupt the proximal blood supply
• Vessel-sparing urethroplasty — no proven advantage over traditional EPA; reserve it for:
  • Proximal supply already compromised → recurrence after a prior transecting bulbar urethroplasty
  • Distal supply poor → hypospadias, especially after prior repairs
  • Not the best candidate: a young man with a < 2 cm proximal bulbar stricture → standard EPA
• obliterated post-traumatic segment should be treated with transected as disturbed blood vessels will not take the graft

The bulbar ladder by length

• Exam answer: a 3 cm bulbar stricture → free graft (buccal mucosa) substitution urethroplasty
  • Even in a young man — especially if distal bulbar, where the urethra is less compliant
  • EPA would create tension and ischemia at the anastomosis
  • Dilation / DVIU / laser urethrotomy → little to no success
• Graft placement in substitution repair depends on where the stricture sits:
  • Proximal bulbar → graft VENTRAL
  • Distal bulbar → graft DORSAL

Augmentation — General Rule

Graft is better than flap

• Dorsal buccal onlay beats a fasciocutaneous flap → fewer complications · better patient satisfaction · better long-term success
• Dorsal onlay is better for diverticulum issue
• Single-stage over staged repair when feasible → similar long-term outcomes with fewer operations
  • e.g. a recurrent 3 cm bulbar stricture in a urethroplasty candidate → single-stage dorsal onlay buccal mucosa graft
    • DVIU is not first-line > 2 cm (dilation + self-catheterization only for non-candidates)
• Use buccal or lingual mucosa if a graft is needed and available
• Use penile skin if buccal/lingual is not available, suitable, or accepted
• Do not use genital skin graft in case of LS
• Do not use hair-bearing perineal or scrotal flaps unless no other option
• Four grafts used for primary urethral reconstruction:
  • Oral mucosal graft (buccal / labial / lingual)
    • Buccal mucosa is thought to have a panlaminar plexus — this is why it takes so well.
  • Bladder epithelial graft
  • Rectal mucosal graft
  • Full-thickness skin graft. (STSG is for staged repair.)

What makes buccal mucosa the graft of choice

• Easy accessibility · hairless · resistant to infection
• Thick epithelium — promotes easy handling
• Thin, well-vascularized lamina propria — promotes inosculation
• Compatible with a moist environment

Graft has 3 phases to take

1. Imbibition — 48 hrs
   • Hours 0–48 · the graft "drinks" nutrients from the host bed · graft temperature below core body temperature
2. Inosculation — 48 hrs — microcirculation
   • Hours 48–96 · microcirculation restored · graft rises to core body temperature → at 72 h the graft is inosculating
3. Revascularization

• Exam answer: take lasts about 96 h in two phases (imbibition → inosculation); revascularization is the process of take itself
• Take depends on both the nature of the grafted tissue and the host bed → anything that impairs host-bed vascularity impairs take
• Take needs immobilization and close contact with a well-vascularized bed → why grafts are quilted
  • Classic causes of graft failure:
    • Seroma
    • Hematoma
    • Infection
    • Scar tissue
• Graft vs flap — the definition:
  • A flap is transferred WITH its blood supply (preserved or surgically re-established)
  • A graft is transferred to a host bed where a new blood supply develops by take.
    • i.e. tissue excised from a donor site that reestablishes its blood supply by revascularization — that process is take

Skin grafts for penile shaft coverage

• After debridement for Fournier's gangrene → resurface the shaft with an unmeshed, thick (0.012–0.015 inch) split-thickness skin graft (STSG) → highest take and best cosmesis
• Meshed or thinner STSG → contracts more → compromises penile function and cosmesis
• Full-thickness graft → fails to take more often
• Abdominal or thigh flaps → poorer cosmesis

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Ways to gain more length — especially in EPA transecting in pelvic fracture case

1. Mobilize to the level of the suspensory ligament
2. Separate the crura of the corpora
   • = corporal splitting — the first move when the ends still won't meet tension-free after mobilization · gains length without removing bone
   • Split in the midline over 4–6 cm, up to where the corpora fuse · bleeding here = the deep dorsal vein of the penis → suture-ligate it
3. Inferior pubectomy
   • Only after corporal splitting → risks penile shortening · destabilized erection · pelvic destabilization with chronic exercise-related pain
4. Route the urethra around corpora
   • Supracrural rerouting — the last resort, needed in < 10% of uncomplicated cases

Click the algorithm to open it full size.

Order caveat: step 1 is standard, limited mobilization; aggressive mobilization is best kept as the LAST maneuver in PFUI — the proximal supply is already damaged, so stripping the retrograde supply too risks ischemic stenosis. Steps 2 to 4 are agreed as the escalation order. A missing 5th maneuver: sequesterectomy (excise the scar). A transpubic or abdominal-perineal approach is unnecessary for distraction injuries; no BMG or flap is needed — length loss is minimal in most cases.

• These steps (spongiosal mobilization → crural separation → inferior pubectomy → rerouting) = the progressive perineal approach → closes even longer posterior gaps tension-free
  • So a combined transpubic abdominoperineal approach is usually not needed

Deep dorsal vein of the penis — the vein between the corpora

• Lies beneath Buck's fascia, between the paired dorsal arteries · main drainage of the glans and the distal two-thirds of the corpora cavernosa
• Runs behind the symphysis pubis → drains into the periprostatic (Santorini) plexus

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Posterior urethra / PFUI — management

Timing

• Deferred repair at earliest 3 months after trauma — by then the pelvic hematoma has resolved, the prostate has descended into a more normal position, the scar has stabilized, and the patient can lie in lithotomy.
• "If possible, it is desirable to proceed within 3 to 6 months, after trauma"

Endoluminal treatment of posterior stenosis

Rationale: "cut-to-the-light" on an obliterative stenosis will not work and risks a false passage towards the bladder base or rectum.

• Anastomotic recurrence after posterior urethroplasty:
  • Non-obliterative and <1 cm → DVIU
  • After two failed DVIUs/dilatations → redo urethroplasty (three or more incisions are never successful)
• Incising a membranous recurrence:
  • Avoid deep 6 o'clock cuts (rectal injury) and deep 12 o'clock cuts (urosymphyseal fistula)
  • Warn of de novo incontinence in up to 25% (worsening of existing incontinence in up to 15%)

Technique & outcomes

• Repair: most PFUIs are short → mobilization of the corpus spongiosum + primary anastomotic technique via a perineal approach (λ-shaped incision, exaggerated lithotomy).
  • Anastomosis of the proximal anterior urethra can be made to any segment of the posterior urethra — apical, prostatic, or below
  • Technique of choice for a PFUI on suprapubic diversion (posterior urethra almost always obliterated) → deferred (≥3 months), one-stage perineal excision and primary anastomosis (EPA)
• ~10% of PFUIs are complex and may have fistulae — most commonly urethrorectal
• Post-op:
  1. Urine diverted via the SPC; the small silicone urethral catheter is plugged and serves as a stent only.
  2. Bed rest 24–48 h.
  3. Voiding trial with contrast at 3–4 weeks
  4. Void urethrally for 5–7 days, then remove the SPC.
  5. Flexible endoscopy at ~6 months and again at 1 year
• Curative rates for posterior PFUI reconstruction: high 90% range
  • Exam answer: perineal EPA for obliterative posterior stenosis → overall stricture-free rate 85.7%
• Aligning catheters:
  • Total circumferential distraction often does not occur — a strip of epithelium is often left intact, and an aligning catheter may let it heal virtually unscarred.
  • An aligning catheter is a guide, not a traction device.
  • It also drains the liquefying pelvic hematoma.
  • But many still stricture after removal and need definitive repair
    • Some recommend against routine use because realignment is associated with delayed surgical repair and more unsuccessful endoscopic treatments

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Penile urethral strictures

• The one to carry away: EPA is contraindicated in penile strictures >1 cm (chordee).
  • Why: the pendulous urethra has no redundancy → excision shortens it relative to the corpora → ventral chordee
• First-line for a penile stricture = buccal graft augmentation urethroplasty — not dilation or urethrotomy (high recurrence)
  • Contrast bulbar and fossa/meatal strictures, where initial endoscopic treatment is warranted

One-stage vs two-stage

• One stage — when the cause is trauma, instrumentation or catheter-related.
  • The choice depends on surgeon experience, tissue status, circumference and the site of the stricture.

• Two stage — when the cause is failed or crippled hypospadias, lichen sclerosus, or radiotherapy.
  • Stage one opens the urethral plate, removes all fibrous scar and lays the graft
  • Stage two tubularizes the plate around the catheter.
  • Stage it when the urethral plate is inadequate for a single-stage repair, or with heavy scarring, LS, fistula or chordee; staged (mainly buccal) repairs report 71–95% patency
  • Failed hypospadias repair with scarred penile skin → two-stage buccal mucosal graft urethroplasty (oral mucosa = graft of choice)
    • The interval before stage two lets the graft heal before tubularization

The onlay hierarchy

• Onlay procedures — graft or flap — have a higher success rate than tubularized grafts or tubularized skin islands
• Among tubularized repairs, tubularized flaps do better than tubularized grafts
• Dorsal and lateral onlay are likely better than ventral onlay
• In the penile urethra a full-thickness skin graft beats a split-thickness graft — STSG contracts and causes chordee
• Most common complications of penile urethroplasty: fistula and meatal stenosis

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Perineal urethrostomy (PU)

The escape hatch for complex disease — failed hypospadias repairs, LS, multiple failed reconstructions, elderly/comorbid patients.

• Why not just reconstruct?
  • Pananterior reconstruction with multiple grafts is feasible with fair success — but success rates fall with multiple failed urethroplasties, and complex prolonged surgery may not be indicated in the elderly/comorbid
  • Long penile stricture after multiple failed repairs → PU ~90% success vs ~80% for two-stage urethroplasty; single-stage repair is inappropriate without healthy penile urethral tissue (success = long-term patency, no CIC, good patient-reported outcomes)
• Permanent PU for long-segment strictures when urethroplasty is unsuitable (the complex-disease patients above) or self-dilation is impossible — e.g., Parkinsonian tremor
  • Complex reconstruction adds little over PU but more perioperative risk
• BMG-augmented PU — for stricture continuing into the proximal bulbar and/or membranous urethra, where traditional PU can't work.
  • Also indicated after pelvic radiation or LS, which have a higher rate of re-stricture at the PU.
  • The graft is spread-fixed to the corpora (same bed as a dorsal onlay) and decreases the probability of circumferential scarring at the neomeatus.

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Other urethral pathology

• Urethral hemangioma
  • Electrofulguration only to control an acute episode
  • Smaller lesions — laser, which produces less scarring: argon, KTP (532 nm), or Nd:YAG
  • Larger lesions — open excision and urethral reconstruction, sometimes circumferential
  • Avoid tubed GRAFT reconstruction. A tubed flap or mixed tissue transfer may be considered, though staged reconstruction is probably preferable
  • Polidocanol as a sclerosing agent has good initial success in extensive lesions
• Reactive arthritis — the classic triad of arthritis, conjunctivitis and urethritis.
  • Urethral involvement is usually mild and self-limited, and a minor part of the disease.
• Urethral amyloidosis — rare
  • Consider it in any patient with a urethral mass.
  • Presents with hematuria, dysuria or obstruction.
• Urethrocutaneous fistula — an epithelium-lined tract from urethra to skin.
  • Follows urethral surgery, or develops secondary to periurethral infection with an inflammatory stricture, or after treatment of a urethral growth.
  • Treatment must address the underlying process, not just the defect.
• Congenital urethral diverticulum — a transitional-cell-lined pouch
  • Arising from distension of a segment or from attachment by a narrow neck.
  • In males a "congenital" anterior diverticulum may reflect incomplete urethral development, or straddle trauma causing an intracorporeal spongiosal hematoma
  • A congenital diverticulum in the PROSTATIC urethra is a remnant of the müllerian duct

Hematuria — localizing the source

• Initial hematuria → most often the prostatic and anterior urethra (blood sitting in the urethra is flushed out by the first part of the stream)
• Terminal hematuria → trigone, bladder neck or prostate (bleeds as the bladder neck contracts at the end of voiding)
• Total hematuria → bladder or upper tract (blood mixes throughout the stored urine)
• Clot shape: vermiform clots → upper tract source; cuboid clots → bladder source
• Hematuria that clears after catheter placement → more likely prostatic in origin

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Complications of urethroplasty