Urethral Stricture

Definitions — "stricture" is an anterior-urethra word

Segment	Spongiosum?	Correct term
Anterior — penile + bulbar urethra	Surrounded by corpus spongiosum	Stricture
Posterior — membranous + prostatic + bladder neck	NOT surrounded by spongiosum	Stenosis / contracture; if pelvic fracture → PFUI (distraction defect)

• 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 arborise in the glans. (This is the whole rationale for the non-transecting rule under Urethroplasty.)

Etiology

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

Cause	Share
Idiopathic	33%
Iatrogenic	33%
Post-traumatic	19%
Inflammatory	15%
Congenital	—

Anterior urethra — penile & bulbar

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

Detail on each cause:

Cause	Source detail
Straddle / blunt trauma	Spongiosum crushed against the inferior pubic rami. The classic mechanism of anterior stricture, and the commonest cause in developing countries
Iatrogenic	Cystoscopy, urethral dilation, TURP/TURBT, indwelling catheters (injury, pressure necrosis, inflammation). Very prevalent in low/middle-income countries. Silicone catheters + hydrophilic-coated ISC reduce the incidence
Infection	Gonococcal urethritis — historically the commonest, now rare with prompt antibiotics. Role of Chlamydia / Ureaplasma (non-specific urethritis) is unclear — no clear association established
LS	Strictures are longer and more often penile; higher association with urethral cancer. Involves the urethra in 20% of LS cases and is the most common cause of panurethral stricture. Also the most common cause of meatal stenosis
Radiation	Typically bulbomembranous

Lichen sclerosus in more detail

• Previously called balanitis xerotica obliterans; diagnosis is by biopsy
• Appears as a whitish plaque that may involve the prepuce, glans, urethral meatus and fossa navicularis
• 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
• 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

You should determine the following

1. Length of the stricture
2. Location
3. Number
4. 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

Evaluation for stricture

• Hx + Physical Exam
• UA
• PVR (if high → Renal US & Cr)
• UFM → plateau curve
• QoL
• Urethrogram (Retrograde + Voiding)
• Cystoscopy
• MRI is not beneficial for routine strictures or for pelvic fracture urethral distraction defects

Two evaluation principles worth memorising:

• "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. Coning down of the urethra → it is involved in the scar.
  • in select patients, place an SPC to defunctionalise the urethra; after 6–8 weeks the hydro-dilated proximal urethra contracts and the true stricture length can be measured

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
• 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]

DVIU / dilation success — bulbar, <2 cm:

Attempt	Success
1st attempt (no prior)	50–75%
After 1 prior DVIU	0–40%
After 2 prior (3rd attempt)	0%

• 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.

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.
• 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 · 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
• Dilation may be CURATIVE in an epithelial stricture with no spongiofibrosis — the one setting where it is definitive rather than temporising
• Catheterise for 3 to 7 days after dilation
• 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
• 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

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.
• Three technical points that define success — memorise 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
• 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 arborisation in the glans
• obliterated post-traumatic segment should be treated with transected as disturbed blood vessels will not take the graft

The bulbar ladder by length

Length	Repair
< 2 cm	End-to-end anastomosis — mobilise both ends · remove the scar · spatulate · evert · anastomose over a catheter · close the spongiosum
2–4 cm	Anastomotic repair is still possible, but in older patients tissue elasticity is less — use a buccal graft
> 4 cm	Substitution urethroplasty

• 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

• 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) · bladder epithelial graft · rectal mucosal graft · full-thickness skin graft. (STSG is for staged repair.) Buccal mucosa is thought to have a panlaminar plexus — this is why it takes so well.

What makes buccal mucosa the graft of choice

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

Graft has 3 phases to take

1. Imbibition — 48 hrs
2. Inosculation — 48 hrs — microcirculation
3. Revascularization

• 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.
• Dorsal onlay is better for diverticulum issue

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
3. Inferior pubectomy
4. Route the urethra around corpora

Click the algorithm to open it full size.

Order caveat: aggressive mobilization is best kept as the LAST manoeuvre in PFUI — the proximal supply is already damaged, so stripping the retrograde supply too risks ischaemic stenosis. Steps 2 to 4 are agreed as the escalation order. A missing 5th manoeuvre: 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.

Posterior urethra / PFUI — management

Timing

• Deferred repair at earliest 3 months after trauma — by then the pelvic haematoma has resolved, the prostate has descended into a more normal position, the scar has stabilised, 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

Recommendation	Strength
Do not perform endoscopic treatment for an obliterative stenosis	Strong
Perform one attempt at endoluminal treatment for a short, non-obliterative stenosis	Weak
Do not perform >2 DVIU/dilatations for a short non-obliterative recurrence after EPA for traumatic posterior stenosis, if long-term patency is the intent	Weak

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

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
• ~10% of PFUIs are complex and may have fistulae — most commonly urethrorectal
• Post-op: urine diverted via the SPC; the small silicone urethral catheter is plugged and serves as a stent only. Bed rest 24–48 h. Voiding trial with contrast at 3–4 weeks; void urethrally for 5–7 days, then remove the SPC. Flexible endoscopy at ~6 months and again at 1 year
• Curative rates for posterior PFUI reconstruction: high 90% range
• 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 haematoma. 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

Penile urethral strictures

Recommendation	Strength
Do not use DVIU for penile strictures	Strong
Do not use urethral stents for penile strictures	Strong
Offer men with penile urethral stricture disease augmentation urethroplasty by either a single-stage or staged approach, considering previous interventions and stricture characteristics	Strong
Do not offer anastomotic urethroplasty to patients with penile strictures >1 cm — due to the risk of post-operative penile chordee	Strong
Counsel patients with penile strictures that single-stage procedures might be converted to staged ones in the face of adverse intra-operative findings	Strong
Offer an interval of at least 4–6 months before the second stage, provided the first stage outcome is satisfactory	Weak

• The one to carry away: EPA is contraindicated in penile strictures >1 cm (chordee).

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.

Approach	Technique	When
Flap	Orandi	Mid-shaft stricture with a free external urethral meatus
Flap	Jordan	Meatus involved
Graft (buccal)	ASOPA	Any site or length, meatus involved or not

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 tubularises the plate around the catheter.

The onlay hierarchy

• Onlay procedures — graft or flap — have a higher success rate than tubularised grafts or tubularised skin islands
• Among tubularised repairs, tubularised flaps do better than tubularised 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

Perineal urethrostomy (PU)

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

Recommendation	Strength
Offer PU as a management option to men with complex anterior urethral stricture disease	Strong
Offer PU for men not fit or not willing to undergo formal reconstruction	Weak
Choose the type of PU based on personal experience and patient characteristics	Weak
Consider augmented Gil-Vernet-Blandy PU or "7-flap" PU in men with proximal bulbar or membranous stricture disease	Weak

• 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
• 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.

Other urethral pathology

Urethral haemangioma

• 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 haematuria, 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 haematoma
• A congenital diverticulum in the PROSTATIC urethra is a remnant of the müllerian duct

Complications of urethroplasty

Complication	Rate / detail
Permanent ejaculatory dysfunction	As high as 20% after urethroplasty. Semen pools in the urethra and/or loss of force with ejaculation.
Temporary ED	Up to 20% after anterior urethroplasty — same for EPA and graft/flap repairs. Resolves classically by 6 months, with <3–4% permanent. Overall rate of ED after urethroplasty ≈ rate after circumcision. Longer-segment reconstructions → higher risk, though function improves over time.
New-onset penile curvature	Usually after an over-aggressive EPA in the distal bulbar region
Post-void dribbling	Bulbospongiosus midline division may damage muscle + perineal nerves. A muscle- and nerve-sparing perineal approach has been introduced to reduce it
In PFUI	ED in PFUI is often a consequence of the injury itself, not the surgery