Urethral Stricture Repair
Urinary obstruction can occur for many reasons. One reason is a blockage in the flow of urine that may occur from the bladder to the tip of the penis (meatus). Such a blockage is defined as a urethral stricture. Urethral strictures rarely occur in women and are seen more commonly in men. A number of events can lead to stricture formation. The most important of these are: trauma/injury (straddle injury, pelvic fracture), infection (sexually transmitted disease), and post-instrumentation (eg. traumatic urinary catheter placement, transurethal surgery). A urethral stricture may also occur following surgery or radiation therapy for prostate cancer. Following damage to the urethra by any of the above methods, the scar may take many years to develop. As such, a significant number of men will present later in life with an unknown etiology.
Strictures located at the tip of the penis/urethra (urethral meatus) may be caused by trauma; however, another common reason is an inflammatory skin condition known as lichen sclerosis (previously balanitis xerotica obliterans).
In general, urethral strictures are divided into two main categories based on location:
1. Anterior urethra (from the sphincter [control muscle] to the tip of the penis)
2. Posterior urethra (from the bladder to the urethral sphincter)
A clinical visit is recommended to determine the location and length of the urethral stricture. These tests may include any of the following:
Urinanalysis (U/A): performed to rule out hematuria (blood in the urine), infection or other urinary abnormalities.
Urine culture: studies the urine for evidence of infection, which may occur in some people with a urethral stricture.
Uroflowmetry/Peak flow urine study: individuals are asked to void into a special toilet, which measures the speed at which urine flows from the bladder to the end of the urethra. Many individuals with a stricture will have a diminished rate of flow.
Post-void Residual Urine Study: an ultrasound of the bladder is performed, measuring the amount of urine that remains after a "normal" void (urination).
Retrograde Urethrogram (RUG) with Voiding Cystourethrogram (VCUG): X-ray constrast (dye) is used to fill the urethra and bladder as images are obtained, identifying the level of blockage. Men are then asked to void (VCUG) and again x-rays are taken to better outline the level of stricture.
Cystoscopy: using a fiberoptic telescope the urinary tract from the tip of the penis to the bladder can be inspected. This can help rule-out other causes of obstruction or allow the urologist to better characterize the stricture.
Sonourethrogram: This test is usually done in the operating room as part of the pre-operative surgical planning. It involves an ultrasound probe to image the stricture, measure stricture length and assess the degree of urethral scarring.
Most patients will have a urinalysis, urine culture, uroflowmetry, post-void residual study and a RUG/VCUG. Cystoscopy is less commonly used in the diagnostic evaluation of urethral strictures.
The area of urethral stricture surgery depends on where the stricture is located in the urethra. Treatment may involve minimally invasive therapy or open surgery. Minimally invasive therapy is commonly reserved for men with newly diagnosed urethral strictures that are short (< 1-2 cm). Therapy can involve dilating or cutting the urethra at the site of the scar. A successful outcome following either dilation or incision following such treatment occurs in approximately 50% of men.
If the stricture recurs, then we do not recommend repeating dilation or incision. Instead, we recommend open surgical repair, which has a much higher success rate. The type of surgery depends where the stricture is located along the urethra.
Penile strictures: These strictures are located along the penile shaft. Such strictures may be repaired in one operation or require a staged operation for successful outcome. Buccal mucosa (tissue from inside the mouth) or penile skin flaps are utilized for repair of these strictures.
Bulbar strictures: These strictures are located in the urethra between the urinary sphincter muscle and the penile shaft/scrotum junction. They are most commonly repaired in one operation. When the scar tissue is short, the affected tissue can be removed followed by re-suturing the healthy remaining ends back together. Buccal mucosa is not needed for the repair of these short strictures. If the stricture is too long, then the urethra can be repaired using buccal mucosa or skin flaps to increase the diameter of the narrowed urethral lumen.
Posterior strictures: The location of these strictures is between the bladder neck and the urinary sphincter muscle. These strictures are repaired by excising the scar and re-connecting the remaining healthy ends of tissue. Tissue from the mouth and/or skin flaps are rarely utilized.
A urethral catheter will be left in place following surgery for a period of 1-3 weeks depending on the type of surgical repair required. Patients are urged to restrict activity following open surgical for defined period following surgery to ensure healing of the tissues. As with any surgical procedure there are inherent risks and temporary side effects. These will depend on the location of the urethral stricture. We recommend an informed surgical consent before proceeding with open surgery.
Long Term Care
We recommend periodic examination of the patient following surgical repair of the stricture to ensure successful outcome.