Management of Urethral Stricture

Diagnosis and Initial Evaluation

The American Urological Association recommends that urethral stricture should be considered in patients presenting with decreased urinary stream, incomplete emptying, dysuria, urinary tract infections, and rising post-void residual 1, 2
Initial evaluation should include patient-reported symptoms, uroflowmetry (peak flow <15 ml/second suggests obstruction), and ultrasound post-void residual assessment 2, 3
Definitive diagnosis requires urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography 4, 5
Determining stricture length and location is essential for treatment planning and should be done before any non-urgent intervention 2, 6

For symptomatic urinary retention or when catheterization is needed before another surgical procedure, urethral dilation over a guidewire or direct visual internal urethrotomy (DVIU) may be performed 2, 7
Suprapubic cystostomy may be considered if the above measures fail or when definitive treatment is planned soon 2, 7
Either urethral dilation or DVIU may be performed as first-line treatment for short (<2 cm) bulbar urethral strictures, with success rates ranging from 35-70% 8, 5
Urethroplasty should be offered instead of repeated endoscopic management for recurrent anterior urethral strictures, as repeated endoscopic treatments have >80% failure rate 8

For bulbar urethral strictures, short strictures (<2 cm) may be treated with initial endoscopic management (dilation or DVIU), while long strictures or recurrent strictures may require urethroplasty options such as excision and primary anastomosis or augmentation urethroplasty with buccal mucosa graft 5, 6
For strictures due to lichen sclerosus, non-genital tissue grafts (buccal mucosa preferred) should be used, and staged repair with complete excision of the urethral plate may be considered 9

Urinary catheter placement following intervention to divert urine and prevent extravasation is recommended 6
Catheterization period of 24-72 hours is typically sufficient after dilation or DVIU 5
RUG or VCUG typically performed 2-3 weeks after open urethral reconstruction 6
Monitor for complications (stricture recurrence, erectile dysfunction, incontinence) for at least one year 10

Erectile dysfunction may occur transiently after urethroplasty, with resolution typically within six months 6
Ejaculatory dysfunction (pooling of semen, decreased force, discomfort) reported in up to 21% of men following bulbar urethroplasty 6
Urinary incontinence is rare and generally related to the original injury rather than treatment 10
Stricture recurrence is the most common complication, typically developing within the first year 10

Success is defined as no further need for surgical intervention or instrumentation rather than complete anatomic resolution 11
Non-invasive monitoring includes absence of lower urinary tract symptoms, low post-void residual, non-flattened urinary flow pattern on uroflow, and peak urine flow >15 ml/second 11
Endoscopic confirmation involves flexible cystoscopy to directly visualize and confirm lack of recurrence 11

No routine imaging is required for simple endoscopic procedures 11
Urinary catheter should remain in place to divert urine and prevent extravasation after open urethroplasty 11
Perform retrograde urethrography or voiding cystourethrography at 2-3 weeks post-operatively to assess complete urethral healing before catheter removal 11

Monitor patients at 3, 6, 9, and 12 months with symptom assessment, uroflowmetry, post-void residual measurement, and consider flexible cystoscopy if non-invasive parameters are concerning 11, 12

Erectile dysfunction may occur transiently after urethroplasty but typically resolves within 6 months 11
Ejaculatory dysfunction occurs in up to 21% of men after bulbar urethroplasty 11
Assess sexual function at 6-month and 12-month visits using validated questionnaires 11

Do not rely solely on patient symptoms—asymptomatic patients may have significant residual stricture or elevated post-void residual 11
Do not ignore sexual function assessment—proactively counsel patients that most erectile dysfunction resolves by 6 months 11