Reconstructive Urology

Male Urethral Stricture Disease

Urethral strictures are scar tissue that contracts and narrows the urethra, subsequently blocking urine from flowing out of the bladder.

Common causes of strictures include inflammation, infections, trauma, prior surgery and chronic urethral catheter placement. Symptoms can include blood in the urine, slow urine stream, burning or pain with urination, spraying, urinary tract infections, decreased urine output, incomplete emptying and straining to urinate. Strictures can lead to larger complications such as urinary tract infection, bladder inflammation and muscle damage, prostatitis, bladder stones and urethral cancer.

Diagnosis

Identifying strictures early is important to avoid serious kidney or bladder problems. Strictures can be found in a physical exam, through urethra imaging with X-rays or a cystoscopy—a procedure in which a small, fiber-optic camera is placed into the urethra after topical anesthesia to visualize any damage.

Treatment Options

Dilation is an outpatient procedure that involves passing a wire across the stricture and progressively stretching the opening with larger and larger dilators. A catheter is placed for a few days after this procedure. In general, dilation is a temporary management strategy and not curative in nature.

Direct vision of the stricture is achieved by placing a cystoscope (fiberoptic camera) up to the stricture and passing a blade to cut the scar tissue open to re-create a wide opening in the urethra. In general, a catheter is placed for one week. There are cuts or stitches in the skin. Urethrotomy is most effective for very short strictures less than one centimeter long. Potential side effects include bleeding, infection, stricture recurrence, urine leakage and erectile problems.

There are different types of reconstructive options to remove the stricture and recreate the urinary tube. This open surgical procedure is considered the gold standard for stricture correction. With long-term success rates from 80-95 percent depending on location, length and concurrent conditions, urethroplasty provides the most durable results for urethra reconstruction. These procedures generally take two to three hours of surgery, can be performed as an outpatient procedure, and require a urethral catheter for four weeks.

Anastamotic urethroplasty is employed for short strictures of the bulbar urethra. A section of scarred urethra is removed and the two ends are sewn back together. The success rate is 90-95 percent.

Substitution graft urethoplasty is used for longer strictures greater than two centimeters and penile urethra scar tissue. A piece of tissue from the mouth (buccal mucosa) is harvested by an oral surgeon. This mouth graft is used to reconstruct the urethra by patching the damaged area and increasing the tube size. Long-term success is approximately 80-85 percent.

Staged urethoplasty is a rarely technique used for the worst strictures. It is employed for urethras that are damaged for almost the entire length. This option involves multiple staged surgeries before the urethra is entirely repaired.