Male Urethral Stricture Disease

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.

Bladder obstruction from enlargement of the prostate (BPH), scar tissue at the bladder level from prior prostate surgery, urethral cancer and urethral polyps can all mimic stricture symptoms.

Prolonged sitting and pressure from a narrow bicycle seat can cause numbness to the genitalia. Repeated pressure on the urethra can potentially compromise blood flow to the urethra and potentially cause a stricture. Additionally, straddle injuries to the perineum can crush the urethra against the pubic bone, causing damage and scar tissue to the urethra. A common scenario is straddling the cross bar on a bicycle. Furthermore, motorcycles can cause a similar mechanism when the perineum is smashed against the gas tank during an abrupt deceleration. Urologists recommend using a padded, wide saddle and avoid the “long nose” skinny seats. Additionally, avoidance of long rides in excess of 2-3 hours is advised.

There have been many studies looking at outcomes from direct vision urethrotomies for strictures. For the initial first-time attempt, patients can experience success rates ranging from 26-60 percent for strictures less than two centimeters. If another attempt is performed, the long-term success is virtually zero percent.

This is a difficult situation, but there are many alternatives to urethroplasty. One option is to create a shortcut between the bladder and the perineum called a urethrostomy. This would require the patient to sit to urinate. Alternatively, an outpatient procedure call a supra-pubic tube could be considered. Finally, a larger surgical procedure where a new urethra is created by using a piece of bowel could be considered.

These urethral injuries are caused by tearing of the urethra at the junction between the prostate and the membranous urethra. The two ends will heal with a gap between. Once the acute injuries from the injury have resolved (usually 3-6 months) the urethra is reconstructed using an anastamotic one-stage urethroplasty. Grafts are rarely used.

Almost all of these procedures are performed as an outpatient. The incision is injected with local anesthetic and the pain is worst for the first 12-24 hours. Oral narcotic pain medications are provided for this period. Most patients transition to Tylenol or ibuprofen within 3-4 days. Some patients experience cramping of the lower abdomen or pelvis. This is a bladder muscle spasm and medications are provided to alleviate this discomfort.

It depends on the occupation and degree of manual labor. If heavy lifting is required, most patients will require 3-4 weeks off of work until the catheter is removed. If the job allows the patient to work with a catheter under their pants, 1-2 weeks of leave may be all that is required.

Patients must be off all pain medications, having no pain and ambulating with the catheter without difficulty.