Urethral Strictures Treatments
Urethral stricuture treatments
For anyone who has been told they have a urethral stricture (or narrowing of the urethra), it is important to know the following:
- All strictures should be properly imaged prior to any surgery
- Dilations and incisions should only be performed on short strictures
- Repeat dilations and incisions don’t cure the problem and they may decrease the success of future urethroplasty.
- The current standard of care is imaging, one incision or dilation, followed by the urethroplasty procedure.
Most types of urethral strictures can be treated with surgery, specifically a urethroplasty, which is the surgical repair to the narrowing of the urethra. It is often performed through an incision in the perineum (the area between the anus and the scrotum).
The best treatment option for a urethral stricture depends on the cause, the length, the exact location and any prior treatments. At City of Hope, our highly skilled team will create a personalized treatment plan for your specific diagnosis. The team features fellowship-trained urologists who hold the rare distinction of specializing in the repair of male urethral strictures.
Treatments for bulbar strictures
Bulbar urethral strictures may arise from trauma, instrumentation or infection. These are the most common types of strictures that reconstructive urologists treat.
Short strictures that are appropriately imaged may benefit from a direct visual internal urethrotomy (DVIU). For this treatment, the scar tissue in the urethra is cut with a knife to open the urethra. Patients should only have one DVIU, as repeat DVIUs do not cure the disease and can render more effective urethroplasties less effective.
Urethroplasty is the operation used to repair a urethral stricture. There are two primary types of urethroplasty operations for bulbar urethral strictures:
- Anastomotic urethroplasty: Also called excision and primary anastomosis, this procedure cuts out the scarred portion and reattaches the healthy ends of the urethra. This is best for traumatic strictures and short strictures. Some doctors report an unacceptably high rate of sexual side effects with this approach and many experts have aborted this procedure, except in the setting of trauma.
- Buccal mucosa urethroplasty: This procedure opens the urethra and patches the narrow area with an alternative tissue to widen the lumen. This is usually performed with the tissue from the inside of the mouth (buccal mucosa), but penile skin or skin from other sites on the body may also be used.
This is best for long strictures and strictures caused from lichen sclerosis. In addition, this form of repair may have fewer sexual side effects than an anastomotic urethroplasty.
Treatments for bladder neck contractures
Bladder neck contractures typically form after a prior treatment for enlarged prostate, particularly laser treatments and button transurethral resection of the prostate.
Another scenario that can cause a bladder neck contracture is when someone has their prostate removed surgically and a scar forms at the site where the bladder is sewn back to the urethra.
The first treatment option in these scenarios is to perform an incision through the stricture, known as a transurethral incision of the bladder neck contracture. Some doctors then inject a small dose of chemotherapy to prevent the scar from returning. To date, there have been no trials to show that this truly makes a difference, but early reports seem promising.
In cases of radiation induced (or associated) strictures, the success rate decreases with this procedure.
Advanced cases often involve a more aggressive approach. We currently perform anastomosis revision surgery, bladder augmentation surgeries or, if a patient cannot tolerate a large operation, we can place a Foley catheter to aid in bladder drainage.
Treatments for pelvic fracture urethral injury (PFUI)
As the name implies, this is a urethral injury associated with a pelvic bone fracture (usually due to a car accident). When the pelvic bone breaks, the urethra can be torn in half. Many times a catheter will be placed despite the injury. In other cases, the urethra is injured so severely that a tube has to be placed into the bladder through the skin of the low abdomen.
After appropriate imaging, the best option for repair can be determined. In some cases, a direct visual internal urethrotomy (DVIU) may be performed. But like other strictures, only one DVIU should be performed before undergoing an urethroplasty.
In the setting of PFUI, the only option is to perform an anastomotic urethroplasty, focusing on removal of all scar tissue in the urethra.
Treatments for penile urethral stricture and pan-urethral strictures
Penile urethral strictures are caused by a number of conditions: failed hypospadias surgeries, instrumentation, lichen sclerosis (a scarring disease of the penile skin and urethra), infections and trauma. These can occur anywhere along the penile urethra.
The preferred treatment for penile urethral strictures and pan-urethral strictures is a buccal graft urethroplasty. This is a versatile option that can be placed anywhere along the urethra and can even extend the entire length of the urethra. This is particularly true in cases of lichen sclerosis, when the penile skin is likely involved with the disease and therefore should not be used.
In the case of a failed hypospadias repair or previous failed urethroplasty, the procedure is performed in stages. The first stage involves opening the urethra and sewing it to the skin. The second procedure recreates a tube with the help of buccal grafts if needed.
In certain cases, penile skin may be used to widen the narrowed urethra, but using penile skin poses a higher risk of complications than other approaches.
In severe cases, a perineal urethrostomy may be necessary. This procedure involves making the opening of the urethra come out of the perineum (the area between the anus and scrotum), which allows for normal urinary control but does require a man to sit to urinate. This is a highly effective choice but is often considered a last resort.
Treatment options for meatal stricture
Meatal stricture is a narrowing at the very end of the urethra, at the tip of the penis. These strictures can be caused by trauma, lichen sclerosis, instrumentation, infection, failed urethroplasty and other unknown causes. Despite the fact that these strictures seem simpler, proper imaging is still required to help determine proper management.
Meatoplasty is a small incision on the underside of the head of the penis (the glans), essentially making the opening larger. This is an effective option for small, short strictures. When the stricture extends into the fossa or penile urethra, they are treated in a similar fashion to those strictures of the penile urethra.