SUMMARY

Purpose

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The clinical guideline on urethral stricture provides a clinical framework for the diagnosis of urethral stricture and includes discussion of initial management, urethroplasty, reconstruction, contracture, stenosis, special circumstances, and post-operative follow-up care.

Methodology

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment used the Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases and was modified to included females and males (search dates 12/2015 – 10/2022 for males; 01/1990 – 10/2022 for females) and one new Key Question on sexual dysfunction outcomes in men with bulbar urethral strictures was added (search dates: 01/1990 – 10/2022). All searches yielded 11,752 citations; after inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty) and evidence-based statements of Strong, Moderate, or Conditional Recommendation based on risks and benefits were developed. Additional information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

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GUIDELINE STATEMENTS

Diagnosis/Initial Management

1. Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection, and after rising post-void residual. (Moderate Recommendation; Evidence Level: Grade C)
2. After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture. (Clinical Principle)
3. Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)
4. Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion)
5. Surgeons may utilize urethral endoscopic management (e.g., urethral dilation, direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)
6. Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence Level: Grade C)

Dilation/Internal Urethrotomy/Urethroplasty

1. Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
2. Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
3. Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)
4. In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain urethral patency. (Conditional Recommendation; Evidence Level: Grade C)
5. a. Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level: Grade C)b. Surgeons may offer urethral dilation or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)
6. Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)

Anterior Urethral Reconstruction

1. Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle)
2. Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate Recommendation; Evidence Level: Grade C)
3. Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)
4. Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral strictures, given the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation; Evidence Level: Grade C)
5. Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
6. a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)
7. a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation; Evidence Level: Grade A)
8. Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion)
9. Surgeons should not perform a single stage tubularized graft urethroplasty. (Expert Opinion)
10. Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)

Pelvic Fracture Urethral Injury

1. Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate Recommendation; Evidence Level: Grade C)
2. Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)
3. Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion)

Female Urethral Reconstruction

1. Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)

Bladder Neck Contracture/Vesicourethral Stenosis

1. Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion)
2. Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
3. Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)

Special Circumstances

1. In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)

Lichen Sclerosus

1. Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle)
2. In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Level: Grade B)

Post-operative Follow-up

1. Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy, or urethroplasty. (Expert Opinion)

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