Strictures of the male urethra are one of the oldest known surgical afflictions and are a major cause of morbidity and mortality throughout the world. Untreated, strictures may lead to urinary retention, sepsis, bladder and renal failure. Today, the correct approach is to consider reconstruction at the outset. A single dilatation, particularly in the setting of urinary retention (or incipient retention) is reasonable but stricture recurrence is best referred.
Urethral strictures are caused by spongiofibrosis, that is, scarring of the spongy erectile tissue which surrounds the urethral lumen. Breach of the urethral mucosa by trauma or infection leads to extravasation of urine into the delicate spongiosum, followed by inflammation and resolution by fibrosis.
The mainstay of treatment has been dilatation, despite the fact that it is ineffective (long term success of <5%). Many men follow years of painful self-dilatation which is not curative, and in fact, can continue the trauma/scaring cycle and cause any stricture to become longer and denser, making subsequent repair more difficult.
Reconstruction of the urethra is highly specialised and effective. A ‘father’ of West Australian urology, Dr Stan Wisniewski said, “Dilatation is palliation, urethroplasty is cure”.
The likely cause and management of strictures differs by location. The male urethra is divided into three parts:
- Membranous (from prostate to external sphincter)
- Bulbar (sphincter to penoscrotal junction)
- Penile urethra
- Membranous strictures are most commonly associated with pelvic fractures e.g. MVA. These are often managed with initial insertion of a suprapubic catheter and delayed reconstruction. Such injuries are often associated with erectile dysfunction and repair is challenging due to the very deep position of the injury within the pelvis and extensive scarring associated with bone fragments.
- Bulbar urethral strictures are trauma-related, most commonly fall-astride impacts (often quite minor) and iatrogenic injuries (e.g. traumatic catheterisation or an endoscopic procedure e.g. TURP)
Repair of these strictures almost always is achieved in a single stage using either an excision and anastomosis or graft technique, utilizing free grafts of oral mucosa. Results are excellent with 85% patency at ten years, in experienced hands.
- Penile urethral strictures are most commonly associated with Balanitis Xerotica Obliterans (BXO) and /or childhood hypospadias repair. These can be challenging strictures due to the progressive nature of BXO, multiple previous surgeries and disordered blood supply associated with hypospadias. Repair often requires a staged approach, again using free grafts of oral mucosa. With appropriate timing and experience, functional and cosmetic outcomes are excellent.
Key Messages
- Urethral strictures are a major cause of morbidity
- Dilatation is palliation, curing <5% of strictures
- Urethroplasty is curative in 85% with a single procedure in expert hands
References available on request.
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Author competing interests: nil relevant disclosures.
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