Urethral Stricture Disease

Publication Date: April 25, 2023
Last Updated: April 26, 2023

Diagnosis/Initial Management

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, C)
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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, )
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Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to make a diagnosis of urethral stricture. (Moderate, C)
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Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion, )
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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, )
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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, C)
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Dilation/Internal Urethrotomy/Urethroplasty

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

Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle, )
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Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate, C)
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Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate, C)
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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, C)
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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, C)
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Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional, C)
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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, )
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Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion, )
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Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong, A)
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Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion, )
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Surgeons should not perform a single stage tubularized graft urethroplasty. (Expert Opinion, )
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Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle, )
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Pelvic Fracture Urethral Injury

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, C)
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Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion, )
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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, )
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Female Urethral Reconstruction

Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate, C)
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Bladder Neck Contracture/Vesicourethral Stenosis

Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion, )
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Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional, C)
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Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional, C)
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Special Circumstances

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, )
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Lichen Sclerosus

Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle, )
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In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong, B)
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Post-operative Follow-up

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

Overview

Title

Urethral Stricture Disease

Authoring Organization

Publication Month/Year

April 25, 2023

Last Updated Month/Year

December 20, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of male and female urethral stricture

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management

Diseases/Conditions (MeSH)

D014525 - Urethral Stricture

Keywords

Urethral Stricture, decreased urine

Source Citation

Wessells H, Morey A, Vanni A, Rahimi L, Souter L. Urethral Stricture Disease Guideline Amendment (2023). J Urol. 2023 Apr 25:101097JU0000000000003482. doi: 10.1097/JU.0000000000003482. Epub ahead of print. PMID: 37096574.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
288
Literature Search Start Date
January 1, 1990
Literature Search End Date
October 1, 2022