• Definition: a narrowing of the urethra that obstructs the flow of urine.

• Symptoms: weak stream, straining to urinate, pain with urination, feeling like the bladder is not empty, taking 40sec or longer to urinate to completion.

  • If the stream progressively weakens, notify us or your local urologist. If you wait too long, you may end up in acute urinary retention (inability to urinate with an uncomfortably and sometimes painful bladder filled with urine); this would require ER evaluation.

• The most common locations of a stricture include the tip of the penis urethra and at the connection between portions of urethral lengthening (example: between the penis UL and minora UL).

  • For metoidioplasty, the most common location is near the connection to the original urethra.

• Penis swelling may act like a stricture as it compresses the urethra from the outside; swelling resolution will lead to improved voiding symptoms.

• Risk factors for stricture formation:

  • Decreased blood flow:

    • The tip of the urethra is furthest away from the blood vessels.

    • The urethral connection between the phallus urethra and the minora urethra are subject to increased tension, which can lead to decreased blood flow.

  • Smoking, poor nutrition​

• Note: strictures and fistulas may sometimes occur together as they may derive from a similar cause, such as decreased blood flow.​

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SURGERY FOR STRICTURES

• Strictures rarely resolve on their own. They often require intervention.

  • Dilation vs Urethroplasty​

• Cystoscopy and urethral dilation​ with/without steroid or drug injection (an alternative similar treatment is cutting the stricture internally called direct vision internal urethrotomy or DVIU)

  • A camera is inserted into the urethra, and the location(s) of the stricture(s) determined. 

  • Dilation: A guidewire is placed into the narrowed urethral segment, and tapered, surgical dilators are passed over the wire from small to larger in diameter to sequentially stretch the stricture. Sometimes steroid or other scar modulating medication is injected into the scar tissue.

  • DVIU: a special camera with a knife is used to cut the stricture; laser can also be used to cut the stricture.

  • There is no cutting of skin​

  • Catheter duration: about 3-7 days 

  • Success rate: about 40-50% 

• Urethroplasty: 

  • An incision or incisions are made through the skin depending on the location of the stricture(s). Example includes in front of the scrotum to gain access to the most common stricture site.​

  • The stricture is opened and scar tissue is removed, leaving a defect.

    • Small defects can be treated by sewing the neighboring healthy urethral tissue together.​

    • Larger defects are repaired with mouth and/or skin grafts.

    • Largest defects with minimal neighboring healthy tissue are repaired with staging, where the urethral segment is grafted and patients sit to urinate until the grafts mature. Six months later, the open urethral segment is tubularized and the wound closed.

  • Catheter duration: about 2-4 weeks, depending on the type and location of the urethroplasty. 

  • Success rate: about 70-80%

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AFTER URETHROPLASTY OR CYSTOSCOPY WITH DILATION/URETHROTOMY

• A follow-up is warranted every 3-6 months. We generally want to make sure the stricture does not recur.

  • Questions regarding force of stream and ease of voiding are helpful.

  • To quantify things, uroflowometry aka uroflow is performed in the office to measure peak flow rates, average flow rates, void times, and void volumes. There is also a graph that helps the urologist determine if there is no urethral obstruction, mild or moderate obstruction, or severe obstruction. Obstruction usually means the stricture has recurred. 

• For non-local patients, we can calculate an average flow rate in milliliters per second (mL/sec) from their home every 1-3 months.

  • Basically, when patients have a full bladder with a strong urge to urinate, they are instructed to urinate into a large cup that has measurement lines and time the duration of urination.

  • Example: if the patient urinates 300mL in 30 sec, this is considered within range of normal.

  • Average flow rates (ml/sec) help us quantify the patient's stream quality.

    • Around 10mL/sec is considered typical.

    • Around 5ml/sec is worrisome.

    • A trend of consistently weak streams with decreasing average flow rates is indicative of stricture development.

• *NOTE: symptoms and uroflow tests do not guarantee presence or absence of a stricture. A combination of symptoms and test results can raise suspicion, which is then confirmed with a cystoscope (camera to look at the urethra) followed by urethroplasty or dilation/urethrotomy if indicated.

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