This document discusses stricture urethra and its management. It provides details on the epidemiology, etiology, clinical evaluation and surgical options for urethral strictures. Key points include that bulbar strictures are the most common, iatrogenic causes have increased in prevalence, clinical evaluation involves uroflowmetry, retrograde urethrogram and cystoscopy, and surgical options range from dilation and direct visual internal urethrotomy for short strictures to various types of urethroplasty using grafts or flaps for longer or complex strictures.

1. Stricture Urethra
The Present
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. Dept Of Urology, KMC and GRH, Chennai 3

4. Urethra
• Anterior Urethra –Penile and bulbar
urethra
• Posterior Urethra – Prostatic and
membranous urethra
Dept Of Urology, KMC and GRH, Chennai 4

5. ICUD Consensus 2010
• A urethral stricture is defined as a narrowing of the urethra
consequent upon ischaemic spongiofibrosis.
• Since only anterior urethra is covered by corpus spongiosum, the
terminology is used only for anterior urethra.
Dept Of Urology, KMC and GRH, Chennai 5

6. Consensus Conference 2016
• Stricture- Associated with anterior urethra
• Distraction defects- Membranous urethra with pelvic fracture
• Stenosis- Associated with posterior urethra
Dept Of Urology, KMC and GRH, Chennai 6

7. Statistical data
Dept Of Urology, KMC and GRH, Chennai 7

8. Epidemiology
• Prevalance 1-9 per 1000 population.
• Highest in developing countries.
Dept Of Urology, KMC and GRH, Chennai 8

9. Anatomical Incidence
• Bulbar strictures - 44–67 %,
• Penile strictures - 12–39 %,
• Mixed (bulbar and penile)- 6–28 %,
• External meatal or submeatal - (0–23 %),
Dept Of Urology, KMC and GRH, Chennai 9

10. Location and Mean Stricture Length
• Pendulous urethra - 6.1 cm,
• Bulbar urethra - 3.1 cm, and
• Fossa navicularis - 2.6 cm.
Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: etiology and characteristics. Urology.
2005;65(6):1055–8.
Dept Of Urology, KMC and GRH, Chennai 10

11. Etiology
Dept Of Urology, KMC and GRH, Chennai 11

12. Etiology
• Traumatic (Straddle trauma- Mostly Unnoticed)
• Inflammatory (Lichen sclerosis/Gonorrheal)
• Congenital
Dept Of Urology, KMC and GRH, Chennai 12

13. Etiology-Changing Paradigm
Dept Of Urology, KMC and GRH, Chennai 13

14. Iatrogenic Stricture
• Transurethral resection (41 %),
• Prolonged catheterization (36.5 %), and
• Cystoscopy (12.7 %)
Dept Of Urology, KMC and GRH, Chennai 14

15. Etiology
• Ischaemia due to
instrumentation at pressure
points and catheterization with
large lumen catheter.
• At points of bow string
compression.
Dept Of Urology, KMC and GRH, Chennai 15

16. Risk Factors
• Advanced age,
• Sexually transmitted illness,
• Socioeconomic status,
• Race,
• Lichen sclerosus, and
• A history of prostate cancer treatment.
Dept Of Urology, KMC and GRH, Chennai 16

17. Lichen sclerosis and Stricture Urethra
• Previously called Balanitis Xerotica Obliterans
• May be due to autoimmunity/oxidative stress
• Premalignant lesion – penile cancer changes 2.3 -9.3%
• Associated with anterior urethral stricture
Dept Of Urology, KMC and GRH, Chennai 17

18. • 1991-2002 study
• 925 patients underwent urethroplasty for anterior urethral stricture,
130 patients received the diagnosis of LS..
• 14% had LS.
Barbagli et al 2004
Dept Of Urology, KMC and GRH, Chennai 18

19. Lichen Sclerosis and Borrelia Burgdorferi-
Present Status
• Borrelia burgdorferi is not associated with genital lichen sclerosus in
men
Aberer E, Neumann R, Stanek G. Is localized scleroderma a Borrelia infection? Lancet. 1995;2:278.
Weide B, Waltz T, Garbe C. Is morphea caused by Borrelia burgdorferi? A review. Br J Dermatol.
2000;142:636–44.
Edmonds E, Mavin S, Francis N, Ho-Yen D, Bunker C. Borrelia burgdorferi is not associated with
genital lichen sclerosus in men. Br J Dermatol. 2009;160(2):459–60.
Dept Of Urology, KMC and GRH, Chennai 19

20. Gonococcal strictures-Present Scenario
In the previous century more than 90 % of strictures were
inflammatory due to gonococcus.
At present, due to the development of antibiotics, the incidence has
decreased drastically.
Dept Of Urology, KMC and GRH, Chennai 20

21. Mechanism
• Abscess in Paraurethral gland
• Rupture into corpus spongiosum
• Inflammation of corpus spongiosum
• Healing with fibrosis
Dept Of Urology, KMC and GRH, Chennai 21

22. • Urine extravasation
• Spongiofibrosis
• Further stricture upstream
Creep Up Phenomena
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23. Non Gonococcal Urethritis- Any role?
• Not proven.
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24. Clinical
Evaluation
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25. Symptomatology
Common presentation
• Weak urinary stream,
• Straining to void,
• Urinary hesitancy,
• Incomplete emptying,
• Nocturia,
• Frequency, and
• Urinary retention
Dept Of Urology, KMC and GRH, Chennai 25

26. Symptomatology
Less Common
• Post-void dribbling,
• Urinary tract infection,
• Genitourinary pain,
• Hematuria,
• Incontinence
Atypical
• Urethral cancer,
• Renal failure,
• Urethral abscess,
• Fournier’s gangrene,
• Ejaculatory dysfunction,
• Chordee
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27. Investigation- Aims
• Location of the obstruction,
• Length of the obstruction, and
• Associated urethral pathology
Dept Of Urology, KMC and GRH, Chennai 27

28. Uroflowmetry
• Low Q max
• Saw toothed pattern
Dept Of Urology, KMC and GRH, Chennai 28

29. Retrograde Urethrogram
• Dynamic retrograde urethrogram (RUG) - Reliable method to stage
and diagnose urethral stricture or stenosis.
• Sensitivity - 75–100%
• Specificity of 72–97%.
Angermeier KW, Rourke KF, Dubey D, Forsyth RJ, Gonzalez CM. SIU/ICUD consultation on urethral strictures:
Evaluation and follow-up. Urology 2014;83 3 Suppl: S8-17.
Dept Of Urology, KMC and GRH, Chennai 29

30. Cystoscopy
• Cystoscopy - most specific test to diagnose a urethral stricture and
adjunct test for staging.
Dept Of Urology, KMC and GRH, Chennai 30

31. USG /Sonourethrography– Current Status
• Can augment contrast-enhanced studies
• Accurate in determining the length of narrow-caliber annularity
Dept Of Urology, KMC and GRH, Chennai 31

32. Conclusion:
USG is equally efficacious to RGU in detecting anterior urethral
strictures.
However, further characterization of strictures in terms of length,
diameter, etc can be performed with relatively greater sensitivity using
USG.
Choudary et al, 2004
Dept Of Urology, KMC and GRH, Chennai 32

33. Male Urethral Stricture
Guidelines – 2016
• < 2 cm stricture - urethral dilation, direct visual internal urethrotomy
(DVIU), or urethroplasty for the initial treatment.
(Conditional Recommendation; Evidence Strength Grade C)
• ≥2cm stricture – should offer urethroplasty as the initial treatment
(Moderate Recommendation; Evidence Strength Grade C)
Dept Of Urology, KMC and GRH, Chennai 33

34. • Older surgeons
• Following ‘reconstructive
surgical ladder’.
Dept Of Urology, KMC and GRH, Chennai 34

35. Surgical Options
Dept Of Urology, KMC and GRH, Chennai 35

36. Stricture Excision and Primary Anastamosis
• Ideally suited for bulbar strictures 1–3 cm long,
• Can also be successful in some selected cases with proximal bulbar
strictures up to 5 cm in length.
• Not suitable for penile urethra.
Dept Of Urology, KMC and GRH, Chennai 36

37. Dept Of Urology, KMC and GRH, Chennai 37

38. Stricture Excision and Primary Anastamosis
Dept Of Urology, KMC and GRH, Chennai 38

39. Oral Mucosal Graft Urethroplasty
• Suitable for penile stricture
• May be ventral or dorsal onlay technique
Dept Of Urology, KMC and GRH, Chennai 39

40. Penile Skin Vs Mucosal Graft
Dept Of Urology, KMC and GRH, Chennai 40

41. Dorsal Onlay Vs Ventral Onlay
Dept Of Urology, KMC and GRH, Chennai 41

42. Lingual Grafts
BMG long term problems
• Persistent perioral numbness,
• Salivatory changes, and
• difficulty in opening the mouth
• Other complications are bleeding, scarring, and lip deviation or
retraction.
Dept Of Urology, KMC and GRH, Chennai 42

43. Lingual Graft- Demarcation
Dept Of Urology, KMC and GRH, Chennai 43

44. Lingual Graft
Dept Of Urology, KMC and GRH, Chennai 44

45. • Success rate of
100% in penile
strictures.
• Success rate of
81.3% in bulbar
strictures.
Dept Of Urology, KMC and GRH, Chennai 45

46. Augmented Anastomotic urethroplasty
• A combination repair that incorporates the principles of excision and
substitution urethroplasty.
Dept Of Urology, KMC and GRH, Chennai 46

47. Augmented Anastomotic Repair-Short
stricture
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48. Augmented Anastomotic Repair-Long
stricture
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49. Augmentation Stricturoplasty-Dorsal Onlay
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50. Augmentation Stricturoplasty-Ventral Onlay
Dept Of Urology, KMC and GRH, Chennai 50

51. Penile skin flaps
• Can provide upto 15 cms of length.
• But
• Avoid in cases of compromised blood flow (smoking history,
peripheral vascular disease, diabetes, radiation therapy).
• Avoid in old age, even though the results are comparable with young
adults.
• Avoid in penile skin with Lichen sclerosis changes.
Dept Of Urology, KMC and GRH, Chennai 51

52. Longitudinal Vs Transverse - Longitudinal
Pros
• Easy placement
• Ability to tailor length and width
in a straightforward manner.
• Minimal amount of dissection
required to cover the urethra
Cons
• Longer strictures, proximal
penile skin with hair must be
used.
• This can lead to infection, stone,
and obstruction.
• Flap length is contingent on
penile length.
Dept Of Urology, KMC and GRH, Chennai 52

53. Longitudinal Vs Transverse-Transverse
Pros
• Upto 15 cm length
• Excellent cosmesis
• Broad based blood supply
Cons
• More challenging dissection
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54. Proximal Vs Distal
• Distal skin is preferred over proximal skin due to the absence of hair.
• It is accustomed to moist environment
Dept Of Urology, KMC and GRH, Chennai 54

55. Penile skin flap techniques
• Longitudinal Ventral Penile Skin Flap with a Lateral Pedicle (Technique
of Orandi)
• Longitudinal Ventral Penile Skin Flap with a Ventral Pedicle (Technique
of Turner-Warwick)
• Transverse Circular Penile Skin Flap with a Primarily Dorsal Pedicle
(Technique of McAninch)
Dept Of Urology, KMC and GRH, Chennai 55

56. Orlandi Flap
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57. Mc Aninch Flap
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58. Staged urethroplasty
• Urethroplasty can be done in stages for complex anterior urethral
strictures.
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59. Patient reported outcome measures (PROMs)
To measure the outcome of the procedure from Patient’s perspective.
• American Urological Association Symptom Index(Also Known as IPSS)-
For LUTS
• International Index for Erectile Dysfunction – For Erectile dysfunction
• Male sexual health questionnaire – For Ejaculatory dysfunction
• An index purely for stricture urethra is yet to be constructed.
Dept Of Urology, KMC and GRH, Chennai 59

60. Dept Of Urology, KMC and GRH, Chennai 60