Erectile Dysfunction

Urethral stricture is fixed narrowing of the urethral lumen caused by fibrosis of the urethral epithelium and surrounding corpus spongiosum.

Common causes include:

• Previous instrumentation
• Urethral catheter trauma
• Pelvic or perineal trauma
• Sexually transmitted urethritis
• Lichen sclerosus
• Previous hypospadias surgery
• Radiation
• Idiopathic disease

Strictures are described by:

• Anatomical site
• Length
• Degree of obliteration
• Cause
• Previous treatment

These factors determine treatment more usefully than an elaborate numerical classification.

Symptoms include:

• Weak stream
• Spraying
• Straining
• Prolonged voiding
• Incomplete emptying
• Recurrent UTI
• Acute urinary retention
• Post void dribbling
• Ejaculatory difficulty

Repeated treatment for presumed BPH in a younger man with a very poor stream should prompt evaluation for urethral stricture.

Use:

• Uroflowmetry
• Post void residual

A plateau shaped low flow curve supports fixed obstruction.

Retrograde urethrogram: defines:

• Location
• Length
• Degree of narrowing

Add voiding cystourethrography for:

• Nearly obliterative disease
• Posterior urethral pathology

Flexible cystoscopy confirms luminal narrowing but may not define the length beyond a tight stricture.

Dilation or DVIU

Best candidates are:

• Primary
• Single
• Short
• Nonobliterative
• Bulbar strictures

particularly those less than approximately 2 cm.

Perform internal urethrotomy using an appropriate cold or hot knife technique according to expertise.

Repeated DVIU for a recurrent stricture has poor long term success and progressively delays definitive repair. Current 2026 guidance continues to emphasise definitive urethroplasty rather than repeated endoscopic treatment for recurrent disease.

Excision and primary anastomosis

Suitable for selected short traumatic or obliterative bulbar strictures.

Excise fibrotic tissue and create a tension free mucosa to mucosa anastomosis.

Avoid excessive urethral shortening.

Buccal mucosal graft urethroplasty

Preferred for many longer anterior strictures.

Harvest oral mucosa and use it as an augmentation graft.

Can be placed dorsally or ventrally depending on:

• Location
• Spongiosal quality
• Surgeon technique

Lichen sclerosus

Avoid genital skin grafts because the disease can involve them.

Use oral mucosal graft.

Extensive panurethral disease may require staged reconstruction.

Chronic suprapubic catheter

Appropriate when:

• Patient unfit for reconstruction
• Patient declines surgery
• Complex stricture requires urethral rest before urethroplasty

After instrumentation, a period of urethral rest can improve accurate assessment of true stricture extent.