Penile Urethral Stricture

Penile urethral stricture involves the pendulous urethra from the penoscrotal junction to the meatus, including the fossa navicularis. Causes are lichen sclerosus (commonly the largest group), previous hypospadias repair, catheterisation or instrumentation, and infection.

It is less common than bulbar stricture. The thin spongiosum here makes endoscopic treatment unreliable, so repair usually needs tissue replacement.

Pathophysiology. In lichen sclerosus, chronic inflammation of genital skin extends into the meatus and urethral lining, causing progressive fibrosis.

Strictures from instrumentation arise from catheter pressure ischaemia or mucosal tearing.

Reduced force and calibre of stream, spraying, straining, post-void dribble, and meatal pain or bleeding. Examine for white atrophic glans skin, meatal stenosis, phimosis, and a thickened ventral urethra. Complications include periurethral abscess, urethrocutaneous fistula and diverticulum.

• Uroflowmetry and post-void residual.
• Retrograde urethrography with voiding cystourethrography, with oblique views. Cystoscopy or urethroscopy to define the proximal and distal extent.
• Biopsy of suspicious glans or foreskin skin for lichen sclerosus and to exclude carcinoma.
• Urine culture, renal ultrasound, creatinine.

Differential diagnosis.

• Meatal stenosis
• Bulbar stricture
• Phimosis
• Urethral cancer
• Urethral diverticulum
• Urethral stone
• Balanitis

• Meatal stenosis or limited navicular stricture: meatotomy or meatoplasty.
• Dilation or urethrotomy has a high failure rate in the penile urethra and is not advised for lichen sclerosus.
• Single stage urethroplasty: buccal mucosa graft (dorsal onlay or ventral inlay) for short or moderate strictures. Penile skin flaps are acceptable only if the skin is healthy and not affected by lichen sclerosus.
• Two stage repair (buccal graft staged repair, or marsupialisation then closure) for long, dense or lichen sclerosus strictures, with the second stage after 6 months.
• Lichen sclerosus: clobetasol propionate 0.05% ointment, thin layer once daily at night for 4 weeks, then reduced to alternate nights or twice weekly as skin improves, with review at 3 months. Do not use genital skin or foreskin for grafts, as the disease recurs in them. Circumcision treats foreskin involvement but does not treat urethral disease.
• Catheter 2 to 3 weeks after repair, and a single antibiotic dose directed by culture. Complications include fistula, glans dehiscence, chordee, and recurrence.

Monitoring. Uroflowmetry at 3, 6 and 12 months, then yearly. Lichen sclerosus carries a small risk of penile squamous cell carcinoma, so keep long term surveillance and biopsy any non-healing, ulcerated or raised area.

Referral and escalation. Refer to reconstructive urology. Urgent referral for retention, abscess, fistula, or suspicious lesions.