- Observation – occasionally a stricture may be mild enough that no treatment may be needed. Because of the possible complications, this decision is best made only after consultation with a urologist.
- Dilation – dilation is not a permanent solution. Dilation can be performed by inflating a balloon in the urethra or by inserting a catheter into the urethra. In either case, the urethral stricture is stretched to a larger size. However, this process does not treat the underlying scar tissue, so the stricture usually returns. This may be an appropriate treatment in a patient who is too ill to undergo a more involved procedure. It can also be used as a temporary fix in someone who is looking for a short-term solution until a better treatment is available. Some patients may perform self-dilation at home by passing a catheter on a routine basis in order to keep the stricture open.
- Internal Urethrotomy – this is done under anesthesia. A cystocope (camera) is inserted through the penis up to the stricture. A small blade or laser is then inserted through the scope and the stricture is cut to a larger size. The underlying scar tissue is not removed with this process, and no new healthy tissue is brought in so recurrence is common (success ranges from 20% to 70%). Some stricture locations are more likely to be treated successfully than others with this type of treatment. If one internal urethrotomy fails, then later attempts are even more likely to fail.
- Urethral stent – this is usually reserved for posterior urethral strictures due to prostate cancer therapy (radiation or radical prostatectomy). These are difficult strictures to treat and a permanent stent provides a minimally invasive treatment alternative for patients.
- Urethroplasty – this is a broad term that describes several types of “plastic surgical reconstructions” of the urethra with tissue flaps and grafts. This type of surgery is only performed by a few trained experts at centers of excellence across the country. Success rates vary and depend on the reason for the stricture.
Listed below are examples of some of the types of urethroplasty:
- Anastomotic urethroplasty – a.k.a. end-to-end urethroplasty –
For short anterior strictures and nearly all posterior strictures (<2cm), an “end-to-end” urethroplasty is usually done. This operation goes in through the perineum, removes the scar tissue, and then sews the two healthy ends back together again. Patients go home within 1-2 days and have a catheter for 1-4 weeks, depending on the location of the surgery in the urethra. About 90-95% of these surgeries are successful.
- Buccal mucosa graft urethroplasty – This surgery is done for strictures longer than 2cm. This size of stricture requires some reconstruction; otherwise the penis would lose too much length. In this operation, the stricture is opened up but not removed. A graft of skin is laid in to patch the urethra and make the area wider. The graft is taken from the inside of the cheek because this tissue is very similar to the inside of the urethra. Think of this like removing a sagging roof on your house, keeping the basement intact (opening the urethra without removing it) and adding a new roof (the graft). Patients go home within 1-2 days and the catheter stays in for 2-3 weeks. The success rate is 90%.
- Fasciocutaneous flap urethroplasty – this is best for long strictures and strictures in the penile urethra. It involves taking a strip of skin from the end of the penis (the foreskin if the patient is not circumcised) and keeping it attached to its blood supply. The stricture is opened and the flap is added to widen the urethra. 85% of these surgeries are successful.
- Two-stage urethroplasty – this is reserved for the most complex strictures or strictures that have failed a prior urethroplasty. It involves opening the urethra and bringing in some healthy tissue, but not closing the urethra at that time. The new graft is allowed to set for several months before the urethra is rolled together again.
Complications of Urethral Stricture
If left untreated, urethral strictures can lead to:
- Complete inability to urinate (a.k.a. acute urinary retention)
- Bladder dysfunction – as the bladder pushes against the blockage, the muscle wall thickens. This makes the bladder “stronger” but also makes it less flexible. Eventually, the bladder may not stretch properly, making it difficult to hold very much urine at all.
- Urinary tract infection – when a patient is not able to completely empty the bladder, bacteria can grow in the urine left in the bladder.
- Bladder stones – left over urine in the bladder may contain small stone crystals and bacteria that make the development of stones more likely.
- Urethrocutaneous fistula – this is a rare problem in which the urine looks for a “detour” to the skin to get around the urethral stricture. It can lead to dangerous skin infections with “flesh-eating” bacteria.
- Renal failure – rarely, the long-term obstruction can damage the kidneys.