Renal · Urology
The facts most likely to be tested
The most common clinical presentation of a urethral stricture is a weak urinary stream and incomplete bladder emptying.
A history of straddle injury or pelvic fracture is a classic high-yield risk factor for posterior urethral strictures.
Prior urethritis (often from Neisseria gonorrhoeae) or prolonged indwelling catheterization are the most common causes of anterior urethral strictures.
Retrograde urethrography (RUG) is the gold standard diagnostic imaging modality to confirm the location and length of the stricture.
Patients with a urethral stricture often demonstrate a decreased peak urinary flow rate on uroflowmetry.
Urethral dilation or internal urethrotomy are initial management options, but urethroplasty remains the definitive treatment for recurrent or complex strictures.
Complications of untreated urethral strictures include recurrent urinary tract infections, prostatitis, and chronic urinary retention leading to hydronephrosis.
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A 45-year-old male presents to the clinic complaining of a progressively weak urinary stream and post-void dribbling over the past six months. He reports a history of a straddle injury from a bicycle accident ten years ago. Physical examination reveals no suprapubic tenderness, but a decreased peak flow rate is noted on office uroflowmetry. A retrograde urethrography is performed, which demonstrates a focal narrowing in the bulbar urethra.
What is the most appropriate next step in the management of this patient's condition?
Urethroplasty
The patient's history of trauma and classic obstructive symptoms confirm a urethral stricture, and for symptomatic or recurrent cases, urethroplasty is the definitive surgical management.
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High yield triage
Etiology / Epidemiology
Commonly follows urethral trauma, instrumentation, or gonococcal urethritis. Often idiopathic in older males.
Clinical Manifestations
Presents with obstructive voiding symptoms and a weak urinary stream. Look for post-void dribbling.
Diagnosis
Retrograde urethrography (RGU) is the gold standard. Voiding cystourethrography (VCUG) is often used adjunctively.
Treatment
Urethral dilation or urethrotomy for initial management. Urethroplasty is the definitive surgical repair.
Prognosis
High recurrence rates require long-term monitoring. Urinary retention and recurrent UTIs are major complications.
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Epidemiology & Etiology
Strictures result from fibrotic scarring of the urethral lumen. Primary causes include iatrogenic trauma (catheterization, cystoscopy), straddle injuries, and chronic lichen sclerosus. Historically, gonococcal urethritis was a leading cause, though now less common in developed regions.
Pertinent Anatomy
The bulbar urethra is the most common site for strictures. The membranous urethra is highly susceptible to injury during pelvic fractures due to its fixed position at the urogenital diaphragm.
Pathophysiology
Injury to the urethral epithelium triggers an inflammatory response leading to spongiofibrosis. This collagen deposition narrows the urethral lumen, increasing bladder outlet resistance. Chronic obstruction leads to detrusor hypertrophy and eventual bladder decompensation.
Clinical Manifestations
Patients report a weak or spraying urinary stream, hesitancy, and incomplete bladder emptying. Acute urinary retention is a potential emergency. Physical exam may reveal a palpable, thickened urethra or signs of urethral fistula.
Diagnosis
Retrograde urethrography (RGU) is the diagnostic test of choice to define stricture length and location. Cystourethroscopy provides direct visualization but is limited by the inability to pass the scope through severe strictures. Uroflowmetry may show a flattened, low-amplitude curve.
Treatment
Initial management involves urethral dilation or direct vision internal urethrotomy (DVIU) for short, simple strictures. Do not perform aggressive dilation as it increases scar formation. Urethroplasty is the definitive treatment for long or recurrent strictures. Avoid blind instrumentation in the setting of suspected urethral disruption.
Prognosis
Strictures have a high propensity for recurrence even after successful intervention. Patients require long-term follow-up with uroflowmetry to detect early signs of re-stenosis. Complications include recurrent UTIs, prostatitis, and bladder stones.
Differential Diagnosis
BPH: prostate enlargement on DRE
Urethral cancer: hematuria and palpable mass
Prostatitis: tender prostate on exam
Bladder neck contracture: history of prior prostate surgery
Urethral stone: sudden onset pain and obstruction