West Coast Urology  –  Geelong   |   Hamilton    |   Colac   |   Winchelsea

A. PROF RICHARD GRILLS

DR KATHRYN MCLEOD

MR PATRICK PREECE

Urological Surgeons

Stricture Disease and Urethroplasty

To download a PDF document about ‘urethroplasty’ please click:

What is a urethral stricture?

  • The urethra is the water-pipe that runs from the bladder to the tip of the penis in men. A stricture is a blockage of the urethra caused by scar tissue.
  • Causes of stricture formation include:
    • Trauma
    • Infection
    • Inflammatory skin conditions (lichen sclerosis)
    • Previous urethral surgery (e.g. hypospadias repair, TURP) or catheterisation
  • Often no cause of the stricture is identified.


Reasons for treating urethral stricture

  • Stricture related symptoms include strained urination with slow flow, difficulty emptying the bladder, urinary frequency and urgency, urinary tract infections and impaired force of ejaculation. Sometimes urethral bleeding can occur.
  • In severe cases, a complete blockage can result in acute urinary retention.
  • Left untreated for long periods of time, a stricture can damage and weaken the bladder.

The following investigations are usually recommended:

  • Flow rate and bladder scan
    • By urinating into a specialised machine in the office, the velocity of your urine stream can be accurately measured. An ultrasound of your bladder afterwards reveals how much urine is left behind. Both measures reflect the severity of your stricture.
  • Cystoscopy
    • A telescope is threaded along the urethra to visualise the stricture and health of the surrounding tissues, but may not be able to see beyond the narrowing.
  • Retrograde urethrogram
    • A special x-ray that assesses the urethra, including the location, length and calibre of the stricture. A small catheter is placed inside the tip of the penis and contrast (dye) is flushed into the urethra as an x-ray is taken.

‘Endoscopic surgery’ is surgery performed using a telescope.

Urethrotomy: Using a blade to internally splice the scar tissue, opening up the strictured segment of urethra

Urethral dilation: Stretching and splitting the urethral scar tissue by passing larger and larger urethral dilators

  • Both urethrotomy and dilation are performed as day case surgery.
  • You will be asked to perform a urine test 7-10 days before your procedure to exclude infection.
  • You may be left with a catheter for a couple of days to assist with healing and you may also be encouraged to perform intermittent self-catheterisation following the procedure.
  • You can expect some blood in the urine, painful urination and irritable bladder function (increased frequency and urgency) for one to two weeks afterwards.

Intermittent self-catheterisation (self-dilation): The patient is taught to pass a catheter along the urethra every few days to keep the stricture open. This is often recommended in combination with urethrotomy or urethral dilation to decrease the risk of the stricture re-forming.

Results

  • Urethrotomy and urethral dilation are equal in ability to successfully treat a stricture.
  • Long term ‘cure’ rates are only seen in perhaps 50% of suitable cases.
  • If the stricture recurs, a repeat urethrotomy or dilation rarely provides long term cure.
  • In such cases, urethroplasty is usually recommended.
  • Strictures most commonly occur in the bulbar urethra (the segment of urethra that runs behind the scrotum and between the legs; an area called the perineum). Strictures can also affect the urethra running through the penis.
  • Short and very dense strictures in the bulbar urethra can be repaired by removing the scarred segment, and joining the two ends of the urethra back together.
  • This is called an ‘anastomotic urethroplasty’ and has long term success rates of approximately 90%.
  • For longer bulbar strictures or strictures in the penis, an ‘end to end’ repair is not feasible. In such cases, the narrowed part of the urethra is widened by augmenting it with a graft of healthy tissue.
  • The graft is typically taken from the inside lining of the cheek (‘buccal mucosal graft’ or BMG).
  • A ‘BMG urethroplasty’ also has generally excellent outcomes, with long-term success rates of greater than 80% (not needing any further surgery for 10+ years).
  • The operation is performed through an incision on the perineum (between the legs) or on the underside of the penis, depending on where the stricture is located.
  • A graft may be taken from the lining of the cheek (or in very long strictures, both cheeks), resulting in a row of stitches on the inside of the mouth.
  • At the end of the surgery, a catheter is inserted to drain urine and allow the urethra to heal.
  • The procedure takes approximately 3 hours and is performed under a general anaesthetic.
  • It is typically an overnight stay in hospital.
  • The catheter is removed after 3 weeks.

 

Two-stage urethroplasty

  • Most strictures can be repaired during a single operation. However, for strictures that occur towards the tip of the penis, best results are often achieved with a two-stage procedure.
  • During the first surgery, the scarred urethra is opened on the underside of the penis, and a buccal graft is laid down in to widen it. The opened penile urethra and graft are left to settle for 6 months, during which time the patient urinates through an opening further back along the underside of the penis. It may be necessary between stages to sit on the toilet to urinate due to spraying and difficulty ‘aiming’.
  • A second-stage operation is then performed, rolling up the widened urethra and closing it in layers to reform a watertight tube that runs all the way to the tip of the penis (meatus) again. Occasionally an extra graft is added if the urethra at this stage if necessary.

 

MORE INFORMATION

https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Bulbar%20urethroplasty.pdf

 

 

  • Bleeding
    • Some bruising between the legs, of the scrotum and penis is expected and usually settles quickly.

  • Wound and urinary tract infections

  • A numb patch of skin around the wound and back wall of the scrotum
    • If this occurs, it may slowly resolve if the small nerves supplying the skin recover

  • Complications from harvesting a buccal (inner cheek) graft:
    • A feeling of mouth tightness (this typically ‘relaxes’ after a few weeks)
    • Injury to a salivary duct (‘Stensen’s duct’)
    • Altered embouchure (the blowing ability of wind instrument musicians)

  • Recurrent stricture with return of urinary symptoms
    • On average, stricture recurrence rates are approximately 10-20% following urethroplasty. If a stricture recurs, various treatment options exist.

  • ‘Post-micturition dribble’
    • After urinating, several droplets of urine may linger in the widened part of the urethra causing small ‘dribbles’ to occur in your underwear. If this occurs, it can be managed by milking any extra droplets out by running a finger along the underside of the urethra after urinating.

  • Urinary fistula formation
    • An abnormal opening between the urethra and skin with leakage of urine . An uncommon complication typically seen with urethroplasty for complex penile strictures.

  • Decreased force of ejaculation

  • Curvature (or tethering) of the penis with erections (‘chordee’)
    • Although uncommon, it is seen more frequently with anastomotic than BMG urethroplasty.

  • Erectile dysfunction
    • Uncommon (1-3%)

Pre-operative tests

  • You will be given a slip for routine blood tests and a urine test to exclude infection (to be performed 7-10 days before surgery)

Smoking

  • Smoking impairs wound healing and significantly increases the risk of any urethroplasty failing. Your surgeon will insist you quit smoking before urethroplasty.

Medications to stop before the surgery

  • Notify your surgeon if you take any blood thinners, medications for diabetes or medications that weaken your immune system as these may need to be withheld in the lead up to surgery.

Wound care and recovery

  • All stitches are dissolvable.
  • A waterproof dressing will be applied to the wound. If the dressings become wet or soiled, take it off and keep the exposed wound clean and dry.
  • You can shower as normal, but ensure the wound is dry afterwards (pat dry with a towel or use a hair dryer).
  • Minor swelling, bruising and pain can last for a few weeks.
  • Strenuous activity (including sex) should be avoided until the catheter is removed. It is advisable to not go to work during this period, although you will likely be able to sit at a desk and work from home.


The mouth

  • Apply an ice pack to the cheek from which the graft was taken for the first 48 hours to minimise swelling and pain.
  • It is sensible to eat soft food and avoid very hot food for the first week or so following surgery.
  • Twice daily saline gargles are encouraged for the first week (dissolve half a teaspoon of salt in a cup of warm water) .
  • DO NOT USE ‘Listerine’ or any alcohol-based mouth washes.
  • ‘Bonjela’ (an over-the-counter numbing mouth ulcer and teething gel) can be applied to the mouth wound for pain relief.
  • Brush your teeth as normal.


Medications

  • When you leave hospital you will be given:
    • A box of tablet antibiotics
    • Pain relief medication
      • Take regular Panadol and ibuprofen
      • Stronger pain relief can be used if needed
    • Laxatives to prevent constipation


Catheter

  • Before leaving hospital you will be given instructions on how to manage your catheter and leg bag.
  • A little mucous discharge from the penis around the catheter is normal and does not mean infection. If however you have worsening pain or other concerns to suggest infection, please contact your surgeon or urology nurse to discuss.
  • The catheter is usually removed after 3 weeks by the nurse (it may be removed earlier or later in special circumstances).


Driving

  • It is safe to resume driving when you are off strong pain medication, and are moving around freely. This may not be until after the catheter is removed.


Follow up appointments

  • You will be seen in the rooms:
    • 1 week after surgery
      • By the nurse to review the wound
    • 3 weeks after surgery
      • To remove the catheter
    • 3 and 12 months after surgery
      • With a flow rate and bladder scan to assess the strength of the urinary stream. Patients are discharged at that point if all is well.


If you did not receive an appointment when leaving hospital, please contact reception staff at West Coast Urology to make one.


Cause for concern

  • Contact your surgeon if you notice any of the following during the recovery period:
    • Fever, worsening pain, redness or wound discharge
    • Blocked or dislodged catheter
    • Difficulty urinating after catheter removal