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Urethral stricture

Key sources
The following summarized guidelines for the evaluation and management of urethral stricture are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American Urological Association (AUA 2023; 2014), the Canadian Urological Association (CUA 2020), and the World Society of Emergency Surgery (WSES/AAST 2019).
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Guidelines

1.Classification and risk stratification

Severity assessment
Use a validated patient-reported outcome measure to assess symptom severity and impact on the QoL in patients undergoing surgery for urethral stricture.
A
Use a validated tool to assess sexual function in male patients undergoing surgery for urethral stricture.
A
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2.Diagnostic investigations

Initial evaluation
As per AUA 2023 guidelines:
Include urethral stricture in the differential diagnosis of patients presenting with a decreased urinary stream, incomplete emptying, dysuria, UTI, and rising post-void residual.
B
Consider using a combination of patient-reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture, following history, physical examination, and urinalysis.
C

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  • Diagnostic imaging

3.Medical management

Conservative management
Do not perform an intervention in patients with asymptomatic incidental (> 16 Fr) urethral strictures.
D
Consider offering long-term suprapubic catheterization in patients with radiation-induced bulbomembranous strictures and/or poor performance status.
C

4.Therapeutic procedures

Intraurethral/intralesional injections
Administer intraurethral corticosteroids, in addition to intralesional corticosteroids, to stabilize the urethral stricture.
B
Administer intralesional injections only in the context of a clinical trial.
B

5.Perioperative care

Preoperative urethral rest: consider placing a suprapubic cystostomy to promote "urethral rest" before definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation.
C

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  • Intraoperative antibiotic prophylaxis

  • Postoperative catheter removal

6.Surgical interventions

Timing for surgery: as per AUA 2023 guidelines, consider performing a urethral endoscopic intervention (such as urethral dilation or direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral strictures, such as symptomatic urinary retention or need for catheterization before another surgical procedure.
E

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  • Endoluminal management (indications)

  • Endoluminal management (technical considerations)

  • Endoluminal management (postoperative care)

  • Urethroplasty (bulbar strictures)

  • Urethroplasty (meatal stenosis or fossa navicularis/penile strictures)

  • Urethroplasty (panurethral urethral reconstruction)

  • Urethroplasty (tissue grafts)

  • Perineal urethrostomy

  • Cystectomy and urinary diversion

7.Specific circumstances

Patients with traumatic urethral injury, monitoring: monitor patients for stricture formation for at least one year after urethral injury.
B

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  • Patients with traumatic urethral injury (evaluation)

  • Patients with traumatic urethral injury (management)

  • Patients with radiation-induced strictures

  • Patients with lichen sclerosus-related strictures

  • Patients with strictures after prostatic interventions

  • Patients with strictures after hypospadias repair

  • Patients requiring chronic self-catheterization

  • Female patients (evaluation)

  • Female patients (urethral dilation)

  • Female patients (urethroplasty)

  • Transgender patients

8.Patient education

General counseling: counsel about safe sexual practices, educate about symptoms of STIs, and provide access to prompt investigation and treatment in male patients with urethritis.
A

9.Follow-up and surveillance

Follow-up: as per AUA 2023 guidelines, obtain monitoring for symptomatic recurrence after urethral dilation, direct visual internal urethrotomy, or urethroplasty.
E

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  • Management of recurrent strictures

10.Quality improvement

Requirements for urinary catheterization: avoid performing unnecessary urethral catheterization.
D
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