Guideline 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). 1 2 3 4 5 Guidelines 1. Classification and risk stratification Severity assessment: Use a validated patient-reported outcome measure to assess symptom severity and impact on the quality of life 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 https://web.pathway.md/diseases/recLowfEALFyNc5P2 1/8 6/29/23, 3:48 AM Urethral stricture Pathway 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 As per EAU 2023 guidelines, obtain uroflowmetry and estimation of postvoid residual in patients with suspected urethral stricture. A Diagnostic imaging: As per AUA 2023 guidelines: Obtain urethrocystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography for the diagnosis of urethral stricture. B Determine the length and location of the urethral stricture when planning non-urgent intervention for a known stricture. E As per EAU 2023 guidelines, obtain retrograde urethrography to assess stricture location and length in patients with urethral stricture planned for reconstructive surgery. Combine retrograde urethrography with voiding cystourethrography to assess (nearly) obliterative strictures, stenoses, and pelvic fracture urethral injuries. A Show 4 more As per CUA 2020 guidelines: Consider performing cystoscopy over urethrography in the initial evaluation of suspected urethral stricture. C Avoid obtaining MRI in the initial evaluation of suspected urinary stricture. D 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 https://web.pathway.md/diseases/recLowfEALFyNc5P2 2/8 6/29/23, 3:48 AM Urethral stricture Pathway 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 Intraoperative antibiotic prophylaxis: administer intraoperative antibiotic prophylaxis at the time of urethral surgery. A Postoperative catheter removal: As per AUA 2023 guidelines, consider removing the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. C As per EAU 2023 guidelines: Remove the catheter within 72 hours after uncomplicated, direct vision internal urethrotomy or urethral dilatation. B Obtain urethrography after urethroplasty to assess for urinary extravasation before catheter removal. A Consider obtaining the first urethrography 7-10 days after uncomplicated urethroplasty to assess whether catheter removal is possible, especially if the urethral catheter bothers the patient. B 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 As per EAU 2023 guidelines, do not perform urethroplasty within 3 months of any form of urethral manipulation. D Endoluminal management, indications: As per AUA 2023 guidelines: Consider performing urethral dilation or direct visual internal urethrotomy for the initial treatment of patients with short (< 2 cm) bulbar strictures. C Consider performing urethral dilation or direct visual internal urethrotomy when performing endoscopic treatment of urethral stricture. C As per EAU 2023 guidelines, perform direct vision internal urethrotomy/dilatation in patients with a primary, single, short (< 2 cm), and non-obliterative bulbar stricture. B Show 3 more As per CUA 2020 guidelines, consider performing endoscopic management as the initial treatment in patients with symptomatic undifferentiated strictures. C Endoluminal management (technical considerations): use either the hot- or cold-knife techniques for direct vision internal urethrotomy, depending on operator experience and resources. B Show 3 more https://web.pathway.md/diseases/recLowfEALFyNc5P2 3/8 6/29/23, 3:48 AM Urethral stricture Pathway Endoluminal management, postoperative care: As per AUA 2023 guidelines, consider offering self-catheterization after direct visual internal urethrotomy to maintain temporary urethral patency in patients ineligible for urethroplasty. C As per EAU 2023 guidelines, offer intermittent self-dilatation to stabilize the stricture after dilatation/direct vision internal urethrotomy in patients ineligible for urethroplasty. B Urethroplasty, bulbar strictures: As per AUA 2023 guidelines: Consider performing urethroplasty for the initial treatment of patients with short (< 2 cm) bulbar urethral strictures. C Perform urethroplasty for the initial treatment of patients with long ( 2 cm) bulbar urethral strictures, given the low success rate of direct visual internal urethrotomy or dilation. B As per EAU 2023 guidelines, perform transecting excision and primary anastomosis for short post-traumatic bulbar strictures with (nearly) complete obliteration of the lumen and full- thickness spongiofibrosis. A Show 7 more Urethroplasty, meatal stenosis or fossa navicularis/penile strictures: As per AUA 2023 guidelines, consider performing either dilation or meatotomy for the initial treatment of patients with meatal or fossa navicularis strictures. C Show 2 more As per EAU 2023 guidelines, perform open meatoplasty or distal urethroplasty in patients with meatal stenosis or fossa navicularis/distal urethral strictures. B Show 3 more Urethroplasty (panurethral urethral reconstruction): Combine techniques to treat panurethral strictures if one technique is not enough to treat the whole extent of the stricture. B Perform panurethral urethroplasty in specialized centers because different techniques and materials might be needed. B Urethroplasty, tissue grafts: As per AUA 2023 guidelines, consider reconstructing long multi-segment strictures with one- stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. C Use oral mucosa as the first choice of grafts for urethroplasty. E Consider using either buccal or lingual mucosal grafts as equivalent alternatives. B Show 3 more As per EAU 2023 guidelines, use a graft above a flap when both options are equally indicated. Do not use grafts in a tubularized fashion in a single-stage approach. A Show 6 more Perineal urethrostomy: As per AUA 2023 guidelines: Consider performing perineal urethrostomy as an alternative to urethroplasty in patients with anterior urethral strictures. C https://web.pathway.md/diseases/recLowfEALFyNc5P2 4/8 6/29/23, 3:48 AM Urethral stricture Pathway Perform perineal urethrostomy as an alternative to urethroplasty in patients with anterior urethral strictures at high risk for failure of urethral reconstruction. E As per EAU 2023 guidelines, perform perineal urethrostomy as a treatment option in patients with complex anterior urethral strictures. A Show 4 more Cystectomy and urinary diversion: Perform urinary diversion in patients with recurrent or complex urethral strictures with loss of bladder capacity and/or incapacitating local symptoms. B Perform cystectomy during urinary diversion in case of intractable bladder pain, spasms, and/or hematuria. B 7. Specific circumstances Patients with traumatic urethral injury (monitoring): monitor patients for stricture formation for at least one year after urethral injury. B Patients with traumatic urethral injury, evaluation: As per AUA 2023 guidelines, obtain retrograde urethrography with voiding cystourethrogram and/or retro-antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. B As per EAU 2023 guidelines: Obtain retrograde urethrography with voiding cystourethrography to evaluate pelvic fracture urethral injuries. A Obtain retrograde urethroscopy and antegrade cystoscopy as an adjunct to imaging to evaluate pelvic fracture urethral injuries, if further information is required. B As per AAST/WSES 2019 guidelines, obtain retrograde urethrography or selective urethroscopy for the evaluation of traumatic urethral injuries. B Prefer urethroscopy over retrograde urethrography in patients with penile lesions. B Patients with traumatic urethral injury, management: As per AUA 2023 guidelines: Perform delayed urethroplasty instead of endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. E Plan definitive urethral reconstruction for pelvic fracture urethral injury only after major injuries stabilize and patients can be safely positioned for urethroplasty. E As per EAU 2023 guidelines, do not perform endoscopic treatment in patients with obliterative stenosis. Perform progressive perineal excision and primary anastomosis for obliterative stenosis. D Show 8 more Patients with radiation-induced strictures: perform visually controlled dilatation or direct vision internal urethrotomy as first-line therapy in patients with radiation-induced bulbomembranous strictures. B Do not perform deep incisions at the 6 and 12 o'clock positions during direct vision internal urethrotomy. A Show 5 more https://web.pathway.md/diseases/recLowfEALFyNc5P2 5/8 6/29/23, 3:48 AM Urethral stricture Pathway Patients with lichen sclerosus-related strictures: As per AUA 2023 guidelines: Consider performing a biopsy for suspected lichen sclerosus. Perform a biopsy if urethral cancer is suspected. C Do not use genital skin for reconstruction in patients with lichen sclerosus-proven urethral stricture. D As per EAU 2023 guidelines, perform single-stage oral mucosa graft urethroplasty in patients with lichen sclerosus-related strictures, in the absence of adverse local conditions. Do not perform staged bulbar urethroplasty if single-stage urethroplasty is possible. B Do not use genital skin grafts or flaps for augmentation penile urethroplasty in patients with lichen sclerosus. A Patients with strictures after prostatic interventions: As per AUA 2023 guidelines, consider performing dilation, bladder neck incision, or transurethral resection for bladder neck contracture after an endoscopic prostate procedure. E Show 2 more As per EAU 2023 guidelines, perform visually controlled dilatation or direct vision internal urethrotomy as first-line therapy in patients with non-obliterative vesicourethral anastomotic strictures. B Do not perform deep incisions at the 6 and 12 o'clock positions during direct vision internal urethrotomy. A Show 9 more Patients with strictures after hypospadias repair: refer patients with failed hypospadias repair to a specialist center for further management. B Show 2 more Patients requiring chronic self-catheterization: consider offering urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization in male patients requiring chronic self-catheterization (such as neurogenic bladder). E Female patients (evaluation): obtain flow rate and post-void residual measurement and voiding cystourethrography or video-urodynamic testing in all female patients with refractory LUTS. A Female patients (urethral dilation): Perform urethral dilatation to 21-41 Fr as the initial treatment of urethral strictures in female patients. B Perform repeat urethral dilatation and offer planned weekly intermittent self-dilatation with a 16-18 Fr catheter for the first recurrence or plan repeat dilatation. B Female patients, urethroplasty: As per AUA 2023 guidelines, consider using oral mucosal grafts, vaginal flaps, or a combination of these techniques, for reconstruction of urethral strictures in female patients. C As per EAU 2023 guidelines: Perform urethroplasty for a second recurrence in patients unable to perform intermittent self-dilatation or desiring definitive treatment. Determine the technique for urethroplasty by https://web.pathway.md/diseases/recLowfEALFyNc5P2 6/8 6/29/23, 3:48 AM Urethral stricture Pathway the surgeon's experience, the availability and quality of graft/flap material, and the quality of the ventral versus dorsal urethra. A Perform meatotomy/meatoplasty for meatal strictures. B Transgender patients: do not perform endoscopic incision or urethroplasty within 6 months after neophalloplasty. D Show 3 more 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 As per EAU 2023 guidelines, obtain cystoscopy or retrograde urethrography to assess anatomic success after urethroplasty surgery. B Show 2 more Management of recurrent strictures: As per AUA 2023 guidelines, perform urethroplasty rather than repeating endoscopic management in patients with recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. B Show 2 more As per EAU 2023 guidelines, perform direct vision internal urethrotomy/dilatation in patients with a short, veil-like recurrent stricture after prior bulbar urethroplasty. B Show 2 more As per CUA 2020 guidelines: Consider obtaining retrograde urethrography to further stage urethral stricture in patients with a suspected recurrent stricture. Consider referring to a physician with expertise in reconstructive urology. C Consider performing urethroplasty rather than repeating endoscopic management (direct visual internal urethrotomy or dilation) in patients with a recurrent urethral stricture failing prior endoscopic treatment. C 10. Quality improvement Requirements for urinary catheterization: avoid performing unnecessary urethral catheterization. D Show 4 more https://web.pathway.md/diseases/recLowfEALFyNc5P2 7/8 6/29/23, 3:48 AM Urethral stricture Pathway Clinical findings Symptoms Past medical history Dysuria Hypospadias Feeling of incomplete bladder emptying Lichen sclerosus Pelvic radiation therapy Sexual dysfunction Pelvic trauma Split urine stream Penile injury Urinary retention Prostate biopsy Urinary straining Recurrent UTIs Weak urine stream Sexually transmitted diseases Urethral injury Past surgical history Imaging findings Prostatectomy post-void residual References 1. Keith F Rourke, Blayne Welk, Ron Kodama et al. Canadian Urological Association guideline on male urethral stricture. Can Urol Assoc J. 2020 Oct;14 10 305 316. Open 2. N. Lumen Chair), F. Campos-Juanatey, K. Dimitropoulos et al. EAU Guidelines on Urethral Strictures. EAU. 2023. Open 3. Hunter Wessells, Allen Morey, Alex Vanni et al. Urethral Stricture Disease Guideline Amendment 2023 . J Urol. 2023 Apr 25;101097JU0000000000003482. Open 4. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 5. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open https://web.pathway.md/diseases/recLowfEALFyNc5P2 8/8